Cervical Cancer

The Society of Gynecologic Oncologist of the Philippines

(Foundation), Inc.
Unit 414 Manila Astral Tower
1330 Taft Avenue corner P. Faura Street
Ermita Manila
Telefax No: 526-47-87
Website: http://www.sgop.org

Officers 2008-2010

President Rey H. Delos Reyes, MD, MHSA

Vice-President Gil S. Gonzalez, MD
Secretary Ma. Cynthia F. Tan, MD
Treasurer Ma. Lilibeth L. Sia Su, MD
PRO Mary Christine F. Palma, MD
Immediate Past President Efren J. Domingo,MD, PhD

Board of Directors Teresita B. Cardenas, MD

Benjamin D. Cuenca, MD
Aris Luke I. Dungo, MD
Cecilia L. Llave, MD, PHD
Jericho Thaddeus P. Luna, MD
Manuel S. Manabat, MD,
Concepcion D. Rayel, MD
Rafael S. Tomacruz, MD

Philippine Board of Gynecologic Oncology

Chairman Gil S. Gonzalez, MD
Members Cecilia L. Llave, MD, PhD
Virgilio R. Oblepias, MD

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 Cervical Cancer

II. Malignant Disease

Cervical Cancer
STAGE STATUS TREATMENT
GENERAL GUIDELINES
1. Desirous of pregnancy,
1. Cervical cancer is diagnosed by biopsy1(Benedet 2006). no lymphovascular space
2. Cervical cancer is staged clinically (Appendix C.I)1 invasion(LVSI)
3. If clinically indicated, proctosigmoidoscopy and cystos- a. Negative margins –
copy should be done to rule out invasion. Metastatic observe1,15-19 (Benedetti Panici
work-ups include renal imaging studies (IVP), liver 2007 review)
[Level 1b]
function tests, chest x-ray, and skeletal survey1. b. Positive margins - repeat
4. Special diagnostic imaging studies may be done to cone biopsy1,15-19
guide treatment planning: ultrasound, magnetic reso- [Level 1b]
nance imaging (MRI), computed tomography scan (CT
scan), positron emission tomography scan (PET scan), Stage 0a Good 2. Not desirous of pregnancy
PET CT Scan and bone scintigraphy1. These imaging Stage I A 1a surgical a. Extrafascial hyste-
studies will not be part of the staging risk rectomy (EH) with
a. MRI is more accurate than CT scan in determining or without bilateral sal-
the following2 pingo- oophorectomy
i. Primary tumor volume (± BSO)1,15-19
ii. Vaginal invasion [Level 1b]
iii. Parametrial involvement b. Vaginal extrafascial
iv. Bladder and rectal involvement hysterectomy (± BSO)15
b. PET CT scan is more accurate in determining [Level 1b]
lymph node involvement3 c. If positive for lympho-
c. KUB IVP and barium enema not routinely indicated vascular space invasion
anymore as MRI and CT scan are more accurate2 (LVSI): modified radical
d. Cystoscopy and protosigmoidoscopy should be hysterectomy(± BSO)
reserved for women in whom a normal bladder or with bilateral pelvic
rectum cannot be confirmed on clinical or radiologi- lymph node dissection
cal assessment2 1,15,21(Benedetti Panici 2007 Review,
5. Concurrent chemotherapy and complete radiotherapy Koliopoulous 2007 review
(chemoradiation) is the standard of treatment.4-9 [Level2b]
6. For patients who are unable to receive chemotherapy,
radiation treatment alone may be given10. 1. Negative margins-
7. Adenocarcinomas have shown no significant differ- observe1,15-19 (Benedetti Panici
ence in clinical behavior from squamous cell carcino- 2007 review)
[Level 1b]
mas9,10. 2. Positive margins-
Poor a. Repeat Cone/LEEP 1,15-19
MANAGEMENT
surgical (Benedetti Panici 2007 review)
risk b. Intracavitary Radio-
I. Biopsy Proven Premalignant Lesions11(ASCCP 2006 Guidelines) therapy (Brachytherapy):
High Dose Rate (HDR)
LESION TREATMENT or Low Dose Rate (LDR)
3. Positive LVSI pelvic
SATISFACTORY UNSATISFACTORY EBRT + brachytherapy
COLPOSCOPY COLPOSCOPY [Level 3c]
1. Preceded by Diagnostic Excisional
CIN 1 1. Desirous of pregnancy,
ASCUS, ASC-H, Procedures:
no LVSI
LSIL: Follow up LEEP/CONE11
Radical trachelectomyc
every 6-12 months [Level 3a]
and extra-peritoneal or
11,12(ALTS Follow up study 2003)
Laparoscopic pelvic
[Level 2b]
lymphadenectomy22-24,
2. Preceded by HSIL, Good [Level 2b]
AGC: Follow up surgical 2. Not desirous of pregnancy
every 6 months risk Modified radical hyste-
OR Diagnostic exci- rectomy (MRH), bilateral
sional Procedure11,12 pelvic lymph node dis-
[Level 3b] section (BLND) ± BSO16,24
[Level 1b]
CIN 2,3 1. Cryotherapy11 Diagnostic Excisional Stage IA2
[Level 1a] Procedures: Pelvic External Beam
LEEP/CONE11,13,14 Poor Radiotherapy (EBRT)b
2. Conization: Cold- (Massad 2001/Dunn 2003)
surgical + Brachytherapy
Knife Cone Biopsy [Level 2a] risk [Complete RT] 21 (Koliopoulous 2007)
or LEEP/LLETZ11,13,14 [Level2b]
[Level 1a]

