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Skin Radiation therapy > Cervical Cancer > Flashcards

Cervical Cancer Flashcards

1
Q

cervical cancer is the ____ most common gone cancer?

A

3rd

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2
Q

cervical cancer is more common in which races and statuses

A

more common in hispanic and black women and women with low socioeconomic statuses , lower incidence in catholic, mormons and jewish wormen as they have less partners

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3
Q

most common age for cervical cancer

A

20-50y.o.

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4
Q

most common cause for cervical cancer

A

HPV specifically HPV 16 and 18

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5
Q

how long does it take for an HPV infection to become cervical cancer?

A

10-20 years

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6
Q

risk factors for cervical cancer

A

HPV = #1 cause, smoking, oral contraceptives, multiparty, multiparty, herpes virus, multiple sexual partners, estrogen therapy

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7
Q

how long is the cervix

A

2 cm

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8
Q

the cervix connects what?

A

the vagina and uterus

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9
Q

parts of the cervix

A

endocervix- inner part of the cervix made of columnar epithelium
ectocervix-outer part of the cervix made of squamous cells, extends into the vagina
squamo-columnar junction- where the end and ectocervix meet where the squamous epithelium transforms into squamous cell epithelium

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10
Q

lymphatic spread of the cervix

A

usually orderly spread as follows:

Parametrical > pelvic > common iliac > paraortic > sclav (paraortic involvement means a 35% risk of sclav involvement)

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11
Q

distant spread of the cervix

A

lung, bone, liver and brain

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12
Q

most common symptom for cervical cancer

A

is asymptomatic when early, then abnormal vaginal bleeding or discharge is the most common presentation

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13
Q

symptoms of cervical cancer

A

Abnormal vaginal bleeding (most common) or discharge
Discomfort during intercourse
Pelvic/back pain
Odynuria (painful urination)
Hematuria (blood in urine)/hematochezia (blood in stool)

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14
Q

screening for cervical cancer

A

pap smear every 3 years after the age of 21

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15
Q

position for pap smear

A

Pt is in the dorsal lithotomy position (laying supine w/ legs up, knees bent and feet/ankles/calves in stirrups)

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16
Q

when is a colposcopy used?

A

when a patient has a pap smear positive for cervical cancer or for high risk patients

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17
Q

whats a colposcopy?

A

A magnifying microscope is used to visibly examine the cervix for abnormalities
During if any abnormalities are identified a biopsy can be obtained

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18
Q

biopsies used in diagnosing cervical cancer

A

Punch Biopsy: A small piece of tissue is removed using forceps
Endocervical Curettage: Removes tissue from the endocervical canal
Cone Biopsy: A cone shaped piece of tissue from both the ecto and edocervix is removed- used when no tumour is visible but is suspected
Dilatation & Curettage: A procedure which medication is given to the pt to dilate the cervix and allow access to the uterus at which point a curette is used to obtain a biopsy of intrauterine tissue- allows investigation of uterine extansion
Cytoscopy and/or rectosigmoidoscopy: In order to investigate the bladder and lower GI tract

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19
Q

most common pathology of cervical cancer

A

80-90% are SCC

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20
Q

other pathologies of cervical cancer after the most common one?

A

adenocarcinoma and adenosquamous carcinoma

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21
Q

what staging systems are used in staging cervical cancer

A

FIGO and TNM

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22
Q

staging cervical cancer

A

Stage I:
A) Microinvasive disease limited to the cervix
B) Confined to the cervix w/ invasion >5mm deep from the surface or >7mm spread in horizontal direction
Stage II:
A) Extension to vaginal mucosa but not into lower ⅓ of vagina
B) Extension to parametrium but not reaching pelvic side wall
Stage III:
A) Extension to lower ⅓ of vagina
B) Extension to pelvic side wall
Stage IV:
A) Involvement of bladder and rectal mucosa
B) Distant mets

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23
Q

indications for surgery in cervical cancer

A

reserved for early stage cancer

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24
Q

surgical options for cervical cancer

A 
total abdominal hysterectomy
total hysterectomy
subtotal hysterectomy
laser therapy 
cryotherapy 
radical trachelectomy
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25
Q

total abdominal hysterectomy

A

Removal of the uterus, tubes, ovaries, upper vagina, parametrium and pelvic l/n- used for early stage invasive cancer w/ or w/o a small amount of vaginal involvement

26
Q

total hysterectomy

A

removal of cervix and uterus

27
Q

subtotal hysterectom

A

removal of the uterus and not the cervix

28
Q

laser therapy

A

used for precancerous tumours , a laser eliminates abnormal cells

29
Q

cryotherapy

A

liquid nitrogen is used for removing abnormal cells used for pre invasive conditions

30
Q

indications for chemotherapy

A

post-op for high risk early disease

for advanced disease

31
Q

chemo agents used and when

A

used concurrently with XRT
agents are cisplatinum and 5 FU
when just cisplatinum is used, there is 5-6 treatments per week, when cisplatinum + 5FU is used there is 2 treatments every 3 weeks

32
Q

indications for XRT:

A

Post op when 2 or more of the following risk factors are present…
Capillary lymphatic space involvement
Middle third or greater stromal invasion
Tumour =/> 4cm
In combo w/ brachy for stage IB and above
Palliation

33
Q

Use of prone XRT treatment

A

Prone: Not typically used but offers advantage of displacing the small bowel anteriorly- especially beneficial for posthysterectomy pts as the small bowel tends to fall into the treatment field

34
Q

preparation for XRT treatment

A 
Full Bladder:
Stabilize the position of the cervix
Reduce amount of small bowel in the field
Reduce dose to bladder
Empty Rectum: 
Stabilize the position of the cervix
Reduce amount of rectum treated
35
Q

planning CT scanning limits

A

Sup Border – L3/L4

Inf Border – 5cm inf from ischial tuberosities

36
Q

when is the conventional cervical XRT planning technique used?

