Obstetrics/Gynecology Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

July 09, 2018

In This Article

Cervical Cancer

European Society of Gynaecological Oncology, European Society for Radiotherapy and Oncology, and European Society of Pathology

Pelvic examination and biopsy +/− colposcopy are mandatory components to diagnose cervical cancer.

Mandatory initial workup for assessment of pelvic tumor extent and to guide treatment options is pelvic magnetic resonance imaging (MRI). Endovaginal/transrectal ultrasound is an option if performed by a properly trained sonographer.

Cystoscopy or rectoscopy may be considered to provide a biopsy if suspicious lesions in the urinary bladder or rectum are documented on MRI or ultrasound.

In early-stage cervical cancer (T1a, T1b1, T2a1), surgical/pathological staging of pelvic lymph nodes is the criterion standard to assess the prognosis and guide treatment (except of T1a1 and no lymphovascular space involvement [LVSI]).

In locally advanced cervical cancer (T1b2 and higher [except T2a1]) or in early-stage disease with suspicious lymph nodes on imaging, positron emission tomography–computed tomography (PET-CT), or chest/abdomen CT, is recommended for assessment of nodal and distant disease.

Pet-CT is the preferred option for treatment planning before chemoradiotherapy with curative intent.

Para-aortic lymph node dissection, at least up to inferior mesenteric artery, may be considered in locally advanced cervical cancer with negative para-aortic lymph nodes on imaging for staging purposes.

Equivocal extrauterine disease is to be considered for biopsy to confirm or rule out metastatic disease and to avoid inappropriate treatment. Tru-Cut (core-cut) biopsy is the preferred option because it allows histologic assessment of the tissue.

Diagnosis of T1a cancer should be based on a conization (or excision) specimen examined by an expert pathologist. Management must be based on an expert pathology review, with accurate measurement of the maximum horizontal 2 dimensions, depth of invasion, margin status, coexisting pathology, and reliable assessment of LVSI.

Loop or laser conization is preferable to cold-knife conization in women desiring fertility preservation. Maximum care should be taken to provide an intact (unfragmented) specimen with minimal thermal artifact. The cone specimen should be oriented for the pathologist.

Surgical margins of the cone specimen should be clear of both invasive and preinvasive disease (except for preinvasive disease in ectocervix).

Management of patients with stage T1a1 disease should be individualized depending on the age, the desire for fertility preservation, and the presence or absence of LVSI.

In case of positive margins (except for preinvasive disease in ectocervix), a repeat conization should be performed to rule out more extensive invasive disease.

Lymph node staging is not indicated in T1a1 LVSI-negative patients but can be considered in T1a1 LVSI-positive patients. Sentinel lymph node biopsy (without additional pelvic lymph node dissection) is an acceptable method of lymph node staging.

Conization can be considered a definitive treatment, as hysterectomy does not improve the outcome.

Radical surgical approaches such as radical hysterectomy or parametrectomy represent overtreatment for patients with T1a1 disease.

In patients with stage T1a2 disease, conization alone or simple hysterectomy is an adequate treatment.

Parametrial resection is not indicated.

Lymph node staging can be considered in LVSI-negative patients but should be performed in LVSI-positive patients. Sentinel lymph node biopsy alone (without additional pelvic lymph node dissection) appears to be an acceptable method of LN staging.

Routine completion of hysterectomy is not recommended after conservative management of stage T1a disease.

In patients with unequivocally involved pelvic lymph nodes on imaging, definitive chemoradiotherapy is recommended. Para-aortic lymph node dissection, at least up to inferior mesenteric artery, may be considered in patients with negative para-aortic lymph nodes on imaging.

Debulking of suspicious pelvic lymph nodes may be considered.

Definitive management (without tumor-related surgery) consists of concomitant pelvic chemoradiotherapy (platinum based) and brachytherapy or pelvic external beam radiotherapy (EBRT) alone and brachytherapy.

Overall treatment time for the definitive treatment should not exceed 7 to 8 weeks.

Delay of treatment and/or treatment interruptions have to be avoided.

External beam radiotherapy is the recommended minimum as 3-dimensional (3D) conformal radiotherapy. The preferred treatment is intensity-modulated radiotherapy (IMRT) because of the more conformal dose distribution that maximizes sparing of organs at risk.

External beam radiotherapy can be applied as concomitant chemoradiotherapy with total dose of 45 to 50 Gy (1.8 Gy per fraction) and single-agent radiosensitizing chemotherapy, preferably cisplatin (weekly 40 mg/m2), so that definitive radiotherapy is not compromised. If cisplatin is not applicable, alternative treatment options are fluorouracil or carboplatin. External beam radiotherapy may also be applied without concomitant chemotherapy according to treatment selection (ie, patients unfit for any chemotherapy). In such cases, regional hyperthermia may be considered.

Tumor and lymph node–related target volume for IMRT includes the primary cervical tumor and the adjacent tissues such as parametria, uterine corpus, upper vagina, and pelvic lymph nodes (obturator, internal, external and common iliac, presacral). In case of pelvic lymph node involvement indicating an increased risk of para-aortic lymph node spread, EBRT may include the para-aortic region up to the renal vessels (45 Gy). In case of para-aortic lymph node involvement, target volume includes, at a minimum, the region up to the renal vessels.

A reduced target volume for EBRT resulting in a small pelvic field not including the common iliac nodes may be considered in low- and intermediate-risk T1b1 patients with negative lymph nodes on imaging and no LVSI.

Boost treatment for involved lymph node(s) may be applied as simultaneous integrated boost within the IMRT treatment or as sequential boost. The total dose including the contribution from brachytherapy should be 55 to 60 Gy (equieffective dose to 2 Gy per fraction [EQD2]). An alternative treatment option is surgical debulking of enlarged nodes.

Image-guided radiotherapy (IGRT) is recommended for IMRT to ensure safe dose application in the tumor-related targets, to account for motion uncertainties, to reduce margins, and to achieve reduced doses to organs at risk.

Overall treatment time for EBRT should not exceed 5 to 6 weeks.

Reference

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