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Cervical Cancer
Notes:
a. Stages 0, IA1 and IA2 are diagnosed by cone biopsy
(cold-knife or LEEP/LLETZ).1
b. Pelvic EBRT includes the upper half of the vagina.
c. Radical vaginal trachelectomy and laparoscopic
extraperitoneal pelvic lymphadenectomy23 inclusion
criteria:
1. Desire to preserve fertility
2. No clinical evidence of impaired fertility
3. FIGO Stage 1a2-1B1
4. Lesion size less than 2 cms
5. No evidence of pelvic lymph node metastasis
6. No LVSI
7. Informed consent
STAGE STATUS TREATMENT
1. Radical hysterectomy
(RH), BLND ± Para-
aortic lymph node
sampling± BSO25-26
[Level 1a]
2. Concurrent chemotherapya
and pelvic EBRT + Brachy
Stage therapy (Chemoradia-
IB1 , IIA Good tion)27,28 [Level 1a]
(tumor surgical 3. Radical Vaginal Hyste-
diameter risk rectomy ± BSO and extra
<4 cms.) peritoneal or laparoscopy
assisted pelvic lympha-
denectomyb 29,30[Level IC]
4. Radical trachelectomyc
and extra-peritoneal or
Laparoscopic pelvic
lymphadenectomy21-24, treatment with radiotherapy:
[Level 2b]
Concurrent chemotherapya
Poor and pelvic EBRT +
surgical Brachytherapy
risk (Chemoradiation)27,28 1. After protracted chemoradiation (>8 weeks)38,41
[Level 1a]
Notes:
a. Standard Chemotherapy drug to use for concur-
rent treatment with radiotherapy:
Cisplatin 40 mg/ m2 given weekly for 6 courses during
pelvic EBRT1,4-9 [Level 1a]
b. PGH Section of Gynecologic Oncology Eligibility
Criteria for Radical Vaginal Hysterectomy:
1. Selected Stage 1B1 IIA (low risk for parametrial or nod-
al metastasis, tumor size less than 2 cm, no evidence
of metastasis by imaging and metastatic work-up)
2. Pelvic organ prolapse
c. Radical vaginal trachelectomy and laparoscopic/
extraperitoneal pelvic lymphadenectomy23 inclu-
sion criteria:
1. Desire to preserve fertility
2. No clinical evidence of impaired fertility
3. FIGO Stage 1a2-1B1
4. Lesion size less than 2 cms
5. No evidence of pelvic lymph node metastasis
6. No LVSI
7. Informed consent
d. May proceed with RHBSO + lymphadenectomy
even with the presence of resectable lymph node
metastasis with uninvolved parametria.31,32
28
STAGE TREATMENT
1. Concurrent chemotherapya and
pelvic EBRT + Brachytherapy
(Chemoradiation)b 6,33-35
[Level 1b]
2. Neoadjuvant chemotherapy
(three rapidly delivered courses
of platinum-based chemotherapy),
followed by RHBLND ± BSO +
adjuvant postoperative radiation
or chemoradiation36,37[Level 1b].
Chemotherapeutic options
include:
a. Cisplatin-Paclitaxel
Stage IB 2 , II A b. Cisplatin – Vinblastine –
(tumor diameter Bleomycin (PVB)
>4 cms) c. Cisplatin – Ifosfamide
3. Pelvic EBRT concurrent with
chemotherapya followed by
RHBSO with selective lympha-
denectomy (Level 2b)38 (Toral 2005)
4. Primary RHBSO and bilateral
pelvic lymphadenectomy, with
adjuvant chemoradiation1,39,40
(type of radiotherapy will be
dependent on the surgico-patho
logic factors) [Level 2B]
Notes
a. Standard chemotherapy drug to use for concurrent
Cisplatin 40 mg/ m2 given weekly for 6 courses during
pelvic EBRT1,4-9 [Level 1a]
b. Surgical intervention (EHBSO or Type II RHBSO)
is an option for the following cases:
(Level 2b)
2. Bulky residual disease (>2 cm) at the end of radia-
tion therapy42,43
c. Pelvic EBRT (with no midline shield) concurrent with
chemotherapy followed by RHBSO with selective
lymphadenectomy is an option especially for areas
with no brachytherapy facilities (consensus-based)
d. Ongoing trial EORTC 55994 : Randomized phase
III study of neoadjuvant chemotherapy (3 courses
cisplatin based) followed by surgery vs. concomi-
tant radiotherapy and chemotherapy in FIGO Ib2,
IIa >4 cm or IIb cervical cancer
STAGE TREATMENT
Concurrent chemotherapya,b and
pelvic EBRT + Brachytherapy
Chemoradiation4-7,9,39,40 [Level 1a]
Paraaortic lymphadenopathy (size
>1.0 cm) by MRI, CT scan or PET
Stage IIB - IV scan confirmed by FNA or extra-
peritoneal or laparoscopic lympha-
denectomy: extended field radio-
therapy (EFRT)+ brachytherapy
+ concurrent cisplatin chemo-
 Cervical Cancer
therapy44-46 [Level 2A] EBRT52[Level 1B]

