Expert consensus
After induction chemotherapy (3 cycles) re-assessment including cystoscopy, vaginoscopy, and bimanual digital rectal examination under general anesthesia is carried out. Additionally, an MRI scan of the abdomen and pelvis is recommended as described for vaginal tumors. Re-assessment is repeated again after 6 cycles of chemotherapy by endoscopy. Follow-up by ultrasound can be carried out in between to assess response.
If there is no visible residual tumor on imaging, endoscopic biopsies of the cervix, with or without hysteroscopy depending on tumor location, should be obtained. This utilization of biopsies even for patients in CR on imaging is different than the approach for patients with vaginal primaries. If there is no histological evidence of disease, local therapy can be omitted, but patients require a close follow-up (authors opinion: every 3 months for the first 2 years, then every 6 months for the next 3 years). All other cases of uterine RMS require delayed conservative surgical resection and/or RT (with EBRT, proton beam or BT). Residual tumors located at the cervix uteri (especially polypoid lesions) may be treated by partial or total resection of the cervix. Organ preservation is often feasible in combination with BT or EBRT/proton beam therapy. Another surgical option is trachelectomy, in which the cervix and the upper part of the vagina are resected en-bloc and an anastomosis between the persisting uterus and vagina is carried out. Trachelectomy can be performed using an open abdominal or laparoscopic approach.
Brachytherapy is carried out as described previously using individual vaginal molds with a brachytherapy tube placed into the cervix uteri. The uterus may not be functional after irradiation, depending on the uterine length and the length of dwell positions within intra-cervical catheter. Ovarian transposition should be offered to patients treated with brachytherapy for cervical disease (see fertility preservation section below).