A 45-year-old G1P1 presents for her routine annual examination. The patient is a healthy smoker who has no medical problems. Her surgical history is significant for a cesarean delivery with bilateral tubal interruption. You perform a Pap smear, which returns showing high grade squamous intraepithelial lesion (HSIL). She undergoes colposcopy, which is inadequate.
Cone biopsy of the cervix shows squamous cell cancer that has invaded only 2 mm beyond the basement membrane with a lateral spread of 5 mm. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease.
How should you stage this patient’s disease?
Stage Ia1, or microinvasive carcinoma of the cervix, includes lesions stromal invasion 3 mm or less in depth and 7 mm or less in horizontal spread, with no confluent tongues or lymphatic or vascular invasion. Stage Ia2 is stromal invasion more than 3 mm but less than 5 mm, and horizontal spread less than 7 mm.
Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?
The main routes of spread of cervical cancer include vaginal mucosa, myometrium, paracervical lymphatics, and direct extension into the parametrium. The prevalence of lymph node disease correlates with the stage of malignancy. Primary node groups involved in the spread of cervical cancer include the paracervical, parametrial, obturator, hypogastric, external iliac, and sacral nodes, essentially in that order. Less commonly, there is involvement in the common iliac, inguinal, and paraaortic nodes. The presence of lymph node involvement confers a worse prognosis and impacts how the patient is managed. In stage I, the pelvic nodes are positive in approximately 15% of cases and the para-aortic nodes in 6%. In stage II, pelvic nodes are positive in 28% of cases and para-aortic nodes in 16%. In stage III, pelvic nodes are positive in 47% of cases and para-aortic nodes in 28%.
This patient now asks you for your advice on how to treat her cervical cancer.
Your best recommendation is for the patient to undergo which of the following?
The treatment of choice for microinvasive disease in a woman who has completed childbearing is extrafascial (or simple) hysterectomy. If the patient desired fertility sparing treatment, then stage Ia1 disease may be treated with cone biopsy.
A woman is found to have a unilateral invasive vulvar carcinoma that is 3 cm in diameter but not associated with evidence of lymph node spread.
Initial management should consist of which of the following?
Women who have invasive vulvar carcinoma usually are treated surgically. Tumors larger than 2 cm are staged as IB. If the lesion is unilateral, is not associated with fixed or ulcerated inguinal lymph nodes, and does not involve the urethra, vagina, anus, or rectum, then treatment usually consists of radical excision and unilateral inguinal lymphadenectomy. The risk of inguinal node metastasis is around 8%. Inguinal lymphadenectomy involves removal of the superficial inguinal and deep femoral lymph nodes. Unilateral rather than bilateral lymphadenectomy decreases postoperative morbidity. The lymph nodes should be sent intraoperatively for frozen section, and if positive, a bilateral lymphadenectomy should be performed. Radiation therapy, though not a routine part of the management of women who have early vulvar carcinoma, is employed in the treatment of women who have local, advanced carcinoma.
If this woman had multiple medical comorbidities, what would be the best option for management?
Patients with multiple comorbidities who are not considered surgical candidates should be treated with radiation therapy. In some institutions, chemoradiation is preferred, but there is not good data to recommend that routinely.