If with evidence of distant metas- Vaginal cuff Concurrent chemo-

tases on imaging and/or biopsy: or <2 cm therapy, pelvic EBRT
Systemic combination chemo- tumor free and brachytherapy
therapy and individualized radio- margin [consensus-based]
therapy 1[Level 2A]
4. Lymph node Pelvic Concurrent chemo-
Notes: metastasis therapy and pelvic
a. Standard chemotherapy drug to use for concurrent EBRT8,50,52-53 [Level 1B]
treatment with radiotherapy:
Cisplatin 40 mg/ m2 given weekly for 6 courses during Note: If para-aortic
pelvic EBRT1,4-8 [Level 1a] sampling not per-
formed, may do EFRT
b. Other chemotherapy regimens used for concurrent if MRI or CT Scan
treatment with radiotherapy (For locally advanced confirms periaortic
cervical cancer) lymphadenopathy.
1. Carboplatin 300 mg/m2 (AUC 3.9) every 3 weeks
or 60-90mg/m2 (AUC 2) weekly47,48 Para-aortic Concurrent chemo-
2. Cisplatin 40 mg/m2 and Paclitaxel 40 mg/m2 weekly and Common therapyandEFRT29,52-55
for 6 cycles49

iliac [Level 2A]

c. Ongoing trial GOG 219:A Phase III, Randomized 5. Lymphovascu- Concurrent chemotherapy and
Trial of Weekly Cisplatin and Radiation Versus cular space pelvic EBRT30,48,51,52 Delgado1990,
Cisplatin and Tirapazamine and Radiation in Stage

invasion (LVSI) Sedlis 1999, Rotman2006) [Level IB]
IB2, IIA, IIB, IIIB and IVA Cervical Carcinoma Lim-
ited to the Pelvis 6. Endomyome- Concurrent chemotherapy and
trial invasion pelvic EBRT52[Level C]
FINAL HISTOPATHOLOGY REPORT OF CERVICAL
CANCER SPECIMENS: 7. Biopsy proven Systemic chemotherapy and Indivi-
1. Histologic type abdominal dualized radiotherapy52,53
2. Histologic grade

metastasis [Level 2A]
3. Lymphovascular space involvement (LVSI)
4. Parametria CLINICAL SITUATIONS
5. Vaginal cuff – to include distance from tumor to margin
6. Stromal invasion – divided into thirds A. INCIDENTAL FINDING OF INVASIVE CANCER
7. Endomyometrial invasion AFTER SIMPLE HYSTERECTOMY
8. Lymph nodes, to include number and location, 1. Pathologic review
and/or Perinodal fat involvement 2. Chest x-ray
9. Adnexa, if BSO performed 3. CTScan, MRI or PET Scan
10. For MICA, vertical and horizontal invasion in mm 4. Liver function tests
11. For CIN/CIS post-conization (cold-knife or LEEP/ 5. Renal function tests
LLETZ), status of margins and +/- LVSI 6. If tumor size is more than 4 cms: cystoscopy/proctos-
12. Mark a cone specimen at the 12 o’clock position igmoidoscopy
13. No mention of stage of disease in histopathologic
reports Pathologic Review Treatment
Result
SURGICO-PATHOLOGIC PROGNOSTIC FACTORS
Stage 1A1, no LVSI Observation 1 [ Level 2A]
PROGNOSTIC ADJUVANT
FACTORS TREATMENT Stage 1A1 with LVSI, Concurrent chemotherapy
Stage 1A2 and IB1 and pelvic EBRT +
1. Tumor Concurrent chemotherapy and Negative margins, Brachytherapy Chemo-
size >2 cm** pelvic EBRT50,51 [Level Ib: 4 cms] negative imaging studies radiation54 [Level 2A]
Consensus based
Complete parametrectomy
with upper vaginectomy
2. Greater than Concurrent chemotherapy and
with pelvic lymphadenec-
1/3 stromal pelvic EBRT30,50,52 Delgado1990, Sedlis 1999,
tomy +/-paraaortic lymph
invasion Rotman2006)
[Level IB]
node sampling54 [Level 2A]

3. Positive Parametrium Concurrent chemo- Stage 1A1 with LVSI, Concurrent chemotherapy
lines of therapy and pelvic Stage 1A2 and above and pelvic EBRT + Brachy-
resection EBRT52Delgado 1990 Positive margins, gross therapy chemoradiation55
[Level 1B] residual disease, positive [Level 2A]
imaging studies
Surgical Concurrent chemo- If paraaortic lymphadeno-
margins therapy and pelvic pathy: give EFRT55 [Level 2A]

