Cervical cancer

Question 1

What is the annual incidence of cervical cancer in the United States?

Answer 1

∼12,000 cases/yr of cervical cancer in the United States.

Question 2

What is the mean age of presentation for cervical cancer?

Answer 2

The mean age of presentation for cervical cancer is in the 40s in the United States.

Question 3

List the 7 lifestyle factors associated with an increased risk of cervical cancer.

Answer 3

Lifestyle factors associated with increased risk of cervical cancer:

1. Early onset of sexual activity
2. Larger number of sexual partners
3. Exposure to high-risk partners
4. Hx of STD
5. Smoking
6. High parity
7. Prolonged use of oral contraceptives

Question 4

HPV is detectable in what % of cervical cancer?

Answer 4

HPV is detectable in >99% of cervical cancer.

Question 5

Roughly what % reduction in mortality has been achieved with PAP screening for cervical cancer?

Answer 5

There has been an ∼70% reduction in cervical cancer mortality with PAP screening.

Question 6

What does ASCUS stand for (on a PAP result), and how should it be managed?

Answer 6

ASCUS stands for Atypical Squamous Cells of Unknown Significance. About two-thirds can resolve spontaneously. Pts can undergo repeat PAP in
6 mos and then colposcopy if abnl.

Question 7

How should LGSIL seen on PAP be managed?

Answer 7

LGSIL resolves spontaneously ∼40% of the time; therefore, like with ASCUS, pts can undergo repeat PAP in 6 mos with colposcopy if abnl.

Question 8

How should a HGSIL result from a PAP be managed?

Answer 8

All pts with HGSIL should undergo colposcopy with Bx. One-third of these pts can still resolve spontaneously, but waiting without further investigation is not recommended d/t concern for progression.

Question 9

What % of HGSIL progresses to invasive cancers?

Answer 9

22% of HGSIL progress to invasive cancer. This is in contrast to ASCUS (<1%) and LGSIL (∼5%).

Question 10

What % of cervical cancers are caused by HPV-16 and -18?

Answer 10

> 70% of cervical cancers are caused by HPV-16 and -18.

Question 11

What HPV subtypes cause the most cases of benign warts?

Answer 11

HPV subtypes 6 and 11 cause most cases of benign warts.

Question 12

What HPV subtypes do Cervarix and Gardasil 9 protect against, respectively?

Answer 12

Cervarix protects against HPV types 16 and 18. Gardasil 9 protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. This vaccine can be given to males and females of ages 9–26 yo to protect against cervical cancer, vulvar cancer, anal warts, and genital warts.

Question 13

In the United States, what % of cervical cancers are SCCs vs. adenocarcinomas?

Answer 13

With regard to cervical cancers in the United States, 80% are SCCs, while ∼20% are adenocarcinomas.

Question 14

List 5 histologic subtypes of adenocarcinoma of the cervix.

Answer 14

Subtypes of adenocarcinoma of the cervix:

1. Mucinous
2. Adenosquamous
3. Endometrioid
4. Clear cell
5. Glassy cell

Question 15

Name the 3 common presenting Sx of cervical cancer

Answer 15

Most common presenting Sx of cervical cancer:
Abnl vaginal bleeding
Postcoital bleeding
Abnl vaginal discharge
Dyspareunia
Pelvic pain

Question 16

What specific area of the cervix is the most common point of origin for cervical cancer?

Answer 16

The transformation zone is the most common point of origin for cervical cancer. It is a dynamic area b/t the original and present squamocolumnar junction.

Question 17

What should be included in the workup for a cervical mass?

Answer 17

Pelvic mass workup: H&P, including HIV status, careful pelvic exam in the office, basic labs, pregnancy test, EUA with Bx, for any visible lesions, and pelvic imaging.

Question 18

What are the areas at risk for local extension of cervical cancer?

Answer 18

Cervical cancer can spread locally to the uterine corpus, parametria, and vagina. These should be carefully assessed during a physical exam. Tumor size and parametrial involvement are better assessed by rectovaginal exam. Cervical tumors can also spread to the bladder anteriorly or rectum posteriorly.

