NEW CONCEPT OF

CERVICAL CANCER MANAGEMENT

Chinese Society of Gynecologic Oncology

Obstetrics & Gynecology Center of Medical School of
Tsinghau University

Zeyi Cao M.D.

zeyicao@263.net Tel:13801081287 Zeyi Cao M.D
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 Cervical Cancer FIGO 2009 Staging

① Omit 0 staging ( CIN III )

② ⅡA：： Ⅱa tumor size prognoses same to I B

Ⅱa No paramitrial invasion
Ⅱa1 Nake eye tumor ≤ 4cm
Ⅱa2 Nake eye tumor> 4cm

Zeyi Cao M.D

 FIGO Recommendation
Lymphovascular space invasion (LVSI not
including in staging but report separetly 。

 Lympha node not including in staging but encourege

using PET/CT, CT/MRI(≦IB1)
cystoroscopy or rectoroscopy（≧IB2)

 From global cost and effective using Clinical Staging

Zeyi Cao M.D

Variations in Cervical Cancer
• Ages
– FIGO (2001) : 60 yrs ( in 50’s) to 50 yrs (in 90’s)
– China (2005 from 1342 cases): 55 yrs to 42 yrs
(33 yrs), youngest 17 yr-old

• Histopathology
– >90% SCC and 5% of ACC
– In China: SCC 74%, ACC >25%
– The Ratio of SCC/ACC decrease from 10:1 to
4:1
Zeyi Cao M.D
 Some key points
1.About lymph node matatstsis
CT ,MRI, or PET-CT evaluation
IA1 LVSI (+) Pelvic lymphadenectomy
IA2 above Pelvic lymphadenectomy ± Para-Aortic sampling
2.Radical Trachelectomy and pelvic lymphdenectomy
Only for IA2~IB1 squamous adenocarcinoma adenosquamous
small cell carcinoma not included
3. IB2 IIA﹥4cm:
Neoadjuvant Chemotherapy followed Radical Hysterectomy
4.IIB~III: Chemotherapy Radical Hysterectomy Chemotherapy
or RT
5.Laparoscopy Surgery and Robot Surgery?

Zeyi Cao M.D

 Radiation Therapy

• Ib1~IVa primary select radical radiation therapy and

concurrent chemotherapy

• Pelvic RT including all lymph node

• Brachytherapy + Pelvic RT is key point

• Total （A point 80~85Gy）treatment time within 7-8

weeks
Zeyi Cao M.D
Concurrent Chemotherapy

Cisplatin 40 mg/m2/wk X 5-6 weeks

Max dose 70 mg/m2/wk
Cisplatin+ 5FU
Cisplatin 70-75 mg/m2 d1, + 5FU
1000 mg/m2/day X 4d(96 h)
q 4 wks X 3-4 cycles
Zeyi Cao M.D
IA1~IIA primary treatment

IA1，Extrafascil hysterectomy or
Observe: desires fertility, cone
biopsy margins(-), or
Radical Hysterectomy II + Pelvic
Lymph node dissection
LVSI (+)
IA2，Radical Hysterectomy II +
Pelvic Lymph node dissection
+_Para-Aortic sampling or
Brachytherapy + pelvic RT or
Radical Trachelectomy for
fertility preservation
Zeyi Cao M.D
 IB1 and IIA（≦4cm):
Radical Hysterectomy III +
Pelvic Lymph node dissection
± Para-Aortic sampling or
Brachytherapy + pelvic RT

IB2 and IIA、﹥4cm）：

1.Radical Hysterectomy III +
Pelvic Lymph node dissection
± Para-Aortic sampling（2B类)
2.Pelvic RT + Concurrent Cisplatin –
containing Chemotherapy+Brachytherapy
3. Pelvic RT + Concurrent Cisplatin –
containing Chemotherapy + Adjuvant
Hysterectomy+Brachytherapy
Zeyi Cao M.D
 Modification of surgical skills on radical
hysterectomy III
• History of Wertheim hysterectomy >100 yrs