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Cervical Cancer
B. In Association with Pregnancy
MRI may be done to assess extent of disease 10
Age of Early Stage Late Stage
Gestation (Stage I – II A) (Stage II B – IV)
Early Good surgical risk
Pregnancy RHBLND ± BSO10 Primary cases Urinary diversion and/or
up to Chemoradiation10
20 weeks Poor surgical risk
AOG Chemoradiation10
May delay treatment
till after delivery1
20-28 weeks Antepartal Chemoradiation
AOG chemotherapy
(Cisplatin based)
then CS1
Late Good surgical risk
Pregnancy tissue disease Multidisciplinary Team, which
After CS – RHBLND *CS followed by
28 weeks ± BSO1,10 Chemoradiation10
* Perform Poor surgical risk Antepartal
Cesarean CS followed by chemotherapy
Section (CS)10 Chemoradiation56 (Cisplatin based )
at best time then CS56
of fetal
survival
Notes:
1. There is no standard definition on what constitutes
significant treatment delay.1
2. The duration of the treatment delay should be influ-
enced by clinical stage and histopathologic findings
of the tumor, gestational age at diagnosis, and the
parents’ desire regarding their unborn child. Close
clinical surveillance is mandatory.1
3. No long term studies have looked into giving neoadju-
vant chemotherapy in an attempt to prevent disease
progression
4. Delivery should be performed not later than 34 weeks
of gestation.1
OTHER CLINICAL SITUATIONS
Ovarian 1. Age ≤45years old57
conservation [Level 2B]
during radical 2. Early stage disease
surgery in young (up to IIA)57,58 [Level 2B]
patients57 3. Squamous large cell histo-
logy57-58,61-64 [Level 2B]
4. Cervical stromal involve-
ment inner 1/357 [Level 2B]
5. No family history of ovarian
or breast cancer1,58
6. Tumor size ≤2 cm60,62
7. No lymph node metastasis
or LVSI60-64
8. Absence of extracervical/
corpus spread62,63
9. No gross abnormalities in
the ovaries62,63
10. No need for post-
operative radiation57,58,62,63
30
Non-metastatic Exploratory laparotomy
adnexal masses (EL), BSO and appropriate
surgical procedures as
indicated, before chemo-
radiation
Option: Laparoscopy
with urinary stenting followed by primary
obstruction treatment10
Primary cases Medical or surgical decom-
with gut pression followed by
obstruction primary treatment
Hemato-/hydro-/ Drainage by cervical
pyometra dilatation or EHBSO
(post RT)
Connective Patients should be seen by the
(All stages should ideally include a
requiring RT) rheumatologist.
Ideally, patient’s disease
should not be active at the
time of radiotherapy.
PERSISTENT OR RECURRENT DISEASE
PELVIC
With prior surgery, no Chemoradiation1,65
prior radiotherapy [Level 2A]
With prior radio- Appropriate surgery (Type I
therapy, central (Type I or II extended
disease with hysterectomy) may be
tumor size ≤2 cm performed1,66 [Level C] (if
adverse surgico-prognostic
factors are present, adjuvant
chemotherapy should be
instituted)
With prior radiotherapy, Platinum-based chemo-
central disease with therapy or best support-
tumor size > 2 cm and ive care1,44
noncentral disease
With prior chemo- Nonplatinum-based
radiation, central chemotherapy or best
disease with tumor supportive care1,44
size >2 cm and non-
central disease
EXTRAPELVIC OR PARAAORTIC
Multiple sites, Systemic chemotherapy or
unresectable best supportive care1,44,67
[Level 2A]
Isolated site Tumor resection44[ Level 2A]
Tumor directed radiotherapy44
[Level 2A]
Systemic chemotherapy or
best supportive care 1,44,67
[Level 2A]

