Cervical Cancer Flashcards
Describe cervical cancer screening recommendations
- 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
What is the most common site for carcinogenesis of the cervix
Ectocervix, squamno-columnar junction at external os
What cells line the ectocervix
Squamous epithelium
Describe LN drainage in cervical cancer
Obturator , internal iliac, external iliacs , presacral, common iliac, para aortic
External iliacs via round ligament
presacral and common iliacs via uterosacral ligament
What is the most common site of distant spread
Lungs, supraclav, bone
Describe staging of cervical cancer
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
Describe the incidence of cervical cancer histologies
70% SCC
30% adeno
What is removed in a trachelectomy
Usually done in HSIL, IA1-1B1 < 2 cm
- Cervix
- small portion of the vagina (not more than 25-50% upper vagina)
- Bladder and rectum mobilized to peritoneal reflection
- Uterus and ovaries are spared
WHat is removed in a simple/extrafascilar hysterectomy
Usually done in stage IA1 cervical cancer or endometrial cancer (BSO)
- cervix is moved
- uterus is removed
- ovaries may be removed
- vaginal margin 1-2 mm
- Bladder is mobilised to base of cervix
What is removed in a modified radical hysterectomy
Usually done with 1A1 with LVSI or IA2
or in endometrial cancer with cervix involved
- Cervix is removed
- Uterus is emoved
- ovaries can be removed
- vaginal margin is 1-2 cm
- Ureters tunnel through broad ligament
- Bladder is immobilized to upper vagina
uterine artery is ligated at ureter
uterosacral ligaments are partially resected
What is removed in a radical hysterectomy
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
What is the treatment for stage 1A1
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
What is the treatment for stage 1A2
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)
What is the treatment for 1B1, 1B2, IIA1
Radical hysterectomy (Class III) + PLNDx (+/- PALNS)
Definitive EBRT + brachytherapy +/- concurrent CHT
What is the testament for IIA2 to IVA?
Definitive EBRT + brachytherapy + concurrent CHT
Benefits of surgery over radiation:
- Additional pathologic information is gained by surgical pathology
- Preserved ovarian function
- No secondary malignancy risk
- Improved sexual functioning, vaginal stenosis, vaginal dryness
- Improved late GI toxicity
- Shorter treatment time (one-and-done)
- Psychologically easier for patients to comprehend surgery than radiation
What is the time frame during which all RT should be given by
7-8 weeks
What are the benefits of IMRT
IMRT has less acute and late GI toxicity and less heme toxicity than 3D RT for cervix cancer
Describe the volumes in a cervical cancer tx plan
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
Desribe the contouring process
- 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
How does contouring process change if common iliacs are invovled
add para-aortics up to L1/2
How does contouring process change if paraaortics are involved
add para-aortics up to T11/12
How does contoring change of distal 1/3 vagina involvement
add inguinals
What workup must be completed prior to brachy
Perform physical examination and obtain MRI prior to brachytherapy to assist w/ planning
