OQ: Cervical Cancer Flashcards
What is risk of residual disease after ckc for AIS?
Neg margins – 20% residual AIS, 2% risk undiagnosed cancer, recurrent AIS 2.6%
Pos margin - 60% residual AIS, 6% invasive adenocarcinoma, recurrent AIS 20%
Pt is s/p rad hyst. When would you recommend post op RT? Do you recommend concurrent chemo? If yes then what agent? Why?
Those who meet sedlis (HIR) or peters criteria (high risk)
Sedlis (GOG99)
Size stromal invasion
+LVSI any deep ⅓ stromal invasion
+LVSI 2cm middle ⅓ stromal invasion
+LVSI 5cm superficial ⅓
-LVSI 4cm middle
(47%) reduction in risk of recurrence (relative risk = 0.53, P = 0.008, one-tail) among the RT group, with recurrence-free rates at 2 years of 88% versus 79% for the RT and NFT groups. No diff in OS or distant recurrence, benefit is in local recurrence.
Peters (GOG109) - +parametria, pelvic LN, or +margin
cis+5FU q3 weeks x 4 cycles with EBRT vs EBRT only
4yr PFS: 80% chemoRT vs 63% RT alone (SS). OS: 81% chemo RT vs 71% RT alone (SS). Gr3-4 Toxicity 3 vs 17%, mostly hematologic
ChemoRT specifically beneficial in lesions >2cm, 2 or more nodal mets, adeno subtypes.
2cm bulky pelvic LN at rad hyst - abort vs continue? Why?
Abort!
Landoni 1997 Lancet - surgery with adjuvant RT for peters criteria or <3mm margin (63% got RT) vs primary radiation (no chemo). Similar OS (74vs 83% NS) and PFS (RR 25% vs 26%), but surgery+RT resulted in significantly more gr2-3 complications (surgery 28%, RT 12%) esp lymphedema (9% vs 0%).
Right…surgery + RT vs. RT had similar outcomes, but worse toxicity in combined arm.
A 2021 international retrospective study showed that completion of radical hysterectomy (361 pts) compared to aborting hyst (154 pts) does not improve survival in patients with intraoperatively detected lymph node involvement, regardless of tumour size or histological type.
What is innervation of the bladder? Where does it come from and how does it come in? How do you manage bladder dysfunction after rad hyst? How often is bladder dysfunction after type 2 rad hyst? Type 3 rad hyst?
- Parasympathetic – (uterosacral ligament) pelvic nerves
- Sympathetic – (cardinal ligament) inferior mesenteric ganglion L1,2,3-> hypogastric nerve
- Somatic – (pelvic floor towards urethra) pudendal nerve S2,3,4
–If posterior cardinal ligament preserved, hypotonic bladder in 30%, incontinence in 10%.
–Denervation results in detrusor hypertonicity. Radiation may exacerbate bladder dysfunction. UTD: bladder dysfunction is present in 70 to 85 percent of women for up to 12 months postoperatively, including urinary incontinence or retention.
–Morrow: for type 3 rad hyst, 75% have normal bladder function at 2 weeks, nearly all at 3 wks
Sentinel lymph nodes in cervical cancer? How reliable is it? Do you send frozen?
Senticol 1 study - stage 1A1 +LVSI to stage 1B1 (<4cm), all received SLN Bx and full lymphadenectomy. 0% false negative rate if bilateral mapping. Sensitivity 77% if unilateral mapping (23% false neg).
Senticol2 - quality of life is better with SLNbx alone (sln vs sln+pln; primary outcome- complications; secondary outcome- QOL). Metaanalysis confirm safety and sensitivity 97-100% if <4cm, neg PET, bilateral mapping, and ability to ultrastage.
Ongoing SENTICOL3 and SentiX study looking at oncologic outcomes.
Who do you do rad hyst in?
1A1 with LVSI to 1B2 <4 cm tumors without parametrial involvement, SCC, adenocarcinoma, no metastatic disease on imaging.
How do you select MIS vs laparotomy?
