Manage special clinical scenarios in cervical cancer, including inadvertent hysterectomy, malignancy arising in the cervical stump, and pregnancy-associated disease, according to the individual disease factors and patient circumstances.
Inadvertent hysterectomy
For patients with squamous cell carcinoma after simple hysterectomy, apply the SHAPE trial findings to guide management. These findings show that simple (extrafascial) hysterectomy with lymph node assessment is non-inferior to radical surgery in low-risk early-stage cervical cancer.1
Current management options include:2
- providing full pelvic radiotherapy
- considering radical surgery (parametrectomy, upper vaginectomy and pelvic lymphadenectomy) when risk factors indicate more extensive treatment.
If gross lymphadenopathy (greater than or equal to 2 cm) shows on imaging, perform an extraperitoneal lymphadenectomy followed by radiotherapy.
Do not perform re-operation when metastatic disease is present or when the hysterectomy specimen indicates a need for postoperative radiotherapy.
Cancer arising in the cervical stump
- Radiotherapy effectively treats cancer of the cervical stump and achieves outcomes comparable to an intact uterus but increases complication rates.
- Consider radical trachelectomy with pelvic lymphadenectomy for selected Stage IB tumours.
Cervical cancer in pregnancy
Cervical cancer in pregnancy requires care for both the patient and the foetus. Consider ethical, cultural and religious factors, and the patient’s choice to continue the pregnancy (after informed consent). Use an interdisciplinary approach to counselling.3
Do not treat preinvasive lesions during pregnancy. Perform expert colposcopy to exclude invasive cancer. Refer to HealthPathways for local referral and guidance.
Treatment of invasive cancer during pregnancy depends on the disease and gestational age at diagnosis:
- Offer immediate stage-appropriate treatment when cervical cancer is diagnosed before 22 to 25 weeks (refer to flow charts below). Delay treatment only if diagnosis occurs in the third trimester.
- Consider planned treatment delay for patients with Stage IA or early Stage IB disease, to support improved foetal outcome.
- Consider neoadjuvant chemotherapy (NAC) to allow further development of the foetus prior to surgery.3
- Offer pelvic lymph node dissection (PLND); para-aortic lymph node dissection (PALND); NAC or termination of pregnancy (TOP) as management options.3
Treatment before 22 to 25 weeks of pregnancy
These flow charts outline treatment strategies for cervical cancer diagnosed before 22 to 25 weeks of pregnancy.
Stage IA2 to IB less than<2 cm flow chart
Stage IB greater than>2 cm flow chart
References
- Plante M, Kwon JS, Ferguson MD, et al. Simple versus Radical Hysterectomy in Women with Low-Risk Cervical Cancer. N Engl J Med. doi: 10.1056/NEJMoa2308900
- Berek J, Hacker N. Cervical cancer. In: Practical gynecological oncology 3rd edition. Eds: Berek J, Hacker N. Sydney: Lippincott Williams & Wilkinson; 2000
- Amant F, Halaska MJ, Fumagalli M, et al. Gynecologic cancers in pregnancy: guidelines of a second international consensus meeting. Int J Gynecol Cancer. 2014;24(3):394-403