Notes:
1. Chemotherapy may be given for palliative intent or
symptomatic care. Chemotherapeutic options in-
clude:
SINGLE AGENT1,44,68,69
a. Cisplatin [Level 1B] – 50mg/m2 every 3weeks
b. Carboplatin [Level 1B]-50 mg/m2 every 3 weeks or
400mg/m2 every 3 weeks
c. Topotecan [Level 1B]-1.5mg/m2 days 1-5 every 4
weeks
d. Paclitaxel [Level 1B]- 170 mg/m2 for 24 hours every
3 weeks
COMBINATION CHEMOTHERAPY1,44,68,69
a. Cisplatin – Topotecan [Level 1B]- GOG 179 Cis 50
mg/m2 day 1, Topo 0.75 mg/m2 days 1-3 every 3
weeks
b. Cisplatin – Paclitaxel [Level 1B]- GOG 169 Cis 50 mg/m2
day 1, Pacli 135 mg/m2 24 hours 3 weeks
c. Cisplatin-Ifosfamide [Level 1B] GOG 110 Cis 50 mg/m2
day 1, Ifos: 5 gm/m2/24 hours every 3 weeks
d. Cisplatin – Gemcitabine [Level 2b] Cis 70 mg/m2
day 1, Gemcitabine 1.25 mg/m2 day 1, 8 every 3
weeks
e. Cisplatin- Irinotecan [Level 2b] Cis 50mg/m2, CPT-
11 100mg/m2 every 3 weeks
f. Cisplatin – Vinoralbine [Level 2b] Cis 75 mg/m2 Vin
30 mg/m2 every 4 weeks
g. Carboplatin-Paclitaxel [Level 2b] Carbo AUC 5-6
day pacli 155-175mg /m2 every 4 weeks
h. Topotecan-Paclitaxel [Level 2b] Pacli 175 mg/m2
day 1, topo 1 mg/m2 days 1-5 every 3 weeks
2. Combination regimens are preferred and are first line
therapy if Cisplatin was previously used as a radio-
sensitizer
3. Ongoing Trial GOG204-A Randomized Phase III Study
of Paclitaxel plus Cisplatin Versus Vinorelbine Plus
Cisplatin Versus Gemcitabine Plus Cisplatin Versus
Topotecan Plus Cisplatin in Stage IVB, Recurrent or
Persistent Carcinoma of the Cervix
FOLLOW UP
1. Weekly while on concurrent chemotherapy and radio-
therapy.
2. Two (2) weeks post-completion of brachytherapy.
3. After completion of treatment, recommended follow-up
is as follows:
a. Physical and pelvic exams every 3 months for the
first 2 years, every 6 months from years 3-5, then
yearly thereafter.70
b. Pap smear every three months for the first 2 years,
followed by pap smear every six months for the 3rd
– 5th year, then annual pap smear thereafter.
NOTE: Perform colposcopy with appropriately
guided biopsy and/or ECC, as warranted.
c. Chest x-ray annually or as indicated70.
d. An annual CT scan, MRI or PET scan for the first
3 years post-treatment is recommended, or when
warranted.
4. Use of a vaginal dilator is suggested after radiotherapy
for women who are sexually active70 Denton 2003 systematic review.
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Cervical Cancer
HORMONAL REPLACEMENT THERAPY (HRT) AFTER
TREATMENT OF CERVICAL CANCER
Hormone therapy may be given to symptomatic women
who have been treated for cervical cancer.
1. HRT significantly reduced long term post radiation
rectal, bladder and vaginal complications71
2. There is no evidence that HRT increases risk of sq-
uamous cell carcinoma. For adenocarcinoma, a risk
of recurrence is noted in a descriptive study72.
REFERENCES
1. Benedet JL, Pecorelli, S, Hacker NF, Ngan HYS. Staging Classifications
and Clinical Practice Guidelines of Gynecologic Cancers by FIGO
Committee on Gynecologic Oncology and IGCS Guidelines Committee,
3rd edition, November 2006.
2. Hricak H, Gatsonis C, Chi DS et al. Role of Imaging in the Pretreatment
evaluation of early invasive cancer: Results of the Intergroup Study
American College of Radiology Network 6651 Gynecologic Oncology
Group 183. J Clinical Oncol 2005; 23(36): 9329-9337.
3. Loft A, Berhelsen AK et al. Diagnostic Value of PET/CT in the evaluation
of patients with cervical cancer : A Prospective Study. Gynecol Oncol.
2007 106: 29-34.
4. Whitney CW, Sause W, Bundy BN, et al. Randomized comparison
of 5-Fluorouracil plus Cisplatin versus Hydroxyurea as an adjunct
to radiation therapy in stage IIB-IVA carcinoma of the cervix with
negative para-aortic lymph nodes: A Gynecologic Oncology Group
and Southwest Oncology Group Study. Journal of Clinical Oncology
1999; 17:1339-1348.
5. Rose PG, Bundy BN, Watkins EB, et al. Concurrent Cisplatin-based
chemotherapy and radiotherapy for locally advanced cervical cancer.
New England Journal of Medicine 1999; 340:1144-1153.
6. Keys HM, Bundy BN, Stehman FB, et al. Cisplatin, radiation, and
adjuvant hysterectomy for bulky stage IB cervical carcinoma. New
England Journal of Medicine 1999; 340:1154-1161.
7. Morris M, Eifel PJ, Lu J, et al. Pelvic radiation with concurrent
chemotherapy compared with pelvic and para-aortic radiation for
high-risk cervical cancer. New England Journal of Medicine 1999;
340:1137-1143.
8. Peters WAI, Liu PY, Barrett R, et al. Cisplatin, 5-Fluorouracil plus
radiation therapy are superior to radiation therapy as adjunctive
therapy in high risk, early stage carcinoma of the cervix after radical
hysterectomy and pelvic lymphadenectomy: Report of a phase III
