Treatment recommendations

Question 1

Stage IA1 SOC

Answer 1

Radical hysterectomy alone

Question 2

Stage IA2 SOC

Answer 2

Radical hysterectomy with PLND

Question 3

Stage IB1

Answer 3

1. Radical Hysterectomy with PLND +/- PORT 2. EBRT + brachytherapy

Question 4

Stage IB2

Answer 4

1. EBRT + Brachytherapy 2. Concurrent weekly cisplatin with EBRT

Question 5

Stage II-IVA

Answer 5

1. EBRT + brachytherapy 2. Concurrent weekly cisplatin with EBRT

Question 6

What are the elements of the history to capture?

Answer 6

1. Hx of vaginal bleeding, vaginal dischage, pelvic pain, change in bowel or bladder habits

Question 7

What are the elements of the physical exam?

Answer 7

1. LND: inguinal and supraclavicular
2. Abdominal
3. GYN:
   1) speculum exam to examine tumor size, and vaginal extension
   2) Bimanual exam to determine if there is vaginal wall involvement
   3) Rectal exam to determine if there is any parametrial extension and determine the width of the cervicx mass

Question 8

What imaging should be ordered at work up?

Answer 8

CT scan of abdomen/pelvis,

PET/CT,

MRI of pelvis

Question 9

Indications for PORT

Answer 9

Combined 2 or more of the following:

1. More than 1/3 cervical stromal invasion
2. LVSI
3. Tumors more than 4 cm

Question 10

Indications for PORCT

Answer 10

One or more the following

1. Positive nodes
2. Parametrial extension
3. Positive margins

Question 11

What PT is needed after RT?

Answer 11

1. Use of vaginal dilator

Question 12

Long term toxicity of RT?

Answer 12

SBO Femoral head fractures Vaginal stenosis Fistula Ureteral stricture

Question 13

Acute complications of RT?

Answer 13

1. Cystitis 2. Diarrhea 3. Nausea 4. Vaginitis 5. Desquamation

Question 14

What are advantages of surgery compared to RT for early stage cervix cancer?

Answer 14

1. Better functional vagina 2. Preservation of ovarian function 3. Reduced second cancers

Question 15

When should inguinal nodes be included in the fields?

Answer 15

When the cervix tumor involves the lower third of the vagina?

Question 16

What are the most important prognostic factors with cervix cancer?

Answer 16

Tumor and Nodal stage

Question 17

For which stage is a simple hysterectomy adequate?

Answer 17

Stage IA1

Question 18

For what stage is brachytherapy alone adeqaute?

Answer 18

Stage IA

Question 19

What is a Class II modified radical hysterectomy?

Answer 19

Removal of uterus

Ureters are unroofed and parametrial and paracervical tissue medial to ureters are removed

Upper 1-2 cm of vaginal cuff are removed

Uterine artery is liagted at the ureter

Question 20

What is point A?

Answer 20

2cm lateral to tandem and 2 cm above external os

Question 21

What dose can cause sterility?

Answer 21

2-3 Gy

Question 22

What dose causes ovarian failure?

Answer 22

5-10 Gy

Question 23

What is the dose to the initial pelvic field?

Answer 23

45 Gy at 1.8 Gy/fx

Question 24

What is the typical sidewall boost?

Answer 24

5.4 to 9 Gy at 1.8 Gy/fx

Question 25

What dose and technique are bulky nodes treated to?

Answer 25

60 Gy with IMRT of 3D conformal

Question 26

What study described the indications for POCRT?

Answer 26

GOG 109 showed that OS and PFS improved with POCRT for patients with +margins, +nodes or parametrial extension

Question 27

What study indicated that OS was better for patients with Stage IB2 or higher cancers treated with chemoRt vs. RT alone?

Answer 27

GOG 123

Question 28

What study showed the indications of PORT?

Answer 28

GOG 92

Question 29

What percentage of cervix cancers are squamous cell carcinoma? Adenocarcinoma?

Answer 29

SCCa: 70% Adeno: 25%

Question 30

What percentage of cervix cancers are squamous cell?

Answer 30

90% are SCCa 10% adenocarcinoma 1% clear cell

Question 31

What is the risk of pelvic and paraaortic nodes for Stages IA to IB?

Answer 31

Pelvic and Paraaortic 1. IA1: 1% vs. 0 2. IA2: 5% vs. 0 3. IB: 15% vs. 5%

Question 32

What is the risk of pelvic and paraaortic nodes for Stages II to IV?

Answer 32

Pelvic and Paraaortic Stage II: 30% vs. 15% Stage III: 50% vs. 25% Stage IV: 50% vs. 35%

Question 33

What labs are needed at work up?

Answer 33

BMP, CBC, HIV

Question 34

How is a tissue diagnosis made?

Answer 34

Cone biopsy of the cervix tumor

Question 35

What special studies are needed?

Answer 35

Cystoscopy or colonoscopy for patients who have symptoms or just Stage IIB or higher disease

Question 36

What are the types of hysterectomy?

Answer 36

Type I: removes no parametrium or vagina Type II: removes parametria medial to the ureters Type III: Removes entire parametria and upper 1/3 of vagina

Question 37

What study supports RT for Stage IB to II disease?

Answer 37

Landoni study ## Footnote 1. Surgery vs. 2. EBRT + LDR implant No difference in OS and DFS. No difference in recurrence rate. Severe complications higher with surgery 28% vs. 12%, p\<0.05

Question 38

What study supports the indications for PoRT? POCRT?

Answer 38

1. Sedlis GOG 92 (Surgery alone vs. surgery + EBRT). RT improves RFS. 2. Peters GOG 109: (Surgery + PORT vs. surgery + POCRT): Chemo improves OS and RFS

Question 39

What are the indications for PO vag brachytherapy boost with EBRT? What dose to you treat to?

Answer 39

1. Closer or positive vaginal cuff margin 2. EBRT to 45 Gy 3. HDR brachytherapy 5 Gy x 3

Question 40

What chemotherapy do you use?

Answer 40

1. Cisplatin 40 mg/m2

Question 42

What dose rate distinguishes HDR vs. LDR?

Answer 42

HDR: \> 12 Gy/hr LDR: 0.5 G/hr