Question 19

Name 3 routes of lymphatic drainage from the cervix.

Answer 19

Routes of lymphatic drainage from the cervix:

1. Lat to the external iliac nodes via the round ligament
2. Post into common iliac and lat sacral nodes via the uterosacral ligament
3. Post–lat into internal iliac nodes

Question 20

What imaging studies are included in FIGO staging of cervical cancer? What common imaging modalities are not allowed?

Answer 20

CXR, barium enema, and intravenous pyelogram data are included in FIGO staging of cervical cancer, as are procedures such as cystoscopy, proctoscopy, and hysteroscopy if there is concern for invasion. CT, PET,
MRI, bone scan, lymphangiography, and laparotomy/laparoscopy data are not allowed to be used for staging but can be obtained for parametrial
invasion, Tx decision making, and planning purposes (but do not influence FIGO staging of the pt).

Question 21

What is the utility of PET scans in cervical cancer?

Answer 21

PET is generally fairly sensitive (85%–90%) and specific (95%–100%) for detection of para-aortic nodes in pts with locally advanced cervical cancer. Interpretation of the primary tumor at the cervix is not very reliable
d/t the high excretion of FDG and the resultant high SUV in the bladder.

Question 22

In what group of cervical cancer pts is evaluation of the urinary tract required?

Answer 22

Cervical cancer pts with more than stage IB1 Dz require imaging of the urinary tract. This can be performed with CT, MRI, or intravenous pyelogram.

Question 23

What is the FIGO (2010) staging for cervical cancer?

Answer 23

Stage IA: microscopic Dz, with ≤5 mm DOI and ≤7 mm horizontal spread. It is further delineated into IA1 (tumors ≤3 mm depth and ≤7 mm wide) and IA2 (tumors >3 mm but ≤5 mm deep and ≤7 mm wide)

Stage IB: clinically visible tumor or >IA2, with IB1 ≤4 cm, and IB2 being bulky tumors >4 cm

Stage IIA: invades beyond uterus/cervix; involves the upper two-thirds of the vagina without parametrial invasion with IIA1 lesions ≤4 cm and IIA2 lesions >4 cm

Stage IIB: invades beyond uterus/cervix and into parametria but not into pelvic wall or lower 3rd of vagina

Stage IIIA: invades lower 3rd of vagina but no extension into pelvic wall

Stage IIIB: invades pelvic sidewall and/or causes hydronephrosis or nonfunctioning kidney

Stage IVA: invades beyond true pelvis or mucosa of bladder or rectum (must be Bx-proven); bullous edema of bladder or rectum does not count

Stage IVB: DMs

Question 24

How does the AJCC version 8 (TNM) staging system for cervical cancer compare with the FIGO system?

Answer 24

In AJCC cervical cancer staging, the T stage corresponds to the FIGO stage, except for FIGO stage IVB. Positive regional LNs are not included in FIGO, but are N1 in AJCC; however they do not influence AJCC stage grouping. Para-aortic nodes are no longer considered M1 Dz in AJCC version 8.

Question 25

What factors are predictive of pelvic nodal involvement in cervical cancer?

Answer 25

Factors that predict for nodal involvement in cervical cancer include DOI, FIGO stage, tumor size, and LVSI (10% without vs. 25% with). It is controversial whether histologic subtype is an independent predictor for
nodal involvement, although some studies show adenocarcinomas having higher rates of DM.

Question 26

Estimate the risk of pelvic LN involvement based on the following DOIs of a cervical cancer: <3 mm, 3–5 mm, 6–10 mm, and 10–20 mm.

Answer 26

Risk of pelvic nodal involvement by DOI:
≤3 mm: <1%
3–5 mm: 1%–8%
6–10 mm: 15%
10–20 mm: 25%

Question 27

Estimate the risk of pelvic LN involvement based on the FIGO stage of cervical cancer.