intergroup study. Gynecologic Oncology 1999; 72:443.
9. Lehman M, Thomas G. Is concurrent chemotherapy and radiotherapy
the new standard of care for locally advanced cervical cancer?.
International Journal of Gynecological Cancer 2001; 11:87-89.
10. Di Saia P and Creasman W. Clinical Gynecologic Oncology, 6th edition
2007
11. Wright TC, Massad LS, Dunton CJ et al. 2006 Consensus Guidelines
for the Management of Women with Cervical Intraepithelial Neoplasia or
Adenocarcinoma in Situ. American Journal of Obstet Gynecol October
2007; 340-345
12. Cox JT, Schiffman M, Solomon D. Prospective follow-up suggests
similar risk of subsequent cervical intraepithelial neoplasia grade 2
or 3 among women with cervical intraepithelial neoplasia grade 1
or negative colposcopy and directed biopsy. Am J Obstet Gynecol
2003;188:1406-12.
13. Massad LS, Collins YC, Meyer PM. Biopsy correlates of abnormal
cervical cytology classified using the Bethesda system. Gynecol Oncol
2001;82:516-22.
14. Dunn TS, Burke M, Shwayder J. A “see and treat” management for
high-grade squamous intraepithelial lesion pap smears. J Low Genit
Tract Dis 2003;7:104-6.
15. Benedetti Panici P, Palaia I et al. Conservative Approaches in Early
Stages of Cervical Cancer. Gynecol Oncol 2007 107:S13-S15.
16. Kolstad P. et al Follow-up study of 232 patients with stage Ia1 and
411 patients with stage Ia squamous cell carcinoma of the cervix
(microinvasive carcinoma). Gynecol Oncol Jun 1989;33(3):265–72.
17. Morris M, Follen M, Silva EG, Copeland LJ, Gershenson DM. Cervical
conization as definitive therapy for early invasive squamous carcinoma
31
Cervical Cancer
of the cervix. Gynecol Oncol Nov 1993;51(2):193–6.
18. Tseng, Horng S, Soong Y, Hsueh S, Hsieh C, Lin H. Conservative
conization for microinvasive carcinoma of the cervix. Am J Obstet
Gynecol 1997;176(5):1009–10.
19. Raspagliesi F, Ditto A, Quattrone P, Solima E, Fontanelli R, Dousias V,
et al Prognostic factors in microinvasive cervical squamous cell cancer:
long-term results. Int J Gynecol Cancer Jan–Feb 2005;15(1):88–93.
20. Ostor AG. Studies of 200 cases of early squamous cell carcinoma of
the cervix. Int J Gynecol Pathol 1993; 12:193-207.
21. Koliopoulos G, Sotiriadis A, Kyrgiou M, et al. Conservative surgical
methods for FIGO stage IA2 squamous cervical carcinoma and their
role in preserving women's fertility. Gynecol Oncol 2004;93:469–473.
22. Roy M, Plante M. Pregnancies after radical vaginal trachelectomy
for early-stage cervical cancer. American Journal of Obstetrics and
Gynecology 1998; 179(6):1491-1496.
23. Shepherd JH, Spencer C Herod J et al. Radical Vaginal Trachelectomy
as a Fertility Sparing Procedure in Women with Early Stage Cervical
Cancer . BJOG 2006; 113: 719-724
24. Dargent D, Martin X, Sacchetoni A, Mathevet P. Laparoscopic vaginal
radical trachelectomy: a treatment to preserve the fertility of cervical
carcinoma patients. Cancer Apr 15 2000;88(8):1877–82.
25. Landoni F, Maneo A, Cormio G, Perego P, Milani R, Caruso O, and
Mangioni C. Class II versus Class III radical hysterectomy in stage IB-
IIA cervical cancer: A prospective randomized study. Gynecol Oncol
2001; 80:3-12.
26. Landoni F, Maneo A, Colombo A et al. Randomized study of radical
surgery versus radiotherapy for stage IB-IIA cervical cancer. Lancet
1997; 350:535-540.
27. Peters W, Liu P, Barrett R, Stock R, Monk B, Berek J, Souhami L,
Grigsby P, Gordon W, and Alberts D. Concurrent chemotherapy and
pelvic radiation therapy compared with pelvic radiation therapy alone
as adjuvant therapy after radical surgery in high-risk early-stage cancer
of the cervix. Journal of clinical Oncology 2000; 18(8):1606-1613.
28. Sedlis A, Bundy B, Rotman M, Lentz S, Muderspach L, and Zaino, R.
A randomized trial of pelvic radiation therapy versus no further therapy
in selected patients with stage 1B carcinoma of the cervix after radical
hysterectomy and pelvic lymphadenectomy: A Gynecologic Oncology
Group Study. Gynecologic Oncology 1999; 73:177-183.
29. Dargent D. A New Future for Schauta’s Operation through a
retroperitoneal Pelviscopy. Eur J Gynecol Oncol 1987; 8:292-296
30. Steed H, Rosen B, MurphybJ. A comparison of laparoscopic assisted
Radical Vaginal Hysterectomy and Radical Abdominal Hysterectomy in
the Treatment of Cervical Cancer. Gynecol Oncol 2004; 93:588-593.
31. Kenter GG, Hellebrekers WJ et al. The case for completing the
lymphadenectomy when positive lymph nodes are found during radical
hysterectomy for cervical carcinoma. Acta Obstet Gynecol Scand 2000
79:72-76.
32. Richard SD, Krivak TC et al. Survival for stage 1B Cervical cancer
with positive lymph node involvement a comparison of completed vs
