Cervical Cancer: Surgical Therapy

Precancerous lesions of the cervix (preinvasive lesions)

CIN (cervical intraepithelial neoplasia) I-III: if persistent (persisting) after colposcopic cytological control (every six months) for up to 24 months

CIN Therapy options
CIN I
  • Colposcopically confirmed ectocervical seat (confirmed by cervical endoscopy)
    • Biopsy (tissue sampling)
    • CO2 laser vaporization (vaporization)
    • Snare conization (use of an electrically heated wire snare to remove a cone/tissue cone).
  • Endocervical (“inside the cervix). Seat
    • Snare conization
CIN II
  • CO2 laser vaporization
  • Loop conization
CIN III
  • CO2 laser vaporization
  • Loop conization

Postoperative regular progress controls. In pregnancy only follow-up controls, further clarification postpartum.

Standard therapy in stage FIGO IA1

  • Fertility-preserving surgery for young women (if they wish to have children):
    • Conization (surgery on the cervix in which a cone of tissue (cone) is excised from the cervix and then examined microscopically).
    • Radical vaginal trachelectomy (RVT; surgery to remove part of the cervix while preserving fertility), combined with laparoscopic (by laparoscopy) pelvic lymph node removal, for early-stage cervical cancer (tumor diameter ≤ 2 cm, FIGO stages IA1 to IB1, V0, pN0)
  • Vaginal/abdominal (simple) hysterectomy.
  • In the case of lymph node involvement (L1) additionally pelvic lymphonodectomy.

Standard therapy in stage FIGO IA2

  • Radical vaginal trachelectomy (RVT), combined with laparoscopic pelvic if necessary paraaortic lymph node removal.
  • Radical hysterectomy (removal of the uterus) with systemic pelvic, possibly paraaortic lymphonodectomy / lymph node removal (usually surgery according to Wertheim-Meigs).
  • Conization, if necessary with trachelectomy in the case of desire to have children.

Standard therapy in stage FIGO IB1*

  • Radical vaginal trachelectomy (RVT) combined with laparoscopic pelvic, and if necessary, paraaortic lymph node removal.
  • Radical hysterectomy with systemic pelvic, if necessary paraaortic lymphonodectomy (usually operation according to Wertheim-Meigs).
  • If necessary, trachelectomy with pelvic lymphonodectomy in childbearing if tumor < 2 cm.

Standard therapy in stage FIGO IB2*

  • Radical hysterectomy with systemic pelvic, possibly paraaortic lymphonodectomy (usually Wertheim-Meigs surgery).
  • If necessary, adjuvant radiochemotherapy (RCTX; combination of radiotherapy and chemotherapy).

Standard therapy in stage FIGO IIA, IIB* .

  • Radical hysterectomy with systemic pelvic, possibly paraaortic lymphonodectomy (usually Wertheim-Meigs operation).
  • If necessary, adjuvant radiochemotherapy (RTCX).

* In stages IB and II, surgery and radiochemotherapy have equivalent long-term outcomes. In premenopausal patients, as in the early stages, surgery is recommended because ovarian function (ovarian function) can be preserved. Standard therapy in stage FIGO III, IV

  • Simultaneous radiochemotherapy (RCTX) as standard therapy.
  • If necessary, exenteration (extensive to complete removal of the organs of the lesser pelvis (pelvis), i.e., urinary bladder, vagina, vaginal vestibule, and possibly rectum) in stage FIGO IV if pelvic wall is clear and bladder and/or rectal infiltration (ingrowth of tumor into rectum) is present

Standard therapy for recurrence

  • Consider the possibility of resection

Operative special situations/developments

They are reserved for exceptional cases and are performed only in highly specialized centers and/or studies:

  • Radical trachelectomy
    • Part 1: Laparoscopy (laparoscopy), inspection of the abdominal cavity, pelvic lymphonodectomy (lymph node removal), sentinel lymphonodectomy if necessary. If the frozen section diagnosis is unremarkable, vaginal surgery follows.
    • Part 2: Partial resection of the cervix with the medial parametria and a vaginal cuff, preserving the internal cervix (remaining CK length 10-15 mm) and the corpus uteri (body of the uterus).
      • Prerequisites:
        • Desire to have children
        • Stage IA1 also with lymphangiosis (ingrowth of tumor cells into the lymphatic vessels).
        • Stage IA2
        • Stage IB1, tumor size ≤ 2cm
        • Tumor-free pelvic lymph nodes (N0)
        • No vascular intrusions (V0)
        • No neuroendocrine differentiation of the tumor.
      • Studies are currently underway to determine whether, in the case of inconspicuous lymph nodes in frozen section, reconization or simple trachelectomy may not be sufficient, since affected lymph nodes have virtually never been found in the removed parametria (connective tissue structures of the pelvic cavity that extend from the wall of the cervix to the urinary bladder, the os sacrum (sacral bone), and the internal lateral wall of the pelvis).
  • Total mesenteric resection (TMMR).
    • The basis is the removal of the tumor along the anatomical-embryonic developmental boundaries according to its morphogenetic origin, sparing anatomical structures that do not belong to this entity
    • Lymphonodectomy sparing the nerves.
      • Advantages: no radiotherapy with a high locoregional recurrence-free rate.
      • Low surgery-related morbidity (bes. sparing of nerve supply to bladder, rectum, residual sheath).
      • Surgery:
        • En bloc resection of the uterus with vaginal cuff and mesometrium.
        • Removal of the rectouterine subperitoneal connective tissue to the inferior hypogastric plexus
        • Pelvic/paraaortic lymphonodectomy with protection of the superior hypogastric plexus.
  • Vaginal radical surgery (Schauta-Armreich).
    • This surgical method has experienced a renaissance at some centers, particularly for tumors <4 cm, because the former shortcoming of no lymphonodectomy is compensated for by laparoscopic pelvic and para-aortic lymph node removal.
  • Laparoscopic total radical hysterectomy (LRH).
  • Laparoscopic mesenteric resection

Further notes

  • LACC (Laparoscopic Approach to Cervical Cancer) study: minimally invasive radical hysterectomy achieves worse results than traditional open surgery for early-stage cervical cancer (up to FIGO IIA). 91.1% of patients were stage IB1, meaning the tumor was smaller than 4 cm and lymph node involvement was not evident; Significant differences were:
    • Disease-free survival at 4.5 years: 86.0% after minimally invasive surgery versus 96.5% after open surgery (without recurrence)
    • 3-year overall survival: 93.8 versus 99.0% = hazard ratio of 6.0 (1.77 to 20.30) for premature death
    • Aside: most recurrences had occurred at 14 of the 33 hospitals.
  • Early cervical cancer (up to stage IIB): to assess tumor aggressiveness and adjust therapeutic approach accordingly, bilateral sentinel node biopsy (bilateral sentinel lymph node tissue sampling) could be a safe alternative to systematic pelvic lymphadenectomy (removal of pelvic lymph nodes): disease-free and disease-specific survival did not differ significantly between the two groups.