Cervical Cancer

Question 1

What are some of the main risk factors seen with Cervical Cancer?

Answer 1

HPV (high risk types: 16 and 18), immunosuppression, HIV, smoking, early coitus, high risk sexual partner.

Question 2

For stage I cervical cancer how is this primarily treated?

Answer 2

In general the tx strategy is surgery +/- RT depending on if they have high risk pathologic features.

Question 3

What are the high risk features should be absent if the patient desires fertility preservation?

Answer 3

Tumor>2cm, LVI, lymph node involvement, endocervical extension

Question 3

What are the high risk features that would determine for Stage IA/IB/IA2-IB2 that patients need adjuvant therapy?

Answer 3

Positive surgical margins, positive pelvic or para-aortic nodes, extension to the parametria.GW slide mentioned deep cervical stromal invasion

Question 4

In general, what are the options for early stage (Stage IA1-2, IB1 and IB2) who desire fertility preservation?

Answer 4

Cone biopsy with negative margins + pelvic lymphadenectomy or radical trachelectomy+ pelvic lymphadenectomy

Question 5

For Stage IA1-2 with LVSI what are the treatment options?

Answer 5

You can do a radical hysterectomy with pelvic lymphadenectomy or EBRT w/vaginal brachytherapy.

Question 6

For any cervical tumor that is 4cm or higher but limited to the cervical uteri? What is the tx? What stages does this correspond to?

Answer 6

They are no longer candidates for surgery, they will need chemo/RT. This includes pelvic EBRT+chemo+brachytherapy. This is Stage IB3. Take note here that EBRT w/cisplatin and brachytherapy is Cat 1 Rec! However radical hysterectomy w/pelvic node dissection is a Cat 2B rec.

Question 7

What adjuvant tx is given for those patients with early stage cervical cancer after surgery w/high risk features?

Answer 7

EBRT with Cisplatin +/- Vaginal brachytherapy

Question 8

When a patient has a localized distant metastatic recurrence what can be offered?

Answer 8

You can consider resection +/- EBRT or local ablative therapies +/- EBRT. You can also consider EBRT +/- concurrent chemo. NCCN says after surgery you should consider adjuvant tx.

Question 9

What is the preferred tx for advanced stage cervical cancer if they have a positive PDL-1? What defines a positive PDL-1?

Answer 9

Pembrolizumab+Cisplatin/Pactliaxel +/- Bevacizumab. Can also swap Cisplatin with Carboplatin. A CPS greater than or equal to 1 is defined as positive.

Question 10

If a patient with advanced cervical cancer does not have a positive PDL-1 status, what is the preferred tx?

Answer 10

Cisplatin/Paclitaxel/Bevacizumab (Cat 1 rec), this is preferred over Carboplatin/Paclitaxel/Bevacizumab.

Question 11

Besides Carbo/Cisplatin and Paclitaxel for advanced cervical cancer, what are some chemo options if their PDL-1 is neg? What to offer if there is a contraindication to Bevacizumab?

Answer 11

Topetecan/Paclitaxel/Bevacizumab. Topetecan/Paclitaxel if there is a contraindication to Bevacizumab. Cisplatin/Topetecan. You can also do Cisplatin or Carbo w/Paclitaxel alone if Bev is contraindicated.

Question 12

What are the preferred option for metastatic cervical cancer after first line treatment?

Answer 12

Pembro for MSI-H/dMMR or PDL-1 positive tumors. Tisotumab Vedotin. Cemiplimab

Question 13

What is the mechanism of action of Tisotumab Vedotin and what receptor does it recognize?

Answer 13

It’s an antibody drug conjugate. It contains mono-methyl aurostatin E which binds to tubulin leading to inhibition of polymerization (microtubule). It binds to the tumor factor receptor.

Question 14

What are some major side effects seen with Tisotumab? What is the survival benefit?

Answer 14

Fatigue, neuropathy, keratitis, dry eyes, and neutropenia. Can get alopecia. Phase 3 study showed that it has a OS and PFS benefit.

Question 15

What is the tx of Stage IA vulvar cancer, how is this defined?

Answer 15

Stage IA-less 2cm lesion with less than or equal to 1mm of invasion. You treat this with simple partial vulvectomy.

Question 16

What is tx of Stage IB and select Stage II Vulvar cancer and how is this stage Stage IB defined?

Answer 16

Stage IB is defined as greater than 2cm lesion with more than 1mm invasion. If it’s a lateral lesion you do radical vulvectomy with ipsilateral inguinofemoral lymphadenectomy. Central lesion-bilateral lymph node evaluation. SNLB is also another option if you can’t do lymphadenectomy. Remember after surgery typically need EBRT (if neg margins can hold).

Question 17

What is the definition of Stage II cervical cancer? What is stage IIB specifically? Remember Stage IB3 or higher can’t get surgery (exception is Stage IIA1)

Answer 17

Carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall. Stage IIB is parametrial involvement.

Question 18

What is the preferred treatment for Stage IIA1? This is a higher than stage than IB3 but isn’t treated with chemo/RT

Answer 18

Preferred is Radical hysterectomy w/pelvic lymphadenectomy +/- para aortic node dissection (Cat 2B) or the Cat2B Rec is pelvic EBRT plus brachytherapy +/- concurrent chemo