NCCN CERVICAL CANCER – Flashcards
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What three things are under the Seidlis criteria?
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Tumor size Stromal Invasion LVSI
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Is a type a hysterectomy?
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Simple/extrafascial hysterectomy
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Is a type B hysterectomy?
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Modified radical hysterectomy
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What is a type C hysterectomy?
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Radical hysterectomy
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When is EUA cystoscopy/proctoscopy used?
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Greater then stage 1B2
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What is the primary treatment for stage 1A with no LVSI?
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- Cone biopsy with negative margins - preferably with 3 mm negative margins
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What do you do if the cone margins or positive.fertility Sparring?
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Repeat the cone or performance a trachelectony
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How do you treat stage 1A1 with LVSI and stage 1A2 Fertility Sparring?
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1. Cone biopsy with negative margins preferably 3 mm negative margins. Plus lymph node dissection 2. Radical trachelectomy plus pelvic lymph node dissection
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How do you treat stage 1B1 cervical cancer?
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Radical trachelectomy plus pelvic lymph node dissection
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What to resize has fertility scaring surgery for IB1 disease most validated for?
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Less than 2 cm
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What should you do after childbearing patients who have fertility sparing surgery for cervical cancer?
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Hysterectomy strongly advised
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How do you treat stage 1A1 nonfertility sparing with no LVSI?
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Cone followed by extrafascial hysterectomy
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What do you do at the cone margins or positive?
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1. Perform a simple hysterectomy or modified radical hysterectomy with pelvic lymph node dissection 2. Or consider repeat cone to better evaluate depth of invasion
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How do you treat stage 1A1 with LVSI and stage IA2 non fertility Sparring?
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1. Modified radical hysterectomy plus pelvic lymph node dissection 2. Pelvic radiation plus Brachytherapy total point A dose 70-80 Gy
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How do you treat IB1 and stage IIA1 cervical cancer?
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1. Radical hysterectomy plus public lymph node dissection 2. Pelvic radiation plus Brachytherapy total point A dose: 80-85 Gy
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How do you treat stage 1B2 and stage IIA2 cervical cancer?
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1. Definitive pelvic radiation therapy 2. Radical hysterectomy with pelvic lymph node dissection
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What tumor size has the best detection rate for SLN mapping?
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< 2 cm
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Concurrent cisplatin based chemotherapy with radiation utilizes what chemotherapy?
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Cisplatin as a single agent or cisplatin plus 5FU
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How do you treat patients with cervical cancer who have negative nodes, negative margins, and negative parametrium?
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1. Observation 2. Pelvic RT if combine high risk factors plus cisplatin based chemotherapy
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How do you treat patients who have positive pelvic nodes and/or positive surgical margin and/or positive parametrium?
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Pelvic RT plus concurrent cisplatin containing chemotherapy plus or minus vaginal brachy therapy
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How do you treat patients with positive para-aotic lymph nodes at the time of surgical staging?
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Check a chest CT or a P ET - CT scan 1. if negative- para aortic lymph node RT plus cisplatin plus pelvic RT plus Breaky therapy 2. If positive for distant metastasis consider a biopsy and systemic therapy if positive if negative then perform the above
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What is an alternative treatment for IB2 and IIA2?
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Check radiographic imaging or surgical staging with extraperitoneal or laparoscopic lymph node dissection
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When performing imaging for cervical cancer if there is positive adenopathy by CT, MRI or PET what do you do?
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It depends on whether it's pelvic or periotic lymph nodes or distant metastasis that are involved
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If pelvic lymph nodes only are positive on imaging how do you manage these patients?
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1. Pelvic RT with concurrent cisplatin containing chemotherapy and brachy therapy +-PA RT 2. Exztraperitoneal or laparoscopic lymph node dissection in
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What if both pelvic lymph nodes and periotic lymph nodes or positive?
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Consider extraperitoneal or laparoscopic lymph node dissection followed by extended field RT containing cisplatin and Brachytherapy
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What if the patient has distant metastasis that his biopsy confirmed on imaging?
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Systemic therapy with individualize RT
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How do you treat a patient with cervical cancer with pelvic lymph nodes that are positive and Para aortic lymph nodes that are negative by surgical staging?
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Pelvic RT plus concurrent cisplatin containing chemotherapy and vaginal Brachytherapy
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How do you treat patients with PA lymph nodes positive buy surgical staging?
