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GYN > Cervical Cancer > Flashcards

Cervical Cancer Flashcards

1
Q

Describe cervical cancer screening recommendations

A
  • 21-29- PAP smears Q 3 years
  • > 30 PAP and HPV contesting Q5 years, or PAP every 3 years
  • No further testing if after >65 if 3 negative PAPs in a row or 2 negative PAP and contesting
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2
Q

What is the most common site for carcinogenesis of the cervix

A

Ectocervix, squamno-columnar junction at external os

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3
Q

What cells line the ectocervix

A

Squamous epithelium

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4
Q

Describe LN drainage in cervical cancer

A

Obturator , internal iliac, external iliacs , presacral, common iliac, para aortic

External iliacs via round ligament
presacral and common iliacs via uterosacral ligament

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5
Q

What is the most common site of distant spread

A

Lungs, supraclav, bone

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6
Q

Describe staging of cervical cancer

A

Stage I: confined to cevix
1a: <5mm depth of invasion
1a1: <3
1a2: 3-5mm

Ib: : > 5 mm of invasion
1b1: 2-4 cm
1b2: < 4 cm
1b3: > 4m

Stage II:
IIa: proximal 2/3 vagina
IIa1:<4 cm
IIa2:>4 cm

IIb: parametrial invasion

III
IIIa: distal 1/3 vagina
IIIb:pelvic side wall or hydro
IIIc:
IIIc1: pelvic nodes
IIIc2: paraaortic nodes

IVa: invades adjacent organs
IVb: distant mets

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7
Q

Describe the incidence of cervical cancer histologies

A

70% SCC
30% adeno

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8
Q

What is removed in a trachelectomy

A

Usually done in HSIL, IA1-1B1 < 2 cm

  1. Cervix
  2. small portion of the vagina (not more than 25-50% upper vagina)
  3. Bladder and rectum mobilized to peritoneal reflection
  4. Uterus and ovaries are spared
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9
Q

WHat is removed in a simple/extrafascilar hysterectomy

A

Usually done in stage IA1 cervical cancer or endometrial cancer (BSO)

  1. cervix is moved
  2. uterus is removed
  3. ovaries may be removed
  4. vaginal margin 1-2 mm
  5. Bladder is mobilised to base of cervix
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10
Q

What is removed in a modified radical hysterectomy

A

Usually done with 1A1 with LVSI or IA2
or in endometrial cancer with cervix involved

  1. Cervix is removed
  2. Uterus is emoved
  3. ovaries can be removed
  4. vaginal margin is 1-2 cm
  5. Ureters tunnel through broad ligament
  6. Bladder is immobilized to upper vagina
    uterine artery is ligated at ureter
    uterosacral ligaments are partially resected
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11
Q

What is removed in a radical hysterectomy

A

Done for IB1-2, IIA1
1. Cervix is removed
2. Uterus is removed
3. ovaries maybe removed
4. upper 25-50% of the vagina are removed
5. Ureters are tunneled through the braod ligament
6. Bladder is mobilized to middle vagina
7. Uterine artery is ligated at internal iliacs

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12
Q

What is the treatment for stage 1A1

A

Fertility sparing treatments include:
1. cold knife conization with 3 mm margins with the addition of a PLND if there is LVSI
2. radical trachelectomy

Non fertility sparing treament:
1. Extrafascial/simple hysterectomy or a modified radical hysterectomy with PLND
2. Brachytherapy alone

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13
Q

What is the treatment for stage 1A2

A

Fertility sparing tx:
1. cold knif 3 mm margins with PLND
2. Radical trachelectomy+PLND

Non fertility sparing tx:
1. Modified radical hysterectomy+PLND
2. Pelvic EBRT + brahcy (+/- chemo if high risk features)

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14
Q

What is the treatment for 1B1, 1B2, IIA1

A

Radical hysterectomy (Class III) + PLNDx (+/- PALNS)
Definitive EBRT + brachytherapy +/- concurrent CHT

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15
Q

What is the testament for IIA2 to IVA?

