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).