Cervical Cancer (must knows) (both NCCN and Perez) (under construction)

Question 1

What are the components of Sedlis Criteria, which are intermediate risk factors that guide adjuvant treatment?

Answer 1

> 1/3 stromal invasion
CLSI (capillary lymphatic space invasion)
T >4 cm

Question 2

What are the predictors of lymph node involvement in cervical adenocarcinoma?

Answer 2

pattern of stromal invasion
LVSI

(not T stage/size)

Question 3

What is the “fertility sparing approach” for FIGO IA1 without LVSI?

Answer 3

conization + negative margins (>3mm)

*repeat cone biopsy if positive margins

Question 4

What is added to the “fertility sparing approach” for FIGO IA1 if “with” LVSI?

Answer 4

+lymphadenectomy

(base treatment is a conization with negative margins, may also consider radical trachelectomy)

consider SLN mapping

Question 5

What is the “fertility sparing approach” for FIGO IA2, IB1 or select IB2?

Answer 5

radical trachelectomy +pelvic lymphadenectomy
±paraaortic lymphadenectomy
consider SLN mapping

Question 6

Although radical trachelectomy has been used for bigger tumors, what is generally considered the cut-off size?

For bigger size than the cuttoff, what approach to radical trachelectomy is preferred?

Answer 6

≤2 cm

abdominal

Question 7

What FIGO stage can be adequately treated by a simple extrafascial hysterectomy?

Answer 7

IA1 no LVSI

Question 8

What are the treatment options for FIGO IA1+LVSI, IA2?

for patients who do not wish to preserve fertility

Answer 8

Modified radical hysterectomy
+pelvic lymphadenectomy
consider SLN mapping

or

Pelvic EBRT + brachytherapy

Question 9

What are the treatment options for FIGO IB1, IB2, IIA1?

for patients who do not wish to preserve fertility

Answer 9

Radical hysterectomy + pelvic lymphadenectomy (1)
±para aortic lymphadenectomy (2b)
consider SLN mapping

or

Pelvic EBRT + brachytherapy
±concurrent chemotherapy (1)

Question 10

What is the preferred treatment (category I NCCN) for FIGO IB3, IIA2 cervical tumors? (>4 cm)

(for patients who do not wish to preserve fertility)

Answer 10

Pelvic EBRT + brachytherapy
+concurrent chemotherapy
(cat1)
+ selective completion +hysterectomy (cat3 for hys)

or

radical hys +pelvic lymphadenectomy ±paraoartic lymphadenectomy (2b)

or

Question 11

If after surgical treatment, findings are negative parametria, negative nodes, negative margins, what are the options?

Answer 11

observe

or adjuvant RT (Sedlis criteria) - Cat 1
±concurrent chemotherapy (2B)

Question 12

If after surgical treatment, findings are + pelvic nodes, or margin, or parametria, what is the next step if imaging is negative for metastases?

Answer 12

EBRT + concurrent chemotherapy (1)
± vag. brachytherapy

EFRT if para-aortic node+

Question 13

If after surgical treatment for advanced FIGO stages (>IIB), imaging findings are negative for nodes, what is the next step?

Answer 13

EBRT + concurrent chemotherapy

+brachytherapy

Question 14

If after surgical treatment for advanced FIGO stages (>IIB), imaging findings are negative for para-aortic nodes, but + for pelvic nodes, what is the next step?

Answer 14

EBRT + concurrent chemotherapy
+brachytherapy
±para-aortic node RT

Question 15

How do you regularly follow-up patients after EBRT?

Answer 15

every 3-6 months for first 2 years
every 6-12 months for succeeding 3-5 years
then annually

Question 16

What are the predictors of para-aortic lymph node metastases in FIGO IB and IIB?

Answer 16

+pelvic node
T >2cm
+common iliac nodes

Question 17

Trials have shown a ___ to ___% decrease in the risk of death following CCRT in locally advanced cervical cancers compared to RT alone.

Answer 17

30 to 50

Question 18

Landmark Trials in Cervical Cancer CCRT

Identify the study group and number based on the primary author:

Whitney et al.

Answer 18

GOG 85

Question 19

Landmark Trials in Cervical Cancer CCRT

Identify the study group and number based on the primary author:

Eiffel et al.
(Morris)

Answer 19

RTOG 90-01

Question 20

Landmark Trials in Cervical Cancer CCRT

Identify the study group and number based on the primary author:

Peters et al.

Answer 20

SWOG 8797 / GOG 109 / RTOG 91-12

Question 21

Landmark Trials in Cervical Cancer CCRT

Identify the study group and number based on the primary author:

Keys et al.
(Stehman et al.)

Answer 21

GOG 123

Question 22

Landmark Trials in Cervical Cancer CCRT

Identify the study group and number based on the primary author:

Rose et al.
(Bundy, Watkins et al.)

Answer 22

GOG 120

Question 23

Landmark Trials in Cervical Cancer CCRT

1. Identify the study population:
2. Describe the study’s control and investigational arm:

Keys/Stehman et al. (GOG 123)

Answer 23

IB2 (bulky IB ≥4 cm)

RT
vs.
RT+cisplatin

RT
vs.
RT+weekly cisplatin (40 mg/m2 IV weekly x 6 wk)

Question 24

Landmark Trials in Cervical Cancer CCRT

1. Identify the study population:
2. Describe the study’s control and investigational arm:

Whitney (GOG 85)

Answer 24

IIB-IVA

RT+hydroxyurea vs. RT+CIS/FU

RT + hydroxyurea (80mg/kg PO 2x/wk)
vs.
RT + cisplatin (50 mg/m2 IV days 1, 28) + 5-FU infusion (1g/m2 per day, days 2–5, 30–33

RT dose: 51 Gy + 30(Pt A)

Question 25

Landmark Trials in Cervical Cancer CCRT

1. Identify the study population:
2. Describe the study’s control and investigational arm:

Rose (GOG 120)

Answer 25

IIB-IVA

RT+hydroxyurea
vs.
RT+weekly cisplatin

---
RT + hydroxyurea (3 g/m2 PO 2x/wk)
vs.
RT+ RT + cisplatin (50 mg/m2 IV days 1, 29) + 5 FU infusion (1 g/m2 per day, days 1–4, 29–33) + hydroxyurea PO (2 g/m2 2x/wk x 6 wk)
and
RT + cisplatin (40 mg/m2 weekly x 6 wk)
versus

Question 26

Landmark Trials in Cervical Cancer CCRT

1. Identify the study population:
2. Describe the study’s control and investigational arm:

Eiffel et al. (RTOG 90-01)

Answer 26

IB2-IVA (≥5 cm + nodes)

EFRT
vs.
RT+CIS/FU

RT (pelvic + para-aortic)
vs.
RT + cisplatin (75 mg/m2 IV day 1) + 5-FU infusion (1 g/m2 per day, days 1–5 3x q3 wk)

Question 27

Landmark Trials in Cervical Cancer CCRT

1. Identify the study population:
2. Describe the study’s control and investigational arm:

Peters et al. (SWOG 8797/GOG 109/RTOG9112)

Answer 27

IB or IIA (post op/pathologic stage)
+ positive pelvic nodes and/or positive margins and/or microscopic involvement of the parametria

RT
vs.
RT+CIS/FU

RT + cisplatin (70 mg/m2 IV) + 5-FU infusion (1 g/m2 days 1–5 x 4 q3 wk)