A

Definitive EBRT + brachytherapy + concurrent CHT

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16
Q

Benefits of surgery over radiation:

A
  1. Additional pathologic information is gained by surgical pathology
  2. Preserved ovarian function
  3. No secondary malignancy risk
  4. Improved sexual functioning, vaginal stenosis, vaginal dryness
  5. Improved late GI toxicity
  6. Shorter treatment time (one-and-done)
  7. Psychologically easier for patients to comprehend surgery than radiation
17
Q

What is the time frame during which all RT should be given by

A

7-8 weeks

18
Q

What are the benefits of IMRT

A

IMRT has less acute and late GI toxicity and less heme toxicity than 3D RT for cervix cancer

19
Q

Describe the volumes in a cervical cancer tx plan

A

CTV4500/25fx = pelvis (uterus + cervix + parametria + 2-3cm vaginal margin + lymph nodes)

CTV5500/25fx = boost involved parametria

CTV5625/25fx = boost involved lymph nodes + 0.3cm

20
Q

Desribe the contouring process

A
  • CTV1: GTV, cervix, entire uterus
  • CTV2: Parametria and superior vagina (2cm below most inferior extent)
  • CTV3: Common, external and internal iliac, and presacral nodes; 7 mm margin around the vessels, excluding adjacent bowel, bone, or muscle
    o Upper border: aortic bifurcation (L4-L5 interspace in 2D era)
    o Presacral nodes to S2-S3 interspace
    o External iliac nodes to top of femoral heads

*include posterior 1cm of bladder and anterior rectum

21
Q

How does contouring process change if common iliacs are invovled

A

add para-aortics up to L1/2

22
Q

How does contouring process change if paraaortics are involved

A

add para-aortics up to T11/12

23
Q

How does contoring change of distal 1/3 vagina involvement

A

add inguinals

24
Q

What workup must be completed prior to brachy

A

Perform physical examination and obtain MRI prior to brachytherapy to assist w/ planning

25
Q

What is the brachy dose

A

30Gy/5fx (EQD2 80-90Gy) to HR-CTV

28Gy/4fx delivering 1-2 fractions weekly,
interdigitated/after EBRT

26
Q

What are brachy coverage goals

A
  1. HRCTV (EQD2 80-90Gy = 6Gy x 5fx) = cervix + GTV at time of brachy
  2. If <4cm residual disease, can consider EQD2 ≥80Gy (5.5Gy x 5fx)
  3. IRCTV (EQD2 60Gy = 5Gy x 5fx) = HRCTV + 2mm; uterine canal
    * D90%>90%
27
Q

How to choose tandem and ovoids/ring

A

Largest ovoids that will fit – lower mucosal dose and better dose depth distribution

Tandem and ring – use if no fornices due to effacement of cervix w/ tumor involvement; better
dose distribution (in general) than tandem and ovoids (EMBRACE)

28
Q

Describe dose constraints in brachy

A

D2cc
Rectum-65Gy
Sigmoid- 70 Gy
Bladder- 80 Gy

29
Q

Describe how to assess for a proper implant in brachy

A

Assessing cervical brachytherapy implant quality – improper implants and packing 
worse DFS and LRC
2022 Resident Study Guide – LKM, DAC, HCG GYNECOLOGY 75
* Tandem should be midway between the ovoids or located mid-ring on AP and lateral
images
* Ovoids should be symmetrical and at the level of the cervical os tandem flange
* There should be absolutely no packing superior to the ovoids

30
Q

How is chemotherapy given

A

Weekly cisplatin 40mg/m2 IV for 5-6 cycles

31
Q

What are some chemotherapy alternatives

A

cisplatin/5-FU, cisplatin/gemcitabine, cisplatin/bevacizumab

32
Q

Should we do chemo adjvuantly following definitive chemoRT

A

Outback carboplatin/paclitaxel x4 cycles following definitive chemoRT demonstrated no OS
benefit and is currently not standard of care (OUTBACK).

33
Q

Who should get adjuvant RT after surgery

A

Sedlis criteria (GOG 92) for adjuvant radiation – any 2 of the following:
1. LVSI
2. Middle/deep 1/3 stromal invasion
3. Tumor size ≥ 4.0cm
* Adenocarcinoma or adenosquamous histology

34
Q

Who should get adjuvant chemoRT after surgery

A

Peters criteria (GOG 109) for adjuvant chemoradiation – any 1 of the following:
1. Positive margins
2. Parametrial involvement
3. Positive lymph nodes
*Note that adjuvant chemoRT improved OS in these patients.

35
Q

Who should get vaginal brachy boost and what is the dose

A

close/positive vaginal margin or deep 1/3 stromal invasion

45Gy/25fx EBRT as above +/- 10Gy/2fx (to 5mm)(or 12Gy/2fx to surface) vaginal cuff brachytherapy

36
Q

What does followup entail

A

PET/CT should be obtained at 3mos s/p definitive RT or chemoRT to assess response (predictive of OS)

Partial response consider additional interval PET vs. biopsy, consider completion surgery

Distant metastases, then chemotherapy

37
Q

What are cervical cancer outcomes

A

Surgery + Adjuvant RT (IA-II)– 5-yr OS 80-90% (GOG 92, 109)

Definitive chemoRT (IIB-IVA) – 8-yr OS 70%, DFS 60% (RTOG 9001)

GYN (4 decks)

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