Answer 27

Pelvic LN+ rates for cervical cancer based on the FIGO stage:
Stage IA1: 1%
Stage IA2: 5%
Stage IB: 15%
Stage II: 30%
Stage III: 50%
Stage IVA: 60%

Question 28

Estimate the risk of P-A nodal involvement based on the FIGO stage of cervical cancer.

Answer 28

P-A LN+ rates for cervical cancer based on the FIGO stage:
Stage IA: 0%
Stage IB: 5%–8%
Stage IIA: ∼10%
Stage IIB: ∼15%
Stage III: 30%
Stage IVA: 40%

Question 29

What are the 5-yr OS rates based on the FIGO stage?

Answer 29

5-yr OS based on FIGO stage:
Stage IA: 93%
Stage IB: 75%–80%
Stage IIA: 80%
Stage IIB: 65%–70%
Stage IIIA: 35%
Stage IIIB: 35%–40%
Stage IVA: 10%
Stage IVB: 0

Question 30

Which key clinical factors are included in the nomogram by Rose et al.?

Answer 30

The Rose nomogram predicts 2-yr PFS, 5-yr OS, and pelvic recurrence using the prognostic factors of histology, race/ethnicity, PS, tumor size, FIGO
stage, tumor grade, pelvic node status, and Tx with concurrent cisplatin. (Rose P et al., J Clin Oncol 2015)

Question 31

What is the most important prognostic factor in cervical cancer?

Answer 31

Tumor stage is the most important prognostic factor in cervical cancer since FIGO staging is based on prognostic factors. Per stage, extent of nodal
involvement is the next most important factor.

Question 32

What is removed in a radical trachelectomy as Tx for cervical cancer?

Answer 32

In a radical trachelectomy, all cervical cancer is removed with a margin, but the internal os is left behind and stitched closed, with a small meatus for
menses to escape. This procedure (performed at select centers) allows future pregnancy, delivered via a C-section. This procedure should be reserved for
women desiring fertility preservation and with stage IA1 as well as select cases of IA2 and small IB1 and tumors <2.0 cm in size.

Question 33

How should pts with preinvasive cervical cancer (HGSIL or CIN III) be managed?

Answer 33

Pts with preinvasive cervical cancer should be managed with colposcopy → conization, LEEP, laser, cryotherapy, or simple hysterectomy.

Question 34

In which subset of cervical cancer pts is simple hysterectomy adequate as definitive management?

Answer 34

Pts with IA1 Dz can be treated with simple abdominal hysterectomy. A cone should be done 1st to ensure that there are no foci of invasion beyond 3 mm
identified. Sometimes, conization is also adequate for IA1, but there must be DOI <3 mm and no LVSI or dysplasia at the margin. (Van Nagell J et al., Am
J Obstet Gynecol 1983) All other pts (≥IA2) should get radical hysterectomy with pelvic LND.

Question 35

What is the difference b/t a class I–III radical hysterectomy (Piver–Rutledge–Smith classification)?

Answer 35

In a class I (aka: total abdominal, simple, or extrafascial hysterectomy), the uterus is removed with little or no removal of vaginal tissue, cardinal ligament, or uterosacral ligament. In a class II (modified radical
hysterectomy) there is removal of the uterus, ureters are unroofed to remove parametrial and paracervical tissue medial to the ureters and 1–2 cm of vaginal cuff, and the uterine artery is ligated at the ureter. In a class III Sg
(radical hysterectomy), there is removal of parametrial and paravaginal tissue to the pelvic sidewall, ligation of the uterine artery at the ureter, and removal of the upper half to two-thirds of the vagina.

Question 36

What stage of cervical cancer can be treated with brachytherapy alone?

Answer 36

Stage IA cervical cancer can be treated with brachytherapy alone with LDR 65–75 Gy or HDR 7 Gy × 5–6 fx, with LC of 97%. (Grisby P et al., IJROBP
1992)

Question 37

When treating cervical cancer pts with brachytherapy, is there a Dz control or toxicity difference b/t LDR and HDR?