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1. If work up is negative for distant metastasis extended field RT with cisplatin and Brachytherapy 2. If work up is positive for distant metastasis systemic therapy with individualized radiation
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Incidental finding of invasive cervical cancer after a simple hysterectomy with stage IA1 disease and no LVSI?
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Observation
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What if the patient had stage IA 1 with LVSI or ; stage IA2?
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1. Pelvic RT with brachytherapy and Cisplatin 2.complete parametrectomy, upper vaginectomy, pelvic lymph node dissection
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How often should vaginal cytology be performed with cervical cancer?
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Annually
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When should imaging be performed during surveillance for cervical cancer?
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As clinically indicated
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What should Patient be educated regarding during surveillance?
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Symptoms of potential recurrence, lifestyle, obesity, exercise, and nutrition counseling
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What should patients be told with regards to vaginal stenosis?
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Should be encouraged to use vaginal dilators and vaginal lubricant/moisturizers example estrogen cream
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How should patients be managed with local regional recurrence with no prior radiation or failure outside of previously treated field?
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Consider surgical resection if feasible followed by two were directed RT with platinum base chemotherapy plus or minus Brachytherapy
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How should patients be managed with local/regional recurrence with prior RT with central disease?
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- Pelvic exenteration plus or minus IORT - - radical hysterectomy or Brachytherapy in patients with disease smaller than 2 cm
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How's your patience be managed with local/regional recurrence with prior RT with noncentral disease?
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- Two were directed RT plus or minus chemotherapy - Resection with I ORT for clothes or positive margins - Clinical trial - Chemotherapy - Best supportive care
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How do you manage patients with distant metastasis with cervical cancer amendable to local treatment?
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- Resection plus or minus RT - Local ablative therapies plus or minus RT - RT plus or minus concurrent chemotherapy -may consider systemic adjuvant chemotherapy he
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How do you manage patients with cervical cancer with distant metastasis not amenable to local treatment?
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- Clinical trial - Chemotherapy - Best supportive care
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With micro invasive cervical cancer defined?
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FIGO stage 1A-1 with no LVSI
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Microvasive cervical cancer has what percent chance of LN metastasis?
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<1%
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How can microinvasive cervical cancer be managed?
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Conservatively with cone biopsy for preservation of fertility or the simple hysterectomy
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What is also reasonable for stage IA1 with LVSI for treatment?
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A cone biopsy with negative margins with laparoscopic pelvic SLN mapping
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What is the preferred treatment for stage 1A-2, 1B, and IIA lesions when fertility preservation is not desired?
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Radical hysterectomy with bilateral pelvic lymph node dissection him
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When is a radical vaginal try colectomy with laparoscopic lymphadenectomy performed?
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Stage Ia-2 Stage IB-1 <2 cm
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How many subsequent pregnancies have been reported after a radical trachelectomy?
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300
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What is the likelihood of second trimester loss?
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10%
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Percentage will carry their gestation to 37 weeks or more?
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72%
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What is the advantage of abdominal radical trachelectomy?
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Provides larger resection of parametria then vaginal approach and is suitable for for select IB1 cases
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How is stage IIB and above usually treated?
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Chemo radiation
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For SLN, what tumor size has the best detection rate?
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< 2 cm
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Where is the dye injected?
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Dye or radiocolloid technetium 99 into the cervix usually at two or four points
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How do you identify the node?
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- Direct visualization of the color dye - A fluorescent camera if ICG was used (indocyanine green) - Gamma probe if 99 TC was used
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Where are the sentinel lymph nodes commonly located?
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Medial to the external iliac vessels, ventral to the hypogastric vessels, or in the superior part of the obturator space
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What type of pathologic evaluation do SLN undergo?
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Ultra staging which allows for a higher detection of micrometastasis that may alter postoperative management
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If failed SLN mapping occurs what should you do?
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Performance of a side-specific nodal dissection
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What is the surgical/SLN mapping Algorithm for early-stage cervical cancer?
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- Excision of all mapped SLN - Any suspicious notes must be removed regardless of mapping - If there's no mapping on the hemipelvis a side-specific LND is performed - Parametrectomy is performed and block with a resection of the primary tumor
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When is a simple hysterectomy type A performed?
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Stage IA-1
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When is a modified hysterectomy/type B performed?
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Stage 1A-1 with LVSI and stage 1A-2
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When is a radical hysterectomy/type C performed?
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Local disease without obvious metastasis including IB-1 and 2 with selected Stage IIA
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When is a simple trachelectomy performed?