No one does MIS anymore after LACC trial showed (HR) 4.5 x risk recurrence at 3 years and 6x risk death. LACC- Non inferiority, randomized phase 3 trial- Most patients (91.9%) had stage IBI disease. 52% of the study subjects had tumor < 2 cm, but fewer of the recurrences came from tumor < 2 cm (< 20%). Large database studies show increased risk of recurrence and death with MIS in tumors <2cm.
How do you counsel pt about risks of lymphedema?
It’s 10-25% if you get surgery + RT. Otherwise risk is low 1-2% with surgery alone or RT alone.
Gog 244- LEG study in gyn onc patients ~ 35% of 138 cervical cancers. The peak incidence of lymphedema was at the 4-6 week assessment. There was no association with radiation or other risk factors.
What preop imaging do you recommend? What is sensitivity/specificity of each for parametrial or nodal disease?
- Stage 1A - CXR
- Stage 1B, 2A considering surgery - MRI, PET/CT
- Stage 2B, 3 - PET/CT only. MRI optional for radiation planning
- Any fertility sparing - MRI
MRI is most sensitive for central disease and parametrial disease but clinical exam is similar - 85-90% sensitive, only 75% sensitive for nodal disease
PET is 90% sensitive for nodal disease but only 55% sensitive for parametrial disease
What are complications of RT? RT + Surgery? RT+chemo?
Complications of RT:
Acute: fatigue, skin erythema, diarrhea, bladder irritation
Chronic: insufficiency fractures esp SI joint (5 yr incidence of 20%), sexual dysfunction, lymphedema, soft tissue necrosis/fibrosis/stenosis incl rectal or bladder (tx with pentoxyfylline- vasodilator, vitE, hyperbaric O2)
Complications of surgery+RT:
Same but ~35% vs 13% gr3 toxicity with addition of surgery. Also increased risk fistula, intestinal perf, intestinal obstruction.
Complications of chemo+RT:
Same and hematologic (neutropenia), GI (nausea, emesis, diarrhea), neutropenic fever, bowel perforation.
What is data for concurrent chemoRT vs RT alone?? What about in the adjuvant setting? What is PFS or OS benefit? What is toxicity difference?
Definitive therapeutic CRT:
3 randomized prospective trials (Morris, Whitney, Rose) showing concurrent cispl based chemo with XRT improves outcome in bulky IB to IVA disease. Surgically staged with PPALND. Generally 10-20% OS advantage over 3-8 years (65% vs 45-55%).
Adjuvant:
Peters, GOG 109: +parametria, pelvic LN, or +margin…cis+5FU q3 weeks x 4 cycles with EBRT vs EBRT only
4yr PFS: 80% chemoRT vs 63% RT alone. OS: 81% chemo RT vs 71% RT alone. Gr3-4 Toxicity 3 vs 17%, mostly hematologic. chemoRT specifically beneficial in lesions >2cm, 2 or more nodal mets, adeno subtypes.
How do you manage stage 2A1 disease? Why?
Generally chemoRT but if lesions are small IB2 or IIA with only fornix involvement, could offer RH/LND. Advantages: surgical staging, oophoropexy in young, and chance of sparing XRT or decreased radiation for better sexual function.
When to do type 2 vs type 3 rad hyst? What is the difference between them?
Difference - uterosacral ligament (at least 2 cm/entire vs 1-2cm from cervix), Parametrium (medial aspect of internal iliac vessels vs resection at ureter bed), amount of vaginal margin ( top ⅓ vs 2cm)
When: NCCN - IA1 s/ LVSI and IA2 mod rad, 1B-IIA1 rad
Data: Some given here, Landoni et al, but not sure it really answers the question, but looked at class II vs. class III and saw similar survival for IB-IIA, any tumor size, less morbidity with type II.
Is any histology a contraindication to rad trachelectomy?
Yes adenoma malignum, small cell carcinoma, large cell, endocervical gastric/intestinal type
What are risks/benefits to transperitoneal vs extraperitoneal LND?
Extraperitoneal – Less risk of fistula or bowel obstruction if pt is going to receive radiation later. 35% risk adverse events with extraperitoneal LND + RT vs 45% with transperitoneal LND+ RT.
