What treatment?

Depending on the stage of the disease, the therapeutic management may involve surgery, external radiotherapy, brachytherapy and chemotherapy, alone or in combination. Conservative treatment can be performed in women of childbearing age with cancer with a good prognosis.

All the national and international recommendations insist on the need to address a competent team in oncology-gynecology and to use multidisciplinary consultation meetings. The grouping of different specialists is indeed important for the quality of decisions, diagnoses and techniques (www.esgo.org).< br>

Early stages

Stages Ia, Ib1, Ib2, IIa1 are grouped together.
Treatment is mainly based on surgery. The type of intervention depends on the stage of the disease determined by clinical examination and MRI. Imaging must not have shown suspicious or diseased lymph nodes.

Ia stages
  - The diagnosis must be made on a piece of conization in order to immediately know all the histological characteristics of the cancer (size and presence of lymphovascular emboli in particular).

  - Stage Ia1 without vascular emboli can be treated by simple hysterectomy or conization in a healthy area. This intervention is performed vaginally with a short hospital stay, most often on an outpatient basis.

It is not necessary to take a lymph node sample.

  - Stages Ia1 associated with lymphovascular emboli and stages Ia2.
They can also be treated with a simple hysterectomy or conization in a healthy area.
A lymph node sample is necessary. The intervention begins with this sample and the absence of lymph node involvement is checked by extemporaneous examination.

Stages Ib1, Ib2, IIa1
They are most often treated with surgery, but radiation therapy is an option in older women or women with no anesthetic contraindications to surgery.

The procedure begins with a lymph node sample.
Pelvic dissection, which removes about fifteen lymph nodes from the small pelvis, is the reference technique. However, the sentinel lymph node technique (link to the specific chapter) is now often proposed by trained teams in the event of participation in the SENTICOL III trial (link to the specific chapter).
The lymph nodes removed are examined during the operation (extemporaneous examination).

  - If one or more lymph node metastases are diagnosed (less than 15% of cases), the operation must be stopped (aortic lymph node dissection stopping at the inferior mesenteric artery may be associated). The treatment will be that of the advanced stages (concomitant radio-chemotherapy with utero-vaginal brachytherapy).

  - If the lymph nodes are undamaged, a “wide” or “radical” hysterectomy is performed. The objective is the excision of the tumor of the cervix and a healthy area surrounding it: vagina, parameters. This procedure requires significant training, as it requires extensive dissection of the ureters, pelvic nerves, bladder and rectum. The risk is to make an insufficient intervention (increasing the risk of recurrence), or to cause permanent sequelae (problems of bladder emptying, etc.).

For 20 years, radical hysterectomies have mainly been performed by laparoscopy or robot-assisted laparoscopy. However, a study with a high methodological level showed that survival was better with laparotomy (classic opening of the belly). Most leading teams now use laparotomy for these procedures, especially for cancers measuring between 2 and 4cm. (Ramirez P, New Engl J Med 2018).

Depending on the histological type and the size of the tumour, the ovaries can be preserved.

In the event of a tumor measuring between 2 and 4cm, or when lymphovascular emboli have been diagnosed on the conization, preoperative Brachytherapy can be proposed.

Finally, a conservative treatment (extensive trachelectomy or Dargent procedure) can be proposed in young women, with a tumor measuring less than 2cm and without embolism.

A post-operative treatment is proposed if a tumor finally measuring more than 4cm is found, an attack on a parameter, an attack on the vagina, lympho-vascular emboli, or a significant depth of stromal invasion (all this information come from the final analysis of the uterus and cervix). This treatment can be vagina brachytherapy