Answer 37

This is uncertain. In Teshima T et al. pts with stages I–III cervical cancer were randomized to HDR Co-60 or LDR cesium-137 therapy. There was no SS difference in 5-yr CSS b/t the 2 groups (stage I, 85%–93%; stage II, 73%–
78%; stage III, 47%–53%). Moderate to severe complications were higher in HDR (10% vs. 4%). (Cancer 1993)

Question 38

Where are points A and B, and what should it correspond to anatomically?

Answer 38

Point A is 2 cm above the external cervical os and 2 cm lat to the central canal/tandem. This should correspond to the paracervical triangle, where the uterine vessels cross the ureter.

Point B is 5 cm lat from the midline at the same level as point A (2 cm above the external cervical os). It is supposed to represent the obturator nodes. The dose to point B is usually 20% of the dose to point A using a
tandem and ovoid system.

Question 39

Before CT-based planning, how were the bladder, rectum, and vaginal points defined for cervical cancer brachytherapy?

Answer 39

Before CT-based planning, the bladder point was the post surface of the Foley balloon at midplane of ovoids on a lat x-ray filled with 7 cc radiopaque fluid and pulled down against the urethra. The rectum point was 5 mm behind the post vaginal wall b/t the ovoids at the inf point of the last intrauterine tandem source or mid vaginal source. The vaginal point was the lat edge of
the ovoids on AP film and mid ovoid on lat film. In the present age of CT planning, an alternative is to contour the organs and calculate the max dose to the organ using 3D planning.

Question 40

What are the dose limits to the bladder, rectum, and vaginal points in cervical cancer brachytherapy for 2D and 3D planning?

Answer 40

In cervical cancer brachytherapy, 2D International Commission on Radiation Units (ICRU) doses are max point doses. Typically in 2D planning the max allowed dose to the rectal point dose is <72 Gy, the max
bladder point dose is <80 Gy, and the max vaginal point dose is <120 Gy.

With 3D planning, limits are volume based and quantified as D2cc which is defined as the min dose within the 2-cc volume of greatest dose. The bladder limit is D2cc <90 Gy equivalent 2 Gy dose (EQD2), rectum and sigmoid limit is D2cc <75 Gy EQD2. (Viswanathan A et al., Brachy 2012)

Question 41

What RT dose can cause ovarian failure? What about sterility?

Answer 41

Ovarian failure can occur with 5–10 Gy of RT. Sterility can occur after 2–3 Gy.

Question 42

What are the typical LDR and HDR in cervical cancer Tx?

Answer 42

In cervical cancer brachytherapy, LDR range is 40–200 cGy/hr, while HDR is much higher >12 Gy/hr. Typically, 1 HDR Tx of 5.5–6.0 Gy takes appx 5–10 min to deliver.

Question 43

What is the role for definitive Sg vs. definitive RT for the management of early stage (IB–IIA) cervical cancers? What study tested these 2 modalities?

Answer 43

In Landoni F et al. pts with stages IB and IIA cervical carcinoma were randomized to Sg (class III) vs. RT (without chemo) for definitive therapy. Adj RT was allowed for the Sg group based on preset criteria. 5-yr OS and DFS were equal (83% and 74%, respectively, for both groups). 64% of Sg pts rcvd adj RT. Grades 2–3 morbidity was higher in the Sg arm (28% vs. 12%).
Pts with adenocarcinoma of the cervix were found to have a survival benefit with hysterectomy. (Lancet 1997)

Question 44

What are the benefits of Sg over RT for the Tx of early-stage cervical cancers?

Answer 44

Benefits of Sg over RT include shorter Tx time, preservation of ovarian function, possibly better sexual functioning after Tx, no 2nd malignancy risk, avoidance of long-term RT sequelae, and psychologically easier for many pts to understand. Sg can also better identify the accurate anatomic extent of Dz

Question 45

What adverse features after Sg are indications for adj RT alone without chemo?

