Migratory cell metastatic adenocarcinoma and precursor lesion adenocarcinoma in situ 8140/2 adenocarcinoma 8140/3 cervical adenocarcinoma, common type 8140/3 mucinous carcinoma, non-specific (NOS) 8480/3 gastric type 8482/3 intestinal type 8144/3 indolent cell type 8490/3 choriocarcinoma 8263/3 endometrioid carcinoma 8380/3 clear cell carcinoma 8310/3 plasmacytoma 8441/3 mesonephric ductal carcinoma 9110/3 mixed adenocarcinoma-neuroendocrine carcinoma 8574/3 benign glandular Epithelial tumors and neoplastic lesions cervical polyps mullerian epithelial papilloma nasal cyst tunnel-like glandular plexus microglandular hyperplasia lobular cervical glandular hyperplasia diffuse laminar cervical duct glandular hyperplasia mesonephric duct remnants and hyperplasia A-S reaction cervical duct endometriosis endometriosis fallopian duct endometrioid chemosis ectopic prostatic tissue other epithelial tumors adenosquamous carcinoma 8560/3 hairy glass cell carcinoma 8015/3 Adenoid basal cell carcinoma 8098/3 adenoid cystic carcinoma 8200/3 undifferentiated carcinoma 8020/3 neuroendocrine tumor low-grade neuroendocrine tumor carcinoid 8240/3 atypical carcinoid 8249/3 high-grade neuroendocrine carcinoma small cell neuroendocrine carcinoma (small cell carcinoma) 8041/3 large cell neuroendocrine carcinoma 8013/3 mesenchymal tumor and aneurysmal lesion benign smooth muscle tumor 8890/0 rhabdomyosarcoma 8905/0 other malignant smooth muscle sarcoma 8890/3 rhabdomyosarcoma 8910/3 adenoid soft tissue sarcoma 9581/3 angiosarcoma 9120/3 malignant peripheral nerve sheath tumor 9540/3 other sarcoma liposarcoma 8850/3 undifferentiated cervical sarcoma 8805/3 ewing sarcoma 9364/3 oncotic lesion post-surgical spindle cell nodule Lymphoma-like lesion mixed epithelial-mesenchymal tumor adenomyoma 8932/0 adenosarcoma 8933/3 carcinosarcoma 8980/3 melanoma blue nevus 8780/0 malignant melanoma 8720/3 germ cell tumor yolk cystic tumor lymphatic and myeloid tumor lymphoma myeloid tumor secondary tumor
(ii) Staging of cervical cancer.
The clinical staging criteria for cervical cancer as modified by the FIGO 2018 meeting are currently used. Clinical staging is determined by gynecologic examination (Table 2). Firstly, the width of horizontal interstitial infiltration is no longer considered in the diagnosis of stage IA. The new version of the criteria only differentiates stage IA1 from stage IA2 according to the depth of interstitial infiltration, mainly because the width may be influenced by human factors. Secondly, the sub-stage of stage IB has been refined, from the original 2 sub-stages to 3 sub-stages, which is more conducive to the selection of postoperative adjuvant therapy and prognosis of patients. The last important change is the inclusion of lymph node metastasis in the staging system, defining lymph node metastasis as stage IIIC, and the addition of evidence labeling for lymph node metastasis (r for imaging lymph node metastasis and p for pathologic confirmation).
Table 2 Clinical staging criteria for cervical cancer of the International Federation of Gynecology and Obstetrics (FIGO 2018)
Staging description Ⅰ Tumor strictly confined to the cervix (extension to the uterine body will be ignored) ⅠA Infiltrating carcinoma diagnosed microscopically only, with a maximum depth of infiltration measured ≤5.0 mm
, the
Vesicular edema cannot be classified as stage IV IVA tumor invading bladder or rectal mucosa IVB tumor spreading to distant organs
VI. Treatment
(A) Treatment modalities of cervical cancer.
Cervical microscopic infiltrating carcinoma (micro-infiltrating carcinoma)
As the determination of stage IA tumor is based on microscopic measurement, the bitten biopsy specimen cannot contain all lesions and cannot measure the extent of lesions, so cone biopsy is required for proper diagnosis.
Extra-fascial total hysterectomy (type I hysterectomy) is feasible for stage IA1 patients without fertility requirements. If the patient has fertility requirements, cervical conization is performed, and patients with negative margins are followed up regularly. Because of the lymph node metastasis rate in stage IA1<1%, lymph node dissection is currently considered unnecessary in stage IA1. If the lymphatic vascular space is invaded, cervical conization (with negative margins) or revisional radical hysterectomy with pelvic lymphadenectomy can be performed.
For stage IA2 cervical cancer, the lymph node metastasis rate is about 3%-5%, and subextensive hysterectomy (type II modified radical hysterectomy) with pelvic lymph node dissection is feasible. For those who want to preserve reproductive function, cervical conization (with negative margins) or radical hysterectomy with pelvic lymph node dissection can be chosen (radical hysterectomy is recommended for patients with reproductive requirements).
Invasive cervical cancer
Stage IB1, IIB2, IIA1: Good prognosis with surgery or radiotherapy.
The surgical approach is type III radical hysterectomy and pelvic lymph node dissection ± abdominal aortic lymph node sampling. The adjuvant postoperative treatment is described as radiation therapy. If the cervical tumor does not exceed 2 cm in diameter, radical hysterectomy with pelvic lymph node dissection ± abdominal aortic lymph node sampling can be chosen for those who require preservation of fertility.
Stage ⅠB3, ⅡA2: the treatment options are: ① Simultaneous radiotherapy.
(2) Radical hysterectomy with pelvic lymph node dissection, abdominal aortic lymph node sampling, and postoperative individualized adjuvant therapy; (3) Surgery after neoadjuvant chemotherapy; (4) Adjuvant hysterectomy after synchronous radiotherapy and chemotherapy. The FIGO guidelines (2018) recommend an additional option for the treatment of locally advanced cervical cancer, namely radical hysterectomy and lymph node dissection after neoadjuvant chemotherapy. The impact of neoadjuvant chemotherapy followed by surgery on the prognosis of patients with cervical cancer is still controversial and is generally recommended in clinical trials or in areas where radiotherapy is not available, especially for pathological types that are relatively insensitive to radiotherapy (e.g. adenocarcinoma).
The overall 5-year survival rate for stage IB is approximately 80%-90%, with only 40%-70% for those with cervical tumors larger than 4 cm in diameter, with high-risk factors such as lymph node metastasis, parametrial invasion, and/or positive cut margins. When choosing treatment for some patients with early-stage cervical cancer, it should be considered that patients with high-risk factors may benefit more from radiotherapy. The standard treatment for locally advanced patients is still considered to be simultaneous radiotherapy.
Stage IIB-IVA: Synchronized radiotherapy (see Radiotherapy and Sensitization Chemotherapy for specific protocols)
 