abandoned radical hysterectomy. Gynecol Oncol 2008: 43-48
33. Keys H, Bundy B, Stehman F, Okagaki T, Gallup D, Burnett A, Rotman
M and Fowler W. Radiation therapy with and without extrafascial
hysterectomy for bulky stage IB cervical carcinoma: a randomized
trial of the Gynecologic Oncology Group. Gynecologic Oncology 2003;
89:343-353.
34. DeJonge ET, Falkson G, Burger W, Schoeman L, Lindeque BG.
Neoadjuvant Cisplatin plus Ifosfamide in patients with stage II B
Cervical Cancer: A single center phase II study. International Journal
of Gynecologic Cancer 1997; 7:158-162.
35. Landoni F, et al. Randomized multicenter phase II trial of neoadjuvant
chemotherapy in the treatment of locally advanced squamous cervical
carcinoma: comparison of Cisplatin, Ifosfamide (IP) vs Paclitaxel,
Cisplatin, Ifosfamide (TIP). Presented at the 12th International Meeting
of the European Society of Gynecologic Oncologists, April 21-24, 2001,
Venice, Italy.
36. Sardi J, Sananes C, Giaroli A, Bayo J, Gomez RN, Vighi S, et al. Results
of a prospective randomized trial with neoadjuvant chemotherapy
in stage IB, bulky squamous carcinoma of the cervix. Gynecologic
Oncology 1993; 49:156 -165.
37. Neoadjuvant chemotherapy for Cervical Cancer Meta-analysis
Collaboration. Neoadjuvant chemotherapy for locally advanced cervical
cancer: a systematic review and meta-analysis of individual patient
data from 21 randomised trials. European Journal of Cancer 2003;
39: 2470-2486.
32
38. Toral JA , Luna JT . Treatment outcomes of Stage 1B2 and Bulky IIA
cervical Cancer at a Tertiary Institution Using four different multimodality
protocols: A retrospective cohort study. Philippine J of Oncol 4(2): 33-46
39. Trimbos J, Lambeck A, Peters A, Wolterbeck R, Gaarenstroom K,
Fleuren G and Kenter G. Prognostic difference of surgical treatment
of exophytic versus barrel-shaped bulky cervical cancer. Gynecologic
Oncology 2004; 95:77-81.
40. Rutledge T, Kamelle S, Tillmanns T, Gould N, Wright J, Cohn D, Herzog
T, Rader J, Gold M, Johnson G, Walker J, Mannel R and McMeeken
S. A comparison of stages IB1 and IB2 cervical cancers treated with
radical hysterectomy. Is size the real difference? Gynecologic Oncology
2004; 95:70-76.
41. Decker MA, Burke J et al. Completion hysterectomy after radiation
therapy for bulky cervical cancer stages IB, IIA and IIB: complications
and survival rates. Am J of obstet Gynecol 2004 191:654-660
42. Morice P, Uzan C et al. The role of surgery after chemoradiation therapy
and brachytherapy for stage IB2/II cervical cancer. Gynecol Oncol 2007
102: S122-S124.
43. Classe JM, Rauch P et al. Surgery after concurrent chemotherapy and
brachytherapy for the treatment of advanced cervical cancer results of
a multicenter study. Gynecol Oncol 2006 :102:523-529
44. National Comprehensive Cancer Network Guidelines for Cervical
cancer. Version 1 2008. Accessed March 15, 2008.
45. Varia M, Bundy B, Deppe G, Mannel R, Averette H, Rose P, and
Connelly P. Cervical carcinoma metastatic to para-aortic nodes:
extended field radiation therapy with concomitant 5-fluorouracil and
cisplatin chemotherapy: A Gynecologic Oncology Group Study.
International Journal of Radiation Oncology 1998; 42(5):1015-1023.
46. Grigsby P, Lu J, Mutch D, Kim R, and Eifel P. Twice-daily fractionation of
external irradiation with brachytherapy and chemotherapy in carcinoma
of the cervix with positive para-aortic lymph nodes: Phase II study of
the radiation therapy oncology group 92-10. Int. J. Radiation Oncology
Biol. Phys. 1998; 41(4):817-822.
47. Higgins RV, Naumann WR et al. Concurrent carboplatin with pelvic
radiation therapy in the primary treatment of cervix cancer. Gynecol
Oncol 2003 89:499-503
48. Dubay RA, Rose PG et al. Evaluation of concurrent and adjuvant
carboplatin with radiation therapy for locally advanced cervical cancer.
Gynecol Oncol 2004 94 :121-124
49. Disilvestro PA, Walker JL et al. Radiation therapy with concomitant
paclitaxel and cisplatin chemotherapy in cervical carcinoma limited
to the pelvis: A phase I/II study of the Gynecologic Oncology group.
Gynecol Oncol 2006 103:1038-1042
50. Rotman M, Sedlis A , Piedmonte MA et al. A Phase III randomized trial
of postoperative pelvic irradiation in stage IB cervical carcinoma with
poor prognostic features: Follow up of a gynecologic Oncology Group
study. Int J Radiation Oncology Biol Phys 65(1):169-176.
51. Chernofsky MR, Felix JC , et al. Influence of quantity of lymphovascular
space invasion on time to recurrence in women with early stage
squamous cancer of the cervix. Gynecol Oncol 2006 100:288-293
52. Delgado G, Bundy B, Zaino R, Sevin BU, Creasman W and Major
F. Prospective surgical-pathological study of disease-free interval