Answer 45

Pts with cervical cancer s/p hysterectomy with –margins and –nodal status but have ≥2 risk features (+LVSI, >4-cm tumors, more than one-third stromal invasion) benefit from adj RT.
The Gynecologic Oncology Group’s study GOG 92 enrolled 277 stage IB cervical cancer pts who underwent Sg and had –nodes but >1 adverse
feature: more than one-third stromal invasion, LVI, or tumor >4 cm. Compared to observation, there was a pelvic RT (46–50.4 Gy) RR of recurrence by 46% (21% vs. 14%, p = 0.007) and trend to OS benefit by ∼10% (71% vs. 80%, p = 0.074). (Rotman M et al., IJROBP 2006)

Question 46

What adverse features after Sg are indications for adj chemo–RT?

Answer 46

In GOG 109, high-risk pts (with at least 1 of the following features: +margin, +nodes, or microscopic parametrial invasion) with initially staged IA2, IB, and IIA cervical cancer treated with radical hysterectomy and pelvic lymphadenectomy were randomized to standard pelvic field RT (49.3 Gy) vs. RT + cisplatin/5-FU for 4 cycles. CRT was sup in both 4-yr OS (81% vs. 71%) and 4-yr PFS (80% vs. 63%). (Peters W et al., JCO 2000)

Question 47

What subset of pts from GOG 109 can be managed with adj RT alone?

Answer 47

The subset analysis of GOG 109 demonstrated that pts with tumors <2 cm and only 1 +node did not benefit from CRT compared with RT alone. (Monk B et al., Gyn Oncol 2005)

Question 48

What trial is currently evaluating adj RT vs. CRT after hysterectomy and LND in pts with intermediate-risk stage I–IIA cervical cancer?

Answer 48

GOG 263 compares adj RT vs. CRT in intermediate-risk pts s/p hysterectomy defined as:

1. LVSI and deep 3rd cervical stromal invasion
2. LVSI and middle 3rd invasion and tumor ≥2 cm
3. LVSI and superficial 3rd invasion and tumor ≥5 cm or
4. No LVSI with middle or deep 3rd invasion and tumor ≥4 cm.

Question 49

For pts with bulky (>4 cm) early-stage cervical cancer, is there an advantage to adding adj hysterectomy to definitive RT

Answer 49

In GOG 71, pts with tumors >4 cm were randomized to RT alone vs. RT + adj hysterectomy. RT consisted of EBRT + brachytherapy (80 Gy to point
A for the RT-alone group, and 75 Gy to point A for the Sg group). At median 9.6-yr f/u, there was no difference in OS or severe toxicity. There was a trend to improved LR (26% vs. 14%, p = 0.08). (Keys HM et al., Gyn Oncol 2003)

An option is to treat with CRT and assess for response at 2 mos. If residual Dz is evident, then salvage Sg can be considered. A downside to adj hysterectomy is the potential for complications d/t the high-dose radiation
delivered to the area, including a relatively high dose to the post bladder wall.

Question 50

For stage IB2 cervical cancer pts, what is the advantage of preop CRT compared with preop RT alone?

Answer 50

In GOG 123, stage IB2 cervical cancer pts were randomized to preop RT vs. CRT → adj simple hysterectomy. RT was whole pelvis (WP) + brachytherapy to a point A dose of 75 Gy. CRT added weekly cisplatin 40 mg/m2. CRT was sup in 3-yr pCR (52% vs. 41%), OS (83% vs. 74%), and pCR (52% vs. 41%). Note: Adj and immediate hysterectomy was included in this trial prior to the results of GOG 71 being available. (Keys HM, NEJM 1999)

Question 51

In stage IB cervical cancer, is there a role for neoadj chemo prior to Sg?

Answer 51

Controversial. GOG 141 looked at stage IB2 pts randomized to radical hysterectomy with nodal dissection +/– neoadj vincristine/cisplatin × 3 cycles. The study closed early, but there was comparable LC and OS in both groups, and PORT was needed in 45%–52% of pts. (Eddy GL et al., Gyn Oncol 2007)

A phase III trial from Italy looked at neoadj chemo + Sg vs. RT alone for stages IB2 to III pts and found sup OS and PFS in the chemo + Sg arm.Benefit was significant only for stages IB2 to IIB group. (Benedetti-Panici P et al., JCO 2002)

EORTC 55994 closed prematurely as interim analysis revealed inf OS in the with neoadj chemo arm compared to Sg without chemo. (Katsumata Br J, Cancer 2013)

Question 52

In locally advanced cervical cancer, what is the OS advantage of definitive CRT over RT alone?