• IVB<
  

  (ii) Surgical treatment.

Surgical treatment is mainly applied to early-stage cervical cancer, i.e. ⅠA >~IIA stage. The surgery consists of both hysterectomy and lymph node dissection. The extent of resection varies by stage. To better describe the extent of surgical resection, several authors have tried to propose various staging systems for cervical cancer surgery, including the Piver staging and the Q-M staging is the surgical staging system for cervical cancer that is accepted and adopted by most scholars nationally and internationally.

1. Piver surgical staging system

The Piver 5, which was proposed in 1974 . type hysterectomy classification system is still widely used today.

used.

Type I: extrafascial hysterectomy. ［Type I: extrafascial hysterectomy.

patients with lymph-vascular space invasion (LVSI)]

Type II: modified radical hysterectomy that also includes the 1/2 sacral, main ligament, and upper 1/3 vagina. (for patients with stage IA1 with LVSI and stage IA2)

Type III: radical hysterectomy including resection of the main ligament adjacent to the pelvic wall, resection of the sacral ligament from the sacral attachment, and resection of the upper 1/2 vagina. 2 of the vagina. (standard radical hysterectomy for patients with stage IB1, IB2, and selective IB3/IIA1)

Type IV: Extended radical hysterectomy. (for some recurrent patients) Type V: pelvic organ contouring. (for some patients with stage IVA and recurrence) 2. Q-M Surgical staging

In order to more accurately describe the scope of surgery and better individualize the surgical plan, 2008 French experts Querleu and Morrow consulted with anatomists and cervical cancer surgeons from around the world to synthesize a new radical cervical cancer treatment This three-dimensional anatomy-based staging is also known as Q-M staging. In 2015 , the US NCCN guidelines recommended the use of Q-M staging .

Q-M staging includes both surgical staging of the uterus and lymph node dissection grading. The surgical staging relates only to the extent of parametrial resection, which is defined by a fixed anatomic structure.

