A 29-year-old woman who desires future fertility undergoes colposcopy-directed biopsy showing squamous cell carcinoma with stromal invasion measuring 2 mm and horizontal spread of 5 mm. Endocervical curettage is negative and no lymphovascular space invasion is seen. What is the most appropriate management?

• A Radical hysterectomy with pelvic lymphadenectomy
• B Simple hysterectomy followed by vault brachytherapy
• C Radical trachelectomy with pelvic lymphadenectomy
• D Cold knife conization with clear margins alone ✓

Explanation

The tumour is FIGO Stage IA1 (stromal invasion up to 3 mm, horizontal spread up to 7 mm). For IA1 without lymphovascular space invasion, the risk of lymph node metastasis is under 1 percent, so a cone biopsy with clear margins is sufficient even when fertility preservation is desired, provided endocervical margins are negative. Radical surgery and trachelectomy overtreat this stage; the low nodal risk is what eliminates option C.

Reference: Williams Gynecology, 4th ed.

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