Answer 52

The benefit of CRT over RT alone in locally advanced cervical cancer was evaluated in RTOG 90-01. (Eifel P et al., JCO 2004) This study randomized stages IIB–IVA, large stages IB–IIA (>5 cm), or LN+ pts and randomized to RT to the pelvis and P-A nodes vs. pelvis RT + 3 cycles of cisplatin/5-FU.
Both arms had brachytherapy with a point A dose of 85 Gy. 8-yr OS was 67% vs. 41%, benefiting the CRT. 5 RCT’s show OS benefit with addition of chemo. (NCI press office, 1999)

Question 53

Which chemo agent is most commonly used during CRT for cervical cancer?

Answer 53

Weekly cisplatin at 40 mg/m2 is the current standard to be given with definitive RT. RTOG 90-01 also utilized cisplatin, but at a dose of 75 mg/m2 q3wks

Question 54

To what subset of pts is adding P-A fields to the pelvic field beneficial in the definitive Tx of cervical cancer?

Answer 54

There are 2 indications where the P-A field should be added to the definitive management of cervical cancer pts: (1) pts with +P-A Dz and (2) pts with +pelvic nodal Dz and not receiving CRT. 2 studies have addressed this:

RTOG 79-20 randomized 337 pts with stage IIB Dz without clinical or radiographic evidence of P-A Dz to the WP (45 Gy) alone vs. WP + P-A field (EFRT) (45 Gy). No chemo was given. Adding the P-A field improved 10-yr OS (55% vs. 44%) without improvement in LC or DM.
However, there was slightly increased toxicity with the P-A field (8% vs. 4%). (Rotman M et al., JAMA 1995)

RTOG 90-01 randomized 386 pts with locally advanced cervical cancers (stages IIB–IVA or IB–IIA with ≥5 cm) or with a +pelvic LN (no P-A nodal Dz) to WP RT + chemo vs. WP + P-A field alone (EFRT). All pts were treated with post-EBRT brachytherapy of 85 Gy to point A. Chemo
was cisplatin 75 mg/m2 + 5-FU 1,000 mg/day × 4 days per 21-day cycle for 3 cycles. Pelvic CRT was sup to EFRT in 8-yr OS (67% vs. 41%), DFS (61% vs. 46%), LRF (18% vs. 35%), and DM (20% vs. 35%). There was a slight increase in P-A nodal failure in the CRT arm (8% vs. 4%, p = NSS). (Morris M et al., NEJM 1999; Eifel P et al., JCO 2004)

Question 55

Describe the borders of typical AP and lat fields in cervical cancer Tx.

Answer 55

In cervical cancer therapy, the typical borders of an AP field are sup to L4–5 or L5/S1, inf to 3 cm below the most inf vaginal involvement or inf obturator
foramen, and lat 2 cm from the pelvic rim. Lat beams would have the same sup and inf extent, with the ant edge to 1 cm ant of the pubic symphysis with
coverage of entire uterus and post edge to include the entire sacrum. For common iliac nodal involvement, extend the field to cover up to L2. For P-A nodal involvement, extend the field to the top of T12 with ∼70% AP/PA 30% lat field weighting if using 3D. The borders can be tailored for early stage vs. more advanced Dz. In the CT planning era, the alternative is to contour the organs and nodes of interest to ensure adequate coverage.

Question 56

Is there benefit in using IMRT to treat intact cervical cancer?

Answer 56

Potentially; a single arm study (Intertecc-2 trial) revealed IMRT reduced acute hematologic and GI toxicity compared to historical 3D outcomes. (Mell L et al., IJROBP 2016)

Question 57

What is a typical EBRT Rx for cervical cancer?

