Cervical Cancer Flashcards
What supports PET-CT in cervical cancer staging?
Addition of PET to DCT resulted in statistically borderline increase in sensitivity to detect LN metastasis in abdomen in advanced cervical cancer.
For stage IB-IIA cervical cancer, which is superior in terms of survival, radical hysterectomy or primary radiotherapy?
Landoni randomized trial. There is no treatment of choice for early-stage cervical carcinoma in terms of overall or disease-free survival. The combination of surgery and radiotherapy has the worst morbidity, especially urological complications.
Which study looked at which patients benefit from radiation after radical hysterectomy and lymphadenectomy?
GOG-092, Sedlis et al., looked at intermediate high-risk features, CLS, stromal invasion, tumor size, RR 0.53 for recurrence free survival if radiation added. Ongoing trial looking at EBRT vs. Cis EBRT.
When should you use adjuvant chemoradiation (los dos) rather than just radiation following radical hysterectomy and lymphadenectomy?
GOG-109, Peters et al. Looked at RT vs. CT+RT and showed improvement in PFS/OS for patients getting CT+RT with high risk features, 1 or more, positive nodes, parametria, or vaginal margin
Is laparoscopic approach appropriate for cervical cancer?
LACC noninferiority trial involving patients with stage IA1 (w/ LVSI), IA2, or IB1 cervical cancer randomized to open or robot hyst, minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy among women with early-stage cervical cancer. Criticized for high survival in open arm and not generalizable to less than 2 cm w/o LVSI. Confirmed in other retrospective studies. Change here was pretty large, DFS dropped by 10%, OS from 99 to 94. :(
What do large retrospective studies show regarding radical trachelectomy?
5 year overall survival rates 97%+. 10% you need complete radical hysterectomy or abandon procedure, ~50% of women go on to try and conceive, pregnancy rates around 70%, half of which result in term pregnancy, 25% had either 2nd trimester loss or preterm delivery.
Why do we give radiosensitizing cisplatin with radiation for cervical cancer?
5 big trials showed reduction in risk of death by 30-50%, very consistent between trials, be it pre-op chemorad for stage IB3 prior to hyst, definitive stage 1B3, II, III, all had better PFS/OS. The Rose study in locally advanced established cisplatin at our dose we use as standard.
Peters 109. GOG 123 1b cervix preop chemorad with hyst better than rad then hyst. Rose study radiation w/ hydroxyurea, rad w/ 5-FU and hydroxyurea, and with platinum. Platinum won at the dose we currently use, 40 mg/m2. Morris trial chemorad vs. pelvic rad + EF, chemorad won. Whitney did platinum with 5-FU with rad vs. rad alone for locally advanced.
Evidence for pelvic exenteration?
Graves 2017 big collection of cases retrospective. Median OS for node neg central recurrence about 73 months. OS 70% at 5 years. No randomized trials.
First line therapy for advanced disease, what’s the evidence?
GOG 204, III RCT looked at advanced cervical cancer adding Bev to cis/taxol or topo/taxol, showed improved 3 months OS. 15% fistulas if previously radiated, though! Avastin particularly helped patients with mid to high risk per Moore criteria.
Moore: The variables examined were race (African ancestry or not), performance status (1 or 0), measurable disease in the pelvis (yes/no), prior platinum as a radiation sensitizer (yes/no), and progression-free interval from the diagnosis of disease (< 365 days or ≥ 365 days). Risk categories included low risk (0–1 factor), mid risk (2–3 factors), and high risk (4–5 factors).
What established carboplatin as active in cervical cancer?
JCOG-0505 noninferiority trial established carboplatin as option, but in patients who were platinum naive there was better survival if they got cisplatin (10 months better!). So if they’ve gotten Cis during radiation, go ahead. If not, then no.
What data supports Pembrolizumab for cervical cancer?
KEYNOTE-158, PD-L1 score positive (> or = 1) cervical cancers, score is # of any PD-L1 positive cells over total number of tumor cells). They looked at ORR, 14%. Enough to get approved 2nd line. Median duration not reached but had some prolonged responses.
Why is paclitaxel added as a doublet to cisplatin?
GOG 169 RCT addition of paclitaxel to cisplatin improves PFS by 2 months (2.8 to 4.8) and had double the response rate (19 to 38%) in women with advanced or recurrent SCC of the cervix. No OS difference that I can see.
Why don’t we routinely perform completion hysterectomy after primary chemoradiation for cervical cancer?
GOG 71: The addition of an adjuvant hysterectomy does not improve survival in women with bulky stage IB cervical cancer, however no chemo added to radiation, and maybe some suggestion of benefit in 4-6 cm tumors. However, later small trials like Gyneco-2 which did treat with chemoRT in IB and stage II, were not powered to show benefit but really didn’t show any clinically meaningful results.
What data do we have on surgical pathological risk factors for cervical cancer?
GOG 49 was a big prospective study of stage I, found >⅓ stromal invasion, LVSI, > 4cm tumor, age ≤ 50 years all risk factors for LN mets, increased risk of relapse and death.
What data is there for sentinel lymph node dissection in cervical cancer?
Retrospective data from MDACC shows “sensitivity 96.4% and NPV of 99.3% (95% CI 95.6%-100%). The false-negative rate was 3.6%.
Senticol 1 showed some aberrant lymphatic pathways could be picked up, Senticol 2 seemed to show good sensitivity and NPV for sentinels and better QOL. Really no prospective survival data for this and, remember, the bar was lower for endometrial cancer where the utility of LND is already debated.