A

Indications: Typically used in a palliative setting

and is a 4 field box with AP/PA field and lats

37
Q

field borders of conventional cervical cancer technique

A

Sup= L5/S1 or L4/L5 (may be increased to T11/12 if paraortics are involved)
Inf= Obturator foramina (may be lower to include entire vagina if involved)
Lat= 2cm lat of pelvic brim
Ant= Symphysis pubis
Post= S2/S3 or 2-3cm post to known extent of disease or to cover 50% of the rectum
If the paraortics are involved then there may need to be extended field or the pelvis and the paraortics may have to be treated separately (requiring a gap calc)

38
Q

phases in conventional cervical cancer technique

A

Phase 1: Treats the entire pelvis to a dose below 20Gy

Phase 2: Boosts the entire parametria an additional 30Gy using a midline shield

39
Q

when is IMRT used in treating cervical cancer?

A

IMRT is used in all curative cases

40
Q

Treatment margins for intact cervical cancer XRT

A

CTV= includes entire GTV, cervix, parametria, ovaries and mesoractum of the uterosacral ligaments- if the upper ⅓ of the vagina is involved then the upper ⅔ should be included and if more of the vagina is involved then the entire vagina should be included- l/n should be included in this as well

41
Q

Treatment margins for post hysterectomy XRT

A 
CTV= all regions of gross or microscopic disease which would include regional l/n, parametrium and upper half of the vagina
PTV= CTV + 7-10mm
42
Q

doses of XRT in cervical cancer

A 
Typically whole pelvis treated to 40-50Gy/ 20-25 (NECC uses 45Gy/25) w/ brachy to follow
45Gy/25 EBRT AND 28Gy/4 HDR brachy
45Gy/25 amd 30Gy/3 at 1Gy/hr PDR brachy
50Gy/25 EBRT and 24Gy/4 HDR brachy
50.4Gy/28 EBRT and 28Gy/4 HDR brachy
43
Q

treatment of stage 1A cervical cancer

A

Conization may be a suitable treatment for lesions <1mm provided all margins are negative and careful follow-up is performed
Larger lesions may be treated with total abdominal/modified radical hysterectomy/trachelectomy or intracavitary brachy (EBRT usually not needed in addition to brachy if the lesion <1cm)
Intracavitary doses would be 60 to 75 Gy, in two LDR insertions or with the equivalent dose using HDR brachytherapy, approximately 10 fractions of 5 Gy per fraction
When the depth of penetration by tumor is <3 mm, the incidence of lymph node metastasis is 1% or less and a lymph node dissection or pelvic external irradiation is not warranted

44
Q

treatment of stage 1B-2A cervical cancer

A

Typically treated w/ total abdominal hysterectomy and pelvic lymphadenectomy
May receive post op chemoradiation

45
Q

treatment of stage 2b-4a cervical cancer

A

Typically receives concurrent chemoradiation
EBRT to 45Gy/25 w/ possible brachy and five to six weekly doses of cisplatin or two doses of cisplatin and 5-FU every 3 weeks

46
Q

treatment of stage 4b cervical cancer

A

Treated palliatively which may include XRT to relieve pain or to stop bleeding

47
Q

most important prognostic indicator in cervical cancer.. what are the other factors?

A 
Stage is the most influential
Other factors include…
Age- younger is worse
Race
L/N involvement
LVI
Histopathology- squamous better than adenocarcinoma
48
Q

what are the 2 main treatment options for stage 1b-2a v

A

XRT or SX

49
Q

What is the best treatment option for a stage IB pt who is 25y.o. and would like to start having children

A

Surgery is preferential

if pt needs XRT she should have an ovarian transposition

50
Q

what is the problem with ovarian transpositions when it comes to fertility

A

pt can maintain fertility however they will not be able to have the child without a surrogatee as this procedure require the detachment of fallopian tubes and ovaries from the uterus and cannot be reattached

51
Q

CT scanning limits

A

L3-L4 to 5 cm ind of ischial tuberosities

52
Q

stage 1a treatment options

A

1) surgery (radical trachelectomy ) for its who want children or extrafascial hysterectomy
2) Brachy 50/10 for HDR or 60-75/2 LDR

53
Q

IF A PT has a stage 1B-2A bulky disease, what extra treatment ill they get?

A

a weekly dose of crisp;actinium

54
Q

stage 1b-2a treatment if children are wanted post therapy

A

if pt wants children- sx id + margins, LN then they will also get XRT- EBRT-45/25 + 15Gy LDR or 11/2 HDR

55
Q

Stage 1B-2A treatment for 60y.o. pt

A

Pt is no longer at child bearing age therefore preservation of ovaries is not necessary- they will receive XRT 45//25 +GDR brachy 28/4

56
Q

LN drainage

A

Parametrical-pelvic-common iliac-paraortic- supraclavicular

57
Q

what LN are most commonly involved in cervical cancer

N.B. not the same as the route of drainage

A

pelvic and common iliac are most common

58
Q

General treatments for stage 2B-4A

A

chemorads

59
Q

Treatment 4B disease

A

palliative chemo cisplatinum + ifosfamide
palliative EBRT
for gene bleeding - ferric sulphate + palliative EBRT 3-4Gy x 3-5Fx

60
Q

what is th out common side effect from XRT

A

anemia- 12-16g/dl hemoglobin levels are normal, below indicates anemia

61
Q

when PA ln are + there is a 35% risk of spread of what?

A

supreclavicular LN

62
Q

pt finishes XRT and experiences abdominal distention and hyperactive bowel sounds… what could this indicate?

A

bowel obstruction

Skin Radiation therapy (40 decks)

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