Type A (minimal paracervical resection type) paracervical tissue is resected to the medial ureter, but the uterosacral ligament and bladder-uterine ligament are largely unresected on the lateral side of the cervix, and the vagina is resected

<1cm, without resection of the paravaginal tissue. (for stage IA1 patients without LVSI) Type B (resection of paracervical tissue up to the ureter) Paracervical tissue resection up to the ureter

Tunnel level, partial excision of the uterosacral and bladder uterine ligaments, no excision of the sacral plexus below the deep uterine vein in the paracervical tissue, and vaginal excision of at least 1 cm (for stage IA1 with LVSI and stage IA2 patients)

B1 as described above

B2 as described above with parametrial lymph node dissection

Type C (resection of paracervical tissue to the junction with the internal iliac vascular system) resection of the cysto-uterine ligament at the level of the bladder, resection of the vagina and associated paravaginal tissue 1.5-2 cm from the tumor or lower edge of the cervix (for IB1, IB2) (for patients with stage IB1, IB2, selective IB3/IIA1)

C1 preserved autonomic nerve C2 not preserved autonomic nerve

Type D (lateral enlarged resection) resection of paracervical tissue up to the pelvic wall, vascularization over the internal iliac vascular system, and exposure of the sciatic nerve root completely free (for some patients with stage IVA and recurrence)

D1 Excision of paracervical tissue to the pelvic wall

D2 As described above, with resection of the inferior abdominal vessels and accessory fascia or muscle tissue (pelvic

expanded resection of the cavity)

Grading of lymph node dissection : The extent of retroperitoneal lymph node dissection, using the artery as an anatomic landmark, is divided into 4 levels. Closed lymph nodes were routinely resected by default. Grade 1 : resection of peri-iliac artery lymph nodes, with Grade 2 demarcated by the bifurcation of the internal and external iliac arteries;< span style="font-family:Times New Roman">Grade 2 : resection of peri-iliac lymph nodes, with Grade 3 demarcated by the bifurcation of the abdominal aorta;Grade 3 : resection of the parietal aortic lymph nodes to the level of the inferior mesenteric artery; Grade 4 : resection of the lymph nodes to the level of the inferior left renal vein of the abdominal aorta .

Postoperative abnormal bladder function, abnormal colorectal motility, and abnormal sexual function due to damage to the pelvic autonomic nerves from radical hysterectomy, radical hysterectomy with preservation of nerves (nerve-sparing radical hysterectomy, NSRH) has been continuously researched and promoted, and NSRH has been used to treat patients with autonomic nerve injury. span style=”font-family:Times New Roman”>NSRH surgery belongs to the Q-M fraction of C1 type radical treatment, NSRH can be accomplished by open, laparoscopic, and robotic laparoscopic routes.

Extrafascial hysterectomy (type I or Type A ) can be done by transvaginal or open or minimally invasive (laparoscopic and robotic laparoscopic) routes. There are now prospective randomized controlled trials showing lower disease-free and overall survival rates with minimally invasive radical hysterectomy compared with open radical hysterectomy.

Lymph node dissection in cervical cancer surgery involves pelvic lymph nodes and abdominal aortic lymph nodes. IA1 (with LVSI) /span>) to IIStage A A should be performed with pelvic lymph node dissection ± abdominal para-aortic lymph node sampling. The study showed that the postoperative pelvic lymph node metastasis rates in patients with stage I and stage II cervical cancer were 0 to 16.5%, respectively. Roman”>0-16.0% and 24.5%-31.0%, respectively. Therefore, selective lymph node dissection according to the status of anterior lymph node metastasis can reduce the incidence of postoperative complications in patients with cervical cancer. The tracers used for sentinel lymph node detection are biological dyes, radioisotopes, and fluorescent dyes, which can be identified by visual recognition, nuclide detection, or infrared light.

detection. Systemic lymph node dissection and localized resection of anterior lymph nodes can be accomplished by open, laparoscopic, and robotic laparoscopic routes.

I-IIA stage squamous cervical cancer has an ovarian metastasis rate of less than 1%, and normal-looking ovaries can be preserved intraoperatively in non-menopausal patients who require preservation of ovarian function. The probability of occult ovarian metastasis in cervical adenocarcinoma is currently considered to be high, so preservation of the ovaries should be done with caution. The preserved ovary can be relocated intraoperatively (e.g., intraperitoneally or high in the retroperitoneal paracolic sulcus) to avoid damage to ovarian function from postoperative pelvic radiotherapy.

