Cervical cancer treatment by stage after stage IB Flashcards
Stages IB and IIA Cervical Cancer Treatment
Standard Treatment Options for Stages IB and IIA are?
Stages IB and IIA Cervical Cancer Treatment
Standard Treatment Options for Stages IB and IIA Cervical Cancer Standard treatment options for stage IB and stage IIA cervical cancer include the following:
1. Radiation therapy with concomitant chemotherapy.
2. Radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy.
The size of the tumor is an important prognostic factor and should be carefully evaluated in choosing optimal therapy.
The size of the tumor is an important prognostic factor and should be carefully evaluated in choosing optimal therapy.[1]
Either radiation therapy or radical hysterectomy and bilateral lymph-node dissection results in cure rates of 85% to 90% for women with Federation Internationale de Gynecologie et d’Obstetrique (FIGO) stages IA2 and IB1 small-volume disease. The choice of either treatment depends on patient factors and available local expertise. A randomized trial reported identical 5-year overall survival (OS) and disease-free survival rates when comparing radiation therapy with radical hysterectomy.[2]
In stage IB2, for tumors that expand the cervix more than 4 cm, the primary treatment should be concomitant chemotherapy and radiation therapy.[3]
Radiation therapy protocols for patients with cervical cancer have historically used dosing at two anatomical points, termed point A and point B, to standardize the doses received. Point A is defined as ?
How much radiation is given
Radiation therapy protocols for patients with cervical cancer have historically used dosing at two anatomical points, termed point A and point B, to standardize the doses received. Point A is defined as 2 cm from the external os, and 2 cm lateral, relative to the endocervical canal. Point B is also 2 cm from the external os, and 5 cm lateral from the patient midline, relative to the bony pelvis. In general, for smaller tumors, the curative-intent dose for point A is around 70 Gy, whereas for larger tumors, the point A dose may approach 90 Gy.
Evidence (radiation with concomitant chemotherapy):
Three randomized, phase III trials have shown an OS advantage for cisplatin-based therapy given concurrently with radiation therapy,[4-7]
Three randomized, phase III trials have shown an OS advantage for cisplatin-based therapy given concurrently with radiation therapy,[4-7] while one trial that examined this regimen demonstrated no benefit.[8] The patient populations in these studies included women with FIGO stages IB2 to IVA cervical cancer treated with primary radiation therapy, and women with FIGO stages I to 11A disease who, at the time of primary surgery, were found to have poor prognostic factors, including metastatic disease in pelvic lymph nodes, parametrial disease, and positive surgical margins.
• Although the positive trials vary somewhat in terms of the stage of disease, dose of radiation, and schedule of cisplatin and radiation, the trials demonstrate significant survival benefit for this combined approach.
• The risk of death from cervical cancer was decreased by 30% to 50% with the use of concurrent chemoradiation therapy.
• Other trials have confirmed these findings.[9,10]
Brachytherapy what are the radiation sources used name the two of them
Which one is used for low dose rate and which one is used for high dose rate.
Brachytherapy Standard radiation therapy for cervical cancer includes brachytherapy after external-beam radiation therapy (EBRT). Although low-dose rate (LDR) brachytherapy, typically with cesium Cs 137, has been the traditional approach, the use of high-dose rate (HDR) therapy, typically with iridium Ir 192, is rapidly increasing. HDR brachytherapy provides the advantage of eliminating radiation exposure to medical personnel, a shorter treatment time, patient convenience, and improved outpatient management.
Is there a difference using low dose Brachy therapy versus high does Brachytherapy
In three randomized trials, HDR brachytherapy was comparable with LDR brachytherapy in terms of local-regional control and complication
When is surgery done after brachy therapy treatment
Surgery after radiation therapy may be indicated for some patients with tumors confined to the cervix that respond incompletely to radiation therapy or for patients whose vaginal anatomy precludes optimal brachytherapy.[16]
What is the difference between extraperitoneal Lymph node sampling versus transperitoneal lymph node sampling
The resection of macroscopically involved pelvic nodes may improve rates of local control with postoperative radiation therapy. [17] Patients who underwent extraperitoneal lymph-node sampling had fewer bowel complications than those who had transperitoneal lymph-node sampling.[18-20]
At what pelvic margin distance should a patient receive pelvic radiation therapy because benefit has been shown
Patients with close vaginal margins (<0.5 cm) may also benefit from pelvic radiation
Why do you avoid doing surgery in patients that need to have a radiation therapy after surgery
Evidence (radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy):
Complications were highest among the patients who received adjuvant radiation after surgery.
• In general, radical hysterectomy should be avoided in patients who are likely to require adjuvant therapy.
Evidence (radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy): 1. An Italian group randomly assigned 343 women with stage IB and 11A cervical cancer to surgery or radiation therapy. The radiation therapy included EBRT and one Cs-137 LDR insertion, with a total dose to point A from 70 to 90 Gy (median 76 Gy). Patients in the surgery arm underwent a class III radical hysterectomy, pelvic lymphadenectomy, and selective, para-aortic lymph-node dissection. Adjuvant radiation therapy was given to patients with high-risk pathologic features in the uterine specimen or positive lymph nodes. Adjuvant radiation therapy was EBRT to a total dose of 50.4 Gy over 5 to 6 weeks.[2][Level of evidence: 1 iiA] • The primary outcome was OS at 5 years, with secondary measures of rate of recurrence and complications. With a median follow-up of 87 months, OS was the same in both groups at 83% (hazard ratio [HR], 1.2; confidence interval [Cl], 0.7-2.3; P= .8).