• Improvement and modification in China

more than 50 years

• Better clinical prognosis

Zeyi Cao M.D

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 5-year-survival rate
-33-year retrospectively with 1342 cases
-5 year survival rate
70-80s 90- 00s
• Stage I : 92.4% to 95.8%，
• Stage II : 69.7% to 76.5%，
• Stage III : 31% to 41%。
• stage I ~ IV: 70.4%
• FIGO ( 2001) stage I ~ IV : 72.2%
Zeyi Cao M.D
 Cervix Cancer
5-Year Survival Data

FIGO Stage 5-Year Survival

I 81-96 %
II 65-87 %
III 35-50 %
IV 15-20 %

Zeyi Cao M.D

 Management of Cervical Carcinoma
Issues for Discussion
• Young cervical cancer patients
– Fertility preserving
– Sexual function preserving
( shift of ovary and prolong vagina)
• Management in different stages
– Early stages
– Late stages
– Huge tumor size IB2
• Bladder function protection
– Nerve sparing radical hysterectomy

Zeyi Cao M.D

 Fertility Preserving Surgery
Conization / LEEP

Indications:
• Desire fertility
• Stage IA1/2 and (-) LVSI
• SGO-MIC ( 3 mm; (-) LVSI)
• DI  6 mm ; (-) LVSI

Zeyi Cao M.D

Radical Trachelectomy + Laparoscopic LND
Indications:
• Desire fertility
• Stage IA1-2 and (+) LVSI
• Stages IB1; TU. < 2 cm;
(-) LVSI
• (-) LNM
• Endocervical margins >
5mm and
> 1 cm endocervical canal
• Cerclage

Zeyi Cao M.D

Sexual function preserving Surgery
• Shift of the ovary

• Protection of ovary by shifting the ovary

out of the pelvic cavity

• To decrease postoperative damage by

radiotherapy

Zeyi Cao M.D

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Sexual function preserving Surgery

• Resection enough vagina(3cm+)

– Avoid recurrence of residue cancer
– Prolong Vagina during operation
• Preserve normal sexual activity ?

Zeyi Cao M.D

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Results of vagina prolongation
• Prolong the vagina 3-5cm, totally in 10-
12 cm
• Satisfied postoperative sexual function
• No obvious discomfort except a
transient postoperative constipation

Zeyi Cao M.D

NACT followed Radical Hysterectomy

The indications for radical hysterectomy were

widen performed especially for younger patients

Ib2 –IIIb?: after 2-3 courses, local lesions size

minimized, performing RH

Zeyi Cao M.D

Postoperative Radiation Therapy
for Cervical Cancer
Indications
• Positive surgical margins
• Parametrial extension
• Nodal metastases
• Large tumors

Zeyi Cao M.D

 Recurrent Management

Single resectable : Surgery and Intraoperative

Radiation Therapy ,IORT

Central recurrent : Exenteration±IORT

Chemotherapy:
Multiple matastasis
unresectable P+T+Topoticon
Zeyi Cao M.D
 Special Situation
Simple hysterectomy found cervical cancer：

1.CIN III, CIS: follow up

2.LVSI (-) IA1: observation

3. LVSI (+) IA1,IA2 or IB:

Concurrent RT and brachytherapy and
Chemotherapy

4.Reoperated Radical Surgery more complications

Zeyi Cao M.D
 Pregnancy and Cervical Carcinoma
• Stage IA: stay treatment

• Stage IA-IB1:Radical Trachelectomy

• Chemotherapy after 13 Weeks until 28 weeks

• Influence of posterity?
Zeyi Cao M.D
 Management of Cervical Carcinoma
Summary
• Early disease:
Conservative Surgery
Conization vs. Rad. Trachelectomy +/- LND

Local advanced Young patient:_NACT followed by

RH and consideration of the ovary and vagina

Advanced disease:
RT+ brachytherapy +concurrent chemotherapy

Recurrent cases: Central, Exenteration, LEER Zeyi Cao M.D

 FUTURE DIRECTION
• New FIGO staging
• Optimal regimen for NACT
• Management of recurrent cervical cancer
• Fertility preserving and quality of life in
young patients
• HPV Vaccine
• Localized and international corporation in
management of cervical cancer
• ………
Zeyi Cao M.D
 再
Tsinghua University2nd Hospital
Obs & Gyne department100049
010-88258727 13801081287
Zeyicao@263.net
见
Zeyi Cao M.D