MKSAP Quiz: Consultation after cervical cancer diagnosis
A 34-year-old woman undergoes consultation after a recent diagnosis of stage IB cervical cancer. She is nulliparous, and she and her partner are hoping to have children. Following a biopsy, what is the most appropriate treatment?
A 34-year-old woman undergoes consultation after a recent diagnosis of stage IB cervical cancer. She is nulliparous, and she and her partner are hoping to have children. Medical history is unremarkable, and she takes no medications.
Colposcopy-directed biopsy of the cervix revealed squamous cell carcinoma with invasion to 6 mm in depth. There is no radiographic evidence of pelvic or abdominal adenopathy and no evidence of distant metastatic disease.
Which of the following is the most appropriate treatment?
A. Concurrent radiation therapy and cisplatin
B. Continuous progestin therapy
C. Fertility-preserving surgery
D. Hysterectomy and pelvic node dissection
MKSAP Answer and Critique
The correct answer is C. Fertility-preserving surgery. This content is available to MKSAP subscribers as Question 50 in the Oncology section. More information about MKSAP is available online.
The most appropriate treatment is fertility-preserving surgery (Option C). This patient has early-stage and low-risk disease, and large case series have demonstrated that radical trachelectomy (in which the cervix is removed) and cervical conization are both effective procedures associated with low risks of recurrence. The choice between trachelectomy and conization is determined by depth of microscopic invasion, among other factors. Only select patients with low-risk disease are appropriate candidates for these procedures. Large series have demonstrated that pregnancy rates are approximately 50%, and many women may become pregnant spontaneously.
Concurrent radiation therapy and cisplatin (Option A) is recommended for patients with stage III cervical cancer but not for patients with stage I cervical cancer. This treatment is associated with greater morbidity and is reserved for patients with greater risks of locoregional and distant recurrence with higher-stage disease. Furthermore, chemoradiation is not a fertility-sparing approach, and this patient wishes to preserve fertility.
Continuous progestin therapy (Option B) may be used as a fertility-sparing approach for select patients with early-stage endometrial cancer but is not a treatment for cervical cancer. Cervical cancer is generally not an endocrine-sensitive cancer, and systemic therapy focuses mostly on the use of chemotherapy.
Hysterectomy and pelvic node dissection (Option D) is appropriate treatment for cervical cancer but does not preserve fertility. This patient could undergo a trachelectomy or cone biopsy with the aim of preserving her fertility. It is appropriate to counsel the patient about both options to inform her regarding the potential risks and benefits of each approach.
Key Point
- For patients with early-stage, low-risk cervical cancer, fertility-sparing surgeries are options.