Adjuvant radiation therapy post surgery
For patients that are intermediate risk
What are your thoughts
Based on recurrence rates in previous clinical trials, two classes of recurrence risk have been defined. Patients with a combination of large tumor size, lymph vascular space invasion, and deep stromal invasion in the hysterectomy specimen are deemed to have intermediate-risk disease. These patients are candidates for adjuvant EBRT.[22] Patients whose pathology shows positive margins, positive parametria, or positive lymph nodes are high-risk candidates for recurrence.
Evidence (adjuvant radiation therapy post surgery):
1. The Gynecologic Oncology Group (GOG) compared adjuvant radiation therapy alone with radiation therapy plus cisplatin plus fluorouracil (5-FU) after radical hysterectomy for patients in the high-risk group. Postoperative patients were eligible if their pathology showed any one of the following: positive parametria, positive margins, or positive lymph nodes. Patients in both arms received 49 Gy to the pelvis. Patients in the experimental arm also received cisplatin (70 mg/m2) and a 96-hour infusion of 5-FU (1000 mg/m2/d every 3 weeks for four cycles); the first two cycles were concurrent with the radiation therapy.[6][Level of evidence: 1 iiA]
• There were 268 patients evaluated with a primary endpoint of OS. The study results were reported early because of the positive results in other trials of concomitant cisplatin and radiation therapy.
• Estimated 4-year survival was 81% for chemotherapy plus radiation therapy and 71% for radiation therapy alone (HR, 1.96; P= .007).
• As expected, grade 4 toxicity was more common in the chemotherapy plus radiation therapy group, with hematologic toxicity predominating.
Radical surgery has been performed for small lesions, but the high incidence of pathologic factors leading to postoperative radiation with or without chemotherapy make primary concomitant chemotherapy and radiation a more common approach in patients with larger tumors. Radiation in the range of 50 Gy administered for 5 weeks plus chemotherapy with cisplatin with or without 5-FU should be considered in patients with a high risk of recurrence.
Radical trachelectomy what is the patients selection criteria
Patients with presumed early-stage disease who desire future fertility may be candidates for radical trachelectomy. In this procedure, the cervix and lateral parametrial tissues are removed, and the uterine body and ovaries are maintained. The patient selection differs somewhat between groups, however, general criteria include the following:
• Desire for future pregnancy.
• Age younger than 40 years.
• Presumed stage IA2to IB1 disease and a lesion size no greater than 2 cm.
• Preoperative magnetic resonance imaging that shows a margin from the most distal edge of the tumor to the lower uterine segment.
• Squamous, adenosquamous, or adenocarcinoma cell types.
Intraoperatively, the patient is assessed in a manner similar to a radical hysterectomy; the procedure is aborted if more advanced disease than expected is encountered. The margins of the specimen are also assessed at the time of surgery, and a radical hysterectomy is performed if inadequate margins are obtained.[26-30]
Para-aortic nodal disease
Para-aortic nodal disease
After surgical staging, patients found to have small-volume para-aortic nodal disease and controllable pelvic disease may be cured with pelvic and para-aortic radiation therapy.[23] Treatment of patients with unresected para-aortic nodes with extendedfield radiation therapy and chemotherapy leads to long-term disease control in patients with low-volume (<2 cm) nodal disease below L3.[18] A single study (RTOG-7920) showed a survival advantage in patients with tumors larger than 4 cm who received radiation therapy to para-aortic nodes without histologic evidence of disease.[24] Toxic effects were greater with para-aortic radiation therapy than with pelvic radiation therapy alone but were mostly confined to patients with previous abdominopelvic
Is there any role for Neoadjuvant chemotherapy In the management of cervical cancer
Several groups have investigated the role of neoadjuvant chemotherapy to convert patients who are conventional candidates for chemoradiation into candidates for radical surgery.[31-35] Multiple regimens have been used; however, almost all utilize a platinum backbone. The largest randomized trial to date was reported in 2001, and its accrual was completed before the standard of care included the addition of cisplatin to radiation therapy.[36] As a result, the control arm utilized radiation therapy alone. Although there was an improvement in OS for the experimental arm, the results are not reflective of current practice. This study accrued patients with stages IB through IVA disease, but improvement in the experimental arm was only noted for participants with early stage disease (stages IB, 11 A, or IVB).
Another study still I’m going
EORTC-55994 (NCT00039338) randomly assigned patients with stages IB2, IIA2, and IIB cervical cancer to standard chemoradiation or neoadjuvant chemotherapy (with a cisplatin backbone for three cycles) followed by evaluation for surgery. With OS as the primary endpoint, this trial may delineate whether there is a role for neoadjuvant chemotherapy for this patient population.
Radiation therapy alone.
Radiation therapy alone External-beam pelvic radiation therapy combined with two or more intracavitary brachytherapy applications is appropriate therapy for patients with stage IA2 and IB1 lesions. For patients with stage IB2 and larger lesions, radiosensitizing chemotherapy is indicated. The role of radiosensitizing chemotherapy in patients with stage IA2 and IB1 lesions is untested. However, it may prove beneficial in certain cases.
