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Case History

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Image not available. A 32-year-old nulliparous woman undergoes her first cervical Papanicolaou smear test which shows a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy shows an abnormal transformation zone with acetowhite changes and punctation extending into the cervical canal. Biopsy is reported as HGSIL. A cold knife cone biopsy reveals a highgrade squamous cell carcinoma with a depth of invasion of 6 mm and horizontal spread of 8 mm. There is no lymphovascular space invasion (LVSI).

What is the appropriate pre-treatment evaluation for a cervical cancer?

What is the best treatment for a patient with a stage IB1 or early stage IIA cervical cancer?

When is fertility preservation an option in cervical cancer?

What are the indications for adjuvant radiotherapy and when should chemotherapy be added?

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Background

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Image not available. Cervical cancer is worldwide the second most common malignancy in women. Introduction of organized screening programmes in industrialized countries has resulted in a noticeable stage shift from more advanced to earlier-stage disease. Small invasive cancers have therefore become a more frequently encountered clinical problem and are often diagnosed at a younger age.

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The practical approach to cervical cancer treatment involves three steps: (a) establishing a diagnosis; (b) staging; and (c) choosing and implementing treatment.

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What is the appropriate pre-treatment evaluation for a cervical cancer?

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Invasive cervical cancer might be encountered when performing colposcopy to evaluate cytological abnormalities. Diagnostic cold knife cone biopsy is indicated when a cancer is suspected and the lesion cannot be fully evaluated (e.g. endocervical extension). When confronted with a clinically evident tumour, an office/outpatient biopsy is sufficient.

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Every patient should be formally staged. The current International Federation of Gynaecology and Obstetrics (FIGO) staging system of cervical cancer is based on clinical evaluation and determines surgical resectability of the disease (Table 45.1). Therefore, clinical examination under anaesthesia (EUA) should be performed and suspected bladder or rectal involvement excluded by cystoscopy and/or sigmoidoscopy. Further examination includes intravenous urography and X-ray examination of the lungs and skeleton. Critics of FIGO staging note that EUA is incorrect in a high percentage of cases.1 Furthermore, substantial data can be obtained from computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and surgical staging. MRI has been increasingly used in cervical cancer and is reported to have a high accuracy in the detection of parametrial involvement and is superior to clinical examination.2 For assessment of lymph node involvement, however, PET scan is the most accurate and CT scan the most cost-effective imaging procedure.

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Table Graphic Jump Location
Table 45.1FIGO staging for cervical carcinoma

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