B21. Cervical cancer; FIGO classification and therapy

FIGO classification

Alternative name for stage	Stage	Description
Early cervical disease	0	Carcinoma in situ
	I	Tumour strictly confined to the cervix
	Ia1	Stromal invasion < 3 mm in depth
	Ia2	Stromal invasion 3 – 5 mm in depth
	Ib	Stromal invasion > 5 mm in depth
	II	Tumour invades beyond the uterus, but not into the pelvic wall or lower third of the vagina
	IIa	Tumour does not invade parametrium, invades upper 2/3 part of vagina
Locally advanced disease	IIb	Tumour invades the parametrium, but not the pelvic wall
	III	Tumour invades pelvic wall or lower third of the vagina or causes hydronephrosis or pelvic lymph nodes or paraaortic lymph nodes
Metastatic disease	IVa	Tumour invades adjacent organs in the pelvis
	IVb	Distant metastasis

(I’ve excluded some of the substages for simplicity)

Management

Surgery is the mainstay of treatment of cervical cancer.

• Conisation or total/simple hysterectomy for stage Ia1
• Radical (Wertheim) hysterectomy up until and including stage IIa

Surgical treatment

Wertheim hysterectomy involves modified radical hysterectomy + pelvic lymphadenectomy, total removal of uterus and its ligaments, and removal of pelvic lymph nodes on both sides.

Hysterectomy obviously takes away the woman’s fertility, but cervical cancer often affects women in their fertile age. A fertility-preserving surgical alternative to hysterectomy for cervical cancer is trachelectomy.

Surgery is not the main treatment in locally advances disease, stage IIb and beyond (i.e., when the parametrium is involved). However, it may be part of the adjuvant treatment.

Chemotherapy and radiotherapy

Radiation is effective in all stages of cervical cancer. External beam radiation therapy (EBRT) may be used, but the bladder is sensitive to radiation, so external radiation for cervical cancer should be limited to 50 Gy. After 50 Gy has been delivered by ERBT, we switch to brachytherapy, usually HDR brachytherapy with afterloading.

For stages IIb to IVa radiochemotherapy is the main treatment. Treatment for stage IVb is palliative and is mostly chemotherapy. Radiochemotherapy may be used as adjuvant treatment after surgery.

The standard chemotherapy regimen is cisplatin-based. Chemotherapy is rarely used alone in the treatment of cervical cancer; it’s almost always combined with radiotherapy.

Radiotherapy may be used as primary therapy in early stages (I – IIa) in cases where surgery is not an option.