in patients with Stage IB squamous cell carcinoma of the cervix: a
Gynecologic Oncology Group study. Gynecologic Oncology 1990;
38:352-357.
53. Zhang. Prognostic factors of stage IB and IIB carcinoma of the cervix
treated by surgery. Liu Za Zhi 2004; 26(8):490-492.
54. Kinney WK, Egorshin EV. Long term survival and sequelae after
Surgical Management of Invasive Cervical Carcinoma diagnosed at
the time of simple Hysterectomy. Gynecol Oncol 1992; 44:22-27
55. Hopkins MOP, Peters WA Invasive Cervical Cancer treated initially by
Standard Hysterectomy. Gynecol Oncol 1990; 36:7-12
56. Tewari K, Cappuccini F et al. Advanced Cervical Carcinoma Associated
with Pregnancy. Int J Gynecol Cancer 1993: 3:57-63
57. Landoni F, Zanagnolo V, et al. Ovarian Metastases in Early Stage
Cervical Cancer: A Multicenter Retrospective Study of 1965 patients (A
cooperative Task Force Study ) Int J Gynecol Cancer 2007 17:623-628
58. Huevos A, Toral, JA. Criteria for retention of the ovaries in cervical
cancer primarily managed by radical hysterectomy. The section of
Gynecologic Oncology Bulletin 2004; 1(1):2-4.
59. Morice P, Juncker L, Rey A, El-Hassan J, Haide-Meder C, Castaign
D. Ovarian transposition for patients with cervical carcinoma treated
by radiosurgical combination. Fertility and Sterility 2000; 74(4):743-
748.
 Cervical Cancer
60. Yamamoto R, Okamoto K, Yukiharo T, Kaneuchi M, Negishi H,
Sakugari N, Fujimoto S. A study of risk factors for ovarian metastases
in Stage IB-IIIB cervical carcinoma and analysis of ovarian function
after transposition. Gynecol Oncol 2001; 82:312-316.
61. Tabata M, ichinoe K, Sakuragi N, Shina Y, Yamaguchi T, Mabuchi Y.
Incidence of ovarian metastasis in patients with cancer of the uterine
cervix. Gynecol Oncol 1986; 28:255-261.
62. Sutton GP, Bundy BN, Delgado G, Sevin BU, Creasman W, Major FJ, Zaino
R. Ovarian metastases in stage IB carcinoma of the cervix: A Gynecologic
Oncology Group study. Am J Obstet Gynecol 1992; 166:50-53.
63. Young RH, Gersell DJ, Roth LM, Scully RE. Ovarian metastases from
cervical carcinomas other than pure adenocarcinomas. Cancer 1993;
71:407-418.
64. Nakanishi T, Wakai K, Ishikawa H, Nawa A, Suzuki Y, Nakamura S,
Kuzuya K. A comparison of ovarian metastases between squamous
cell carcinoma and adenocarcinoma of the uterine cervix. Gynecol
Oncol 2001; 82:504-509.
65. Thomas GM, Dembo AJ, Black B et al. Concurrent radiation and
chemotherapy for carcinoma of the cervix recurrent after radical surgery.
Gynecol Oncol 1987; 27:254-260.
66. Maneo A, Landoni F, Cormio G et al. Radical hysterectomy for recurrent
or persistent cervical cancer following radiation therapy. Int J gynecol
Cancer 1999; 9:295-301
67. Moore DH, Mcquellon RP, Blessing JA, Benda J, Miller DS, Olt G, King
S, Boggess JF, Rocereto TF. A randomized phase III study of Cisplatin
versus Cisplatin plus Paclitaxel in Stage IV B recurrent or persistent
squamous cell carcinoma of the cervix. Society of Gynecologic
Oncologists Abstracts. 2001 Society of Gynecologic Oncologists Meeting.
68. Cadron I ,Vergote, I , Van Gorp T. Chemotherapy for recurrent cervical
cancer. 2007 107:S113-118
69. Hirte HW, Strychowsky JE, Oliver S et al. Chemotherapy for recurrent,
metastatic, or persistent cervical cancer: a systematic review. Int J
Gynecol Cancer 2007;17:1194-1204.
70. Bodurka –Bevers D, Morris M, Eifel PJ . Post therapy surveillance of
women with cervical cancer . An outcomes analysis. Gynecol Oncol
2000 78:187-193
71. Denton AS. Interventions for the physical aspects of sexual dysfunction
in women following pelvic radiotherapy. Cochrane Database of
Systematic Reviews 2003 Issue 1
72. Ploch E. Hormonal replacement therapy in patients after cervical cancer
treatment. Gynecol Oncol. 1987 Feb;26(2):169-77.
73. Lacey J.V.; Brinton L.A.; Barnes W.A.; et al. Use of Hormone
Replacement Therapy and Adenocarcinomas and Squamous Cell
Carcinomas of the Uterine Cervix Gynecol Oncol 2000 77( 1) : 149-154.
74. Sotto LSJ, Manalo AM, Limson GM. Gynecologic oncology for the
clinician, 2nd edition, 1994:68.

Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 33
Cervical Cancer
Available Drugs in the Philippines

Antineoplastics

Alkaylating Agents
Cisplatin
Docistin
Kemoplat
Nippon Kayaku Cisplatin
Platamine
Platinol

Pyrimidine analogs
(Pyrimidine antagonists)
Gemcitabine
Gemita
Gemzar

Other cytotoxic antibiotics

Bleomycin sulfate
Blenoxane

Mitotic Inhibitors
Vinca Alkaloids
Vinorelbine
Vinotel

Camptothecins
Topotecan HCl
Topotel

Taxanes
Paclitaxel
Biomedis Paclitaxel
Intaxel
Paclitaxin
Paxus
Sandoz Paclitaxel
Taxol

Irinotecan
Biomedis Irinotecan
Campto
Irican

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