Answer 57

Typically, cervical cancer pts treated with EBRT rcv RT to the WP to 45 Gy in 1.8 Gy/fx. Sidewall boosts to 50–54 Gy. Persistent or bulky parametrial tumors usually rcv 60 Gy. P-A nodes to 45 Gy if treated electively and sequential boost to 54–65 Gy if positive with 3D-CRT or IMRT.

Question 58

What should be the total Rx dose to the high-risk (HR) CTV for cervical cancer (sum of EBRT + brachytherapy)? Who needs a sidewall boost?

Answer 58

In cervical cancer radiotherapy, the planning aim for the cumulative EQD2 to the HR-CTV (defined as the GTV + the entire cervix + presumed extracervical tumor extension) D90 >85 Gy. T2 MRI after EB can be used
to identify residual GTV (EMBRACE study). Pts with residual side wall or parametrial Dz after EB should rcv a boost in the form of EB or interstitial brachytherapy.

Question 59

Is SBRT boost for cervical cancer equivalent to brachytherapy?

Answer 59

The use of SBRT or other EB modalities has not proven to be sup orequivalent to brachytherapy. The use of brachytherapy should be utilized to achieve an EQD2 dose of D90 >80 Gy as it has a greater OS vs. SBRT/IMRT boost. (Gill et al., IJROBP 2014) Further, image-guided brachytherapy improves OS and reduces grade 3–4 toxicity vs. standard brachy in prospective STIC trial. (Charra-Brunaud et al., Radiother Oncol 2012)

Question 60

Does overall Tx time in cervical cancer impact outcome? Ideally, how long should the RT Tx take?

Answer 60

Yes. Prolonged overall RT Tx time in cervical cancer is associated with poorer outcomes. Ideally, EBRT and brachytherapy should be completed within 7 wks. The effect is more notable in more advanced-stage pts (stages III–IV).

Question 61

Per GOG 240, the addition of what agent improves outcomes for pts with recurrent, persistent, or metastatic cervical cancer?

Answer 61

Addition of bevacizumab to either topotecan-paclitaxel or cisplatinpaclitaxel resulted in an OS benefit extending MS from 13.3 mos to 17 mos. (Tewari KS et al., Lancet 2017)

Question 62

List 3 procedure-related complications seen in cervical cancer intracavitary brachytherapy.

Answer 62

Procedure-related complications seen in cervical cancer intracavitary brachytherapy:

1. Uterine perforation (<3%) although some studies have rates >10%. US is recommended for guidance during insertion. (Small W. et al., Int J Gynecol Cancer 2011)
2. Vaginal laceration (<1%)
3. DVT (<1%)

Question 63

Name the most common acute side effects associated with RT for cervical cancer.

Answer 63

Skin irritation, fatigue, hemorrhoids, colitis-diarrhea, cystitisfrequency/dysuria, and nausea are all possible acute side effects from cervical cancer RT.

Question 64

Name the common long-term side effects associated with cervical cancer RT.

Answer 64

Common long-term side effects of cervical cancer RT include permanent alteration in bowel habit, menopause in the premenopausal age group, chronic cystitis with frequency, and vaginal stenosis with dyspareunia and
postcoital bleeding. The major severe long-term toxicities are most commonly bowel related: rectosigmoid stenosis, requiring possible colostomy, and major rectal bleeding. Hematuria, ureteral stricture, fistula, SBO, and hip fracture or sacral insufficiency fracture can also occur.

Question 65

What should pts do regularly to prevent vaginal stenosis after receiving RT for cervical cancer?

Answer 65

Routine use of a vaginal dilator is essential to preventing vaginal stenosis in pts who have undergone RT for cervical cancer.

Question 66

What was the rate of fistula formation post RT and bevacizumab in GOG 240?

Answer 66

Fistula (any grade) occurred in 15% of pts treated with bevacizumab (1% in chemo alone group); all pts previously irradiated. (Tewari KS et al., Lancet
2017)

Question 67

When after definitive Tx do you order imaging?

Answer 67

A PET/CT is ordered at 3 mos post Tx to assess response which is predictive of survival. If PR → Bx f/b Sg if + or local brachytherapy for small-volume Dz. If distant progressive Dz treat with chemo.