Table II-4-1. Stage I Most Common (Spread Limited to Cervix)
| Ia1 | • ≤3 mm | Total simple hysterectomy | |
| • | Minimal invasion | ||
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| Ia2 | • >3 mm but ≤5 mm | Modified radical hysterectomy | |
| • | Microinvasion | ||
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| IB | • >5 mm | Radical hysterectomy | |
| • | Frank invasion | ||
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USMLE Step 2 l Gynecology
Follow-Up. All patients with invasive cervical cancer should be followed up with Pap smearevery 3 months for 2 years after treatment, and then every 6 months for the subsequent 3 years.
• Patients who have a local recurrence can be treated with radiation therapy; if they had received radiation previously, they might be considered candidates for a pelvic exen-teration.
• Patients with distant metastases should be considered for chemotherapy treatment.
The most active chemotherapeutic agent for cervical cancer is cisplatinum.
Cervical Neoplasia in Pregnancy
A 25-year-old woman with intrauterine pregnancy at 14 weeks by dates is referred because of a Pap smear showing as HSIL (high-grade squamous intraepithelial lesion). On pelvic examination there is a gravid uterus consistent with 14 weeks size, and the cervix is grossly normal to visual inspection.
Diagnostic Tests/Findings
• Effect of pregnancy. Pregnancy per se does not predispose to abnormal cytology anddoes not accelerate precancerous lesion progression into invasive carcinoma.
• Colposcopy and biopsy. A patient who is pregnant with an abnormal Pap smearshould be evaluated in the same fashion as when in a nonpregnant state. An abnormal Pap smear is followed with colposcopy with the aid of acetic acid for better visualiza-
tion of the cervix. Any abnormal lesions of the ectocervix are biopsied.
• Perform an ECC? Owing to increased cervical vascularity, ECC is not performed dur-ing pregnancy.
Management
• CIN. Patients with intraepithelial neoplasia or dysplasia should be followed with Papsmear and colposcopy every 3 months during the pregnancy. At 6–8 weeks postpar-tum the patient should be reevaluated with repeat colposcopy and Pap smear. Any persistent lesions can be definitively treated postpartum.
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• Microinvasion. Patients with microinvasive cervical cancer on biopsy during preg-nancy should be evaluated with cone biopsy to ensure no frank invasion. If the cone biopsy specimen shows microinvasive carcinoma during pregnancy, these patients can also be followed conservatively, delivered vaginally, reevaluated, and treated 2 months postpartum.
• Invasive cancer. If the punch biopsy of the cervix reveals frankly invasive carcinoma,then treatment is based on the gestational age.
– In general, if a diagnosis of invasive carcinoma is made before 24 weeks of preg-nancy, the patient should receive definitive treatment (e.g., radical hysterectomy or radiation therapy).
– If the diagnosis is made after 24 weeks of pregnancy, then conservative management up to about 32–33 weeks can be done to allow for fetal maturity to be achieved, at which time cesarean delivery is performed and definite treatment begun.
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Chapter 4 l Disorders of the Cervix and Uterus
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