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HGSIL Stage 1A-1
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Is a radical Trachelectomy performed?
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Stage IA-2 Stage IB-1 if ; 2 cm and squamous histology
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How much of the vagina is removed with a modified radical hysterectomy?
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1 to 2 cm margin
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How much of the vagina is remove with a radical hysterectomy and trachelectomy?
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1/4 to 1/3 of the vagina
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What is considered standard care for EPRT?
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The use of CT-based treatment planning and conformal blocking
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What is the best imaging modality for determining soft tissue and parametrial involvement in patients with advanced tumors?
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MRI
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What should the volume of a EBRT cover?
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Gross disease is present, parametria, uterosacral ligament, sufficient vaginal margin from the gross disease (at least 3 cm), presacral nodes, other notal volume that risk
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Where do you place EBRT for patients with negative note on Surgical or radiologic imaging?
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The radiation volume should include the entirety of the external iliac, internal iliac and obturator nodal basin
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Who is at higher risk for lymph node involvement?
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- Bulkier tumors - Suspected or confirmed nodes confined to the low true pelvis
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Who should have radiation increase to cover the common iliac as well?
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Patients at risk for lymph node involvement including bulkier tumors and positive nodes confined to the low true pelvis
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How do you treat patients with documented common iliac and/or para-aortic nodal involvement?
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Extended - field pelvic and para-aortic radio therapy is recommended up to the level of the renal vessel
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What is the EBRT dose to cover microscopic nodal disease?
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45 Gy and highly conformal boost of an additional 10-15 Gy may be considered for limited volumes of gross unresected adenopathy
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What chemotherapy is used in concurrent cisplatin based chemotherapy?
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Either cisplatin alone or cisplatin plus 5FU
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Can IMRT be used in replacement of brachytherapy?
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Should not be used as routine alternatives to brachytherapy
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How can vaginal breaking therapy be administered?
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Using ovoid, ring or cylinder combined with an intrauterine tandem
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What is use for Brachytherapy in post hysterectomy patients?
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Vaginal cylinder
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What is used for dosing parameters for brachytherapy?
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Dose at point A
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What type of rate does the NCCN guidelines referred to for dosing for Brachytherapy?
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LDR
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What are the LDR dosing for EBRT per day?
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1.8-2.0 Gy per daily fraction
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What is the dose to point A for brachytherapy for LDR per day?
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40-70 cGy/h
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What is one of the more common HDR approaches?
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- Five insertions with tandem and colpostats, each delivering 6 Gy nominal dose to point A - which gives 30 Gy in five fractions - this is equivalent to 40 GY to point a using LDR brachytherapy
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What is the EBRT dose used to treat patients with an intact cervix?
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45 Gy
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What is the VBT use for patients with an intact cervix?
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30-40 Gy to point A
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What should the total point a dose be?
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80 GY for small volume several tumors 85 GY or greater for large volume cervical tumors
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What should be covered after hysterectomy with regards to adjuvant radiation therapy?
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Upper 3-4 cm if the vaginal cuff, the parametria, and immediately adjacent nodal basin such as the external and internal iliac
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What is IORT?
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Intraoperative radiation therapy
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How does IORT work?
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It delivers a single, highly focused dose of radiation to a tumor bed at risk, Or isolated unresectable residual, during an open procedure
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What is IORT particularly useful in?
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Patients with recurrent disease with in a previously radiated volume
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What is the advantage of IORT?
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You can displace normal tissue from the region at risk
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What is included in Sedlis Criteria?
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LVSI Stromal invasion Tumor resize
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What are the categories of stromal invasion in the Sedlis Criteria?
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Deep 1/3 Middle 1/3 Superficial 1/3 Middle or deep1/3
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What are the category one first line combination chemotherapy's for recurrent or metastatic cervical cancer?
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- Cisplatin/taxol/bevacizumab - cisplatin/taxol - Topotecan/Taxol/bevacizumab
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What other chemotherapies can be first-line chemotherapy and cervical cancer?
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Taxol/carboplatin Cisplatin/Topotecan Topotecan/taxol Cisplatin/gemcitabine
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What category is Jim side of being in cisplatin for first-line chemotherapy for cervical cancer?
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Category 3
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What is first line single agent for cervical cancer?
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Cisplatin Carboplatin Taxol
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Second-line therapy for cervical cancer?
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Bevacizumab Taxotere 5FU Gemcitabine Ifex Irinotecan Mitomycin Topotecan Pemetrexed Vinorelbine
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How many new cases of cervical cancer in the United States and how many will die from disease?
