Cervix CA

Question 1

What are the usual histologies for Cervix CA?

Answer 1

1) Squamous Cell Carcinoma (80%) - High risk
- Large cell Keratinising
- Large cell non-Keratinising
- Small Cell
2) AdenoCarcinoma (15%) - High risk
3) Neuroendocrine

Question 2

What are the risk factors for Cervix CA?

Answer 2

1) Smoking
2) immunocompromised
3) Early age of 1st sexual activity
4) multiple parity
5) Earlier age at first birth
6) Multiple sexual partners
7) Hx of STIs
8) Hx of vulvar/vaginal intraepithelial neoplasms or cancer
9) High risk sexual partner
10) non-white
11) Lower socio-economic status
12) Genetics
13) Sex with uncircumcised male
14) Oral contraceptives usage

Question 3

Tell me more about HPV infection

Answer 3

As high as 45% in women 25-29yo in US
Majority clear the virus w/o specific intervention (90%)
In a minority, the virus persistS

With persistent infection, HPV Genes E6 and E7 are incorporated into cervix cells

• Viral proteins capable of binding to and inactivating tumor suppression proteins are produced. (
• HPV subtype 15 high risk
• HPV 16 and HPV 18 most prevalent, and are responsible for >70% of cervical cancer worldwide

Question 4

What are the 2 HPV Vaccines that you know of:

Answer 4

Gardasil (6,11,16,18)

Cervarix (16,18)

Question 5

What are the low risk HPV subtypes

Answer 5

6,11

- low grade squamous intra-epithelial lesion (SIL)/condylomata

Question 6

What are the high risk subtypes for HPV?

Answer 6

16,18, 31, 33, 52

Question 7

Tell me in brief the FIGO staging for Cervix CA

Answer 7

I - Limited to uterus

I - Extends beyond the cervix, but not to the pelvic side wall or to lower 1/3 of vagina

III - Extends to pelvic side wall or to lower 1/3 of the vagina, or causes hydronephrosis

IV - extends beyond true pelvis; and/or invades mucosa of bladder/rectum; or distant mets

Question 8

Tell me about FIGO Stage I of the cervix

Answer 8

IA:
- invasive carcinoma Dx only by microscopy
IA1:
Lesions 3 cm or less in depth of stromal invasion, 3m and 4cm

Question 9

Tell me about FIGO stage II of cervical CA

Answer 9

II: tumor extends beyond cervix, but not to pelvic side wall and not to lower 1/3 of vagina

IIA1: No parametric like invasion, clinically visible lesion 4cm

IIB: extends to parametria

Question 10

Tell me about FIGO stage 4 for cervix

Answer 10

IVA: Extends beyond true pelvis, and/or invades mucosa of bladder/rectum

IVB: Distant mets

Question 11

What is the GOG score?

Answer 11

= relative risk for the depth X tumor size X capillary space involvement

GOG score 120 = Standard field RT+ brachytherapy OR Small field RT+Brachytherapy

Question 12

What are the indications for adjuvant RT?

Answer 12

> pT2a

Question 13

What is the Sedilis Criteria?

Answer 13

1) >1/3 stromal invasion
2) LVSI
3) Tumor size

Question 14

What are the 5 trials that show better survival rates with concurrent ChemoRT for locally advanced Cervical CA?

Answer 14

1) GOG 123
2) GOG 120
3) GOG 85
4) SWOG 8797
5) RTOG 9001

Question 15

What is GOG 123?

Answer 15

Stehman et al

Aim: Confirm tt concurrent ChemoRT with CDDP a/w improved long-term PFS and OS compared with RT alone in stage IB bulky cervix CA

N=370
Bulky Stage IB cervix Ca, randomized to 2 arms
2 arms:
1) Chemo/RT
2) RT alone 

RESULTS:
4y OS: 85% vs 75% (RT alone)
4y PFS 80% vs 60% (RT alone)

Question 16

What is GOG 120

Answer 16

Peter Rose JCO 2007 (updated analysis at 8y)

N=500
Locally advanced with pathologically Negative para-aortic LN
S/p external-beam RT according to a strict protocol

3 arms:

1) CDDP (40)X 6 weeks
2) CDDP (50) D1, D29 –> FU 4g/m2 over 96 hours D1, 29 + 2g/m2 Hydroxyurea twice weekly X 6 weeks
3) 3g/m2 Oral hydroxyurea twice weekly for 6 weeks

RESULTS:
CDDP-based chemo during pelvic RT improves long-term PFS and OS
No observed increase in late toxicity with CDDP-based ChemoRT.

Question 17

Tell me about the SWOG 8797

Answer 17

Peters et al
N=250
CS IA2, IB, IIA s/p radical hysterectomy and pelvic lymphadenectomy ,+positive LN and/or +margins and/or microscopic involvement of the parametrium

2 arms:

1) RT
2) RT + Chemo

RESULTS:
4y PFS 80% vs 60%(RT)
4y OS 80% vs 70%