Cervical Flashcards

1
Q

HPV 16 and 18 - involved in what % of cervical cancer -1

A

70%

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2
Q

screening - <21yo

A

none

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3
Q

screening - 21-29yo

A

cytology alone q3y

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4
Q

screening - 30-65yo

A

preferred: HPV DNA (looks at 16 and 18) and cytology “co-testing” q5y
acceptable: cytology alone q3y (NOT annual)

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5
Q

screening - >65yo

A

none

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6
Q

screening - guidelines

A

after hysterectomy for benign dz - no screening

if HPV vax - follow std screening, no difference

if abnormal test result - follow NCCN cervical screening guideline

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7
Q

tx - basic concepts -surgery -4

WHEN IS CURE POSSIBLE?

A

primary tx,

varies with stage of dz and desire for fertility (determines surgery type),

MAJOR role in early stage (stage Ia-b, IIa) - GOAL CURE

preferred over XRT as less tox

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8
Q

tx - basic concepts -XRT -4

MAJOR OR MINOR ROLE?

A

MAJOR role in locally adv to advanced dz,

also in adjuvant setting for pts with high risk of recurrence

external beam: outside going in

internal beam: probe in cervix (can not give external beam at doses higher enough to not damage bowel and bladder) (also called intracavitary) VERY IMPT!

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9
Q

tx - basic concepts -chemo -3

COMMON OR LIMITED ROLE?

WHEN WOULD YOU USE CHEMO ALONE?

A

limited role,

  1. concurrent with XRT for currative tx,
  2. palliative tx for advanced or recurrent dz

NOT used alone in absence of metastatic dz

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10
Q

tx - adjuvant XRT by stage Ia-IIa -3

SURGERY THEN +/- ADJ

A
node neg, positive LVSI, tumor >4cm: 
adj XRT (cat 1) +chemosensitization (cat 2b)

LN (+) and/or +surgical margins and/or +parametria:
adj XRT +chemosens (cat 1) +/- vaginal brachy

adenosquamous OR neuroendocrine small cell histology (THESE ARE RARE):
adj XRT

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11
Q

primary tx - advanced stage IB2-IVA - XRT + chemosens - SOC -4

NO SURGERY BECAUSE NOT AN OPTION

WHAT SIZE IS TOO LARGE?

A

lesion too large to surgically resect, >4cm

external beam pelvic radiation (40-60 Gy) + vaginal brachytherapy (80-85 Gy Point A) + concurrent cis 40 mg/m2 weekly

adding chemo reduced death by 20%, 6% improvement in 5yr OS

can also use 5-FU, mitomycin, and paclitaxel (also effective) for women who can not tolerate cis (those with renal dysfunction) (NOTE ALL RADIOSENSITIZING DRUGS)

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12
Q

staging - effect of size and location of dz -2

A

> 4cm

III: if dz outside cervical area LIKE HYDRONEPHROSIS

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13
Q

cisplatin chemoXRT concepts

A

Goal 6 wks of XRT without breaks with 5-6 doses of cis (OS improves with at least 5)

start cis within 24-48h of XRT

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14
Q

cisplatin chemoXRT acute ADR -5

A

myelosuppression,

diarrhea,

electrolyte abnormalities (mostly from diarrhea),

anemia,

N, V

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15
Q

cisplatin chemoXRT long term ADR -3

A

vaginal stenosis (vaginal dialators),

menopause,

bowel obstruction / fistulas (FROM XRT FIBROSIS)

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16
Q

cisplatin chemoXRT monitoring -3

A

labs: CBC, chem, pt wt

others: 
pain scores (local tissue swelling can make worse prior to getting better), 

analgesic use in pts with large tumors

17
Q

recurrence - general principles (5pts)

OPTIONS ARE LIMITED

A

cure unlikely (especially if recurrence in field that was previously radiated)

XRT +/- cis if recurrence isolated AND outside the previously irradiated field

FOR ISOLATED LOCALIZED RECURRENCE ONLY: pelvic exenteration (massive procedure, not common) surgery for highly selected pts

palliative chemo if not candidate for XRT or surgery

single agent tx or BSC appropriate for recurrence within previously irradiated field as responds poorly to chemo

18
Q

recurrence - salvage chemo (3pts)

WHAT IS TOC?

A

cisplatin 50mg/m2 historic TOC, OS 6-7mo, results prior to common use of concurrent XRT-cis,

last decade -> platinum-based doublets is TOC -> trend favors pac-cis doublet, improves OS by 4 months over cis alone

gem-cis doublet least toxic (less leukop, neutrop, anemia, infx)

19
Q

advanced (metastatic) OR recurrent - NCCN 1st line (4pts)

WHICH 3 ARE CAT 1?

A

cis 50 +pac 135 over 3h (cat 1, even though no data) or over 24h (not preferred)

cis 50 D1 +topot 0.75 D1-3 (cat 1, vs cis alone only study to show OS improvement, BUT pac-cis still preferred, no hair loss BUT less convenient)

pac 175 +carbo 6 (cat 1, but phase III study in progress)

cis 50 D1 +gem 1000 D1, 8 (cat 2B, acceptable if pre-existing neuropathy)

20
Q

advanced (metastatic) OR recurrent - NCCN 1st line FOR PTS THAT CAN NOT TOLERATE 2 DRUGS (3pts)

ALSO FOR recurrence within previously irradiated field as responds poorly to chemo

MANY PTS CAN NOT TOLERATE DOUBLETS

A

cis 50

pac 135-175

carbo 5-6

21
Q

advanced (metastatic) OR recurrent - 2nd line -10

A
#bev
#doce
#5FU
#ifos
#irino
#mitomycin
#pemetrexed
#topot
#venorelbine