In recent years, fertility-preserving surgery has been performed in young patients with early-stage cervical cancer without lymph node metastases who desire fertility. Stage IA1 without LVSI is feasible. Cervical conization with negative margins is feasible, and hysterectomy is feasible if the lesion is extensive; IA1 with LVSI and Stage IA2 patients with viable margins Negative (negative margin width preferably up to 3mm) cervical conization / hysterectomy / =”font-family:Times New Roman”>+ transabdominal or laparoscopic pelvic lymph node dissection ± with abdominal para-aortic lymph node sampling, or radical transabdominal, transvaginal or laparoscopic cervical resection + pelvic

luminal lymph node dissection ± with sampling of the para-aortic lymph nodes in the abdomen; IB1 stage (<2cm) pick

with radical hysterectomy + pelvic lymph node dissection ± abdominal para-aortic lymph node sampling. For IA2 to IB1 period with LVSI and IStage IB2 patients have not yet reached a uniform conclusion on the feasibility of fertility-preserving surgery and need to be considered carefully.

Patients with cervical cancer need to select adjuvant therapy after surgery based on risk factors for recurrence to reduce recurrence rates and improve prognosis, as detailed in the section on principles of radiation therapy.

(iii) Radiation therapy.

Medical institutions that are not qualified for radiotherapy should promptly refer patients who need radiotherapy to medical units that are qualified for it. Patients with cervical cancer who require intracavitary brachytherapy should be advised to seek treatment at

Patients with cervical cancer requiring intracavitary brachytherapy should be advised to consult with the appropriate unit prior to external irradiation to avoid interruption of radiotherapy.

For all stages of cervical cancer. Radiotherapy includes external irradiation and brachytherapy or a combination of the two. Studies have shown that simultaneous radiotherapy improves the efficacy and reduces the risk of recurrence compared with radiotherapy alone. In patients with early-stage cervical cancer, pathological examination after surgery reveals high-risk factors (unclear surgical margins, parametrial invasion, lymph node metastasis, etc.) or intermediate-risk factors (intraoperative / if large tumors, deep interstitial invasion and / or interstitial invasion of the vasculature) need to be supplemented with postoperative adjuvant radiotherapy.

style=”margin-left: 53pt”>
• Principles of radiotherapy
  

The principles of radiotherapy for malignant tumors, like other treatments, are to maximize the killing of cancer cells and to protect normal tissues and vital organs as much as possible, i.e., to maximize the therapeutic effect and minimize complications. Therefore, appropriate treatment tools, appropriate irradiation range, adequate irradiation dose, uniform dose distribution, reasonable irradiation volume, and individual treatment are the basic requirements of radiotherapy.

The duration of radiotherapy completion is a necessary factor for optimal outcomes. The duration of radiotherapy beyond 9

weeks have a higher rate of pelvic control failure than patients treated for less than 7 weeks, and the recommended 56 days to complete all external irradiation and brachytherapy.

When radical radiotherapy is administered, a radical dose of radiation is given to the tumor area, and because of the large area and high dose, treatment should focus on the normal tissues and organs adjacent to the tumor, especially those that are sensitive to radiation. The purpose of palliative radiotherapy is to protect the tumor from the radiation. The purpose of palliative radiotherapy is to alleviate symptoms and reduce patient suffering, but it may not necessarily prolong the survival time of patients. Radical and palliative treatments are relative and can be interchanged during treatment depending on the tumor and the patient’s condition.

If radiotherapy is combined with surgery, the decision to use postoperative radiotherapy depends on the tumor and the patient’s condition. Preoperative radiotherapy is planned to reduce the viability of cancer cells or reduce the chance of implantation and spread; to reduce the extent of tumor and improve the surgical resection rate; to kill subclinical lesions and reduce the local recurrence rate. Postoperative radiotherapy is decided according to the pathological examination results after surgery, and has adverse prognostic factors: if there are any high-risk factors such as unclean surgical margins, parametrial invasion, or lymph node metastasis, postoperative adjuvant radiotherapy is required. If intermediate risk factors such as large tumor, deep mesenchymal invasion and / or interstitial invasion of the vasculature are found after intraoperative /, the patient will be treated according to /. span style=”font-family:Times New Roman”>2015 NCCN guidelines for Sedlis criteria (Table 3), postoperative adjuvant pelvic radiotherapy or radiotherapy is required. If lymph node metastasis, positive cut margins, parametrial infiltration, deep mesenchymal infiltration, large local tumor volume in the cervix, and vascular tumor embolism, postoperative radiotherapy is feasible, and postoperative adjuvant radiotherapy reduces local recurrence and improves outcomes, but the use of both surgery and radiotherapy also increases treatment complications.