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12,000 new cases and 4000 will dial disease
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Ethnic groups have high rates of cervical cancer?
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Hispanic, black and Asian women
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What percentage of cervical cancer is occur in developing countries?
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85% of cases and is the leading cause of cancer death and women
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The most important factor in developing cervical cancer?
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HPV
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What are other epidemiologic risk factors associated with cervical cancer?
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History of smoking, parity, OCP use, early age of intercourse, large number of sexual partners, history of sexually transmitted disease, certain autoimmune diseases, chronic immunosuppression
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What is the most common histology for cervical cancer?
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Squamous cell cancer and accounts for 80% of all cervical cancer's
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What accounts for 20% of cervical cancer's?
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Adenocarcinoma of the cervix
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Why has adenocarcinoma of the cervix increased over the past three decades?
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Probably because cervical cytologic screening methods are less effective for adenocarcinoma
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What are evaluation procedures for staging cervical cancer?
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Colposcopy, biopsy, cone of the cervix, cystoscopy, proctosigmoidoscopy
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When is cone biopsy of the cervix recommended?
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If the cervical biopsy is in adequate to define invasiveness or if accurate assessment of micro invasive disease is required
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What does work up for patients with cervical cancer with suspicious symptoms include?
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History and physical examination CBC
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What are recommended for radiologic imaging?
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Chest x-ray, CT, or pet, MRI as indicated
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When is imaging optional?
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For patients with stage smaller then IB1
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When are cystoscopy and proctoscopy recommended?
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If bladder or rectal extension is suspected
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What category is HIV testing?
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Category 3
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What does FIGO system limit imaging to?
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Just x-ray IVP Barium enema
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How is cervical cancer staged?
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Clinical evaluation
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What is the only change for staging cervical cancer under the new guidelines?
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Stage IIA is now subdivided into IIA1 which is 4 cm
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Does LVSI alter the FIGO classification?
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No
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How do some people believe patients with stage I A1 who have extensive LVSI should be treated?
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Like IB1
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What is the definition of micro invasive cervical cancer?
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Stage 1A1 with no LVSI
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What is the incidence of lymph node metastasis and micro invasive cervical cancer?
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Extremely low
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What is used as conservative management of patients with stage IA1 with no LVSI?
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Cone of the cervix
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What is used as conservative management for patients with stage IA1 with extensive link vascular space invasion?
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Cone of the cervix with negative margins and a pelvic lymphadenectomy
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What is the preferred method of a cone when dealing with cervical cancer?
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Cold knife cone - However LEEP is acceptable as long as there are adequate margins, proper orientation and a non-fragmented spectrum without electro surgical artifact
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What can be used as fertility sparing treatment for patients with IA2two or IB2?
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Radical trachelectomy
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What is removed any radical trachelectony?
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The cervix, that'll margins, and supporting ligaments are removed while leaving the main body and fundus of the uterus intact
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What histologies are inappropriate for radical trachelectomy?
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Small cell neuroendocrine and adenoma malignum
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What size tumor is vaginal radical trachelectony use for?
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; 2 cm
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What is the advantage of abdominal radical trachelectony?
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Provides a broader resection of the parametria and provides a less conservative alternative for fertility preservation
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What is a type A hysterectomy?
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Simple/extrafascial hysterectomy
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What is a type B hysterectomy?
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A modified radical hysterectomy
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What is a type C hysterectomy?
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A radical hysterectomy
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Surgical options for patients with stage IA-1 disease?
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Cone of the cervix Simple hysterectomy Modified radical hysterectomy
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What is the preferred treatment for patients with stage IA-2 thru IIA cervical cancer?
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Radical hysterectomy with bilateral pelvic lymph node dissection him
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What is the preferred treatment for patients with stage IIB or greater cervical cancers?
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Definitive chemoradiation
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What is recommended for recurrent or persistent cervical cancer that are confined to the central pelvis?
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Pelvic Exenteration
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In the meta-analysis of data from 1112 patients for cervical cancer who underwent a SLN biopsy what was the detection rate, pooled sensitivity and negative predictive value is?
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- Detection rate 92.2% - pooled sensitivity 88.8% - Negative predictive value 95%
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What is the sensitivity of a SLN better in?
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Patients with tumors equal to or less than 2 cm
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Has been shown to provide enhanced detection of micrometastasis?
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Ultra staging of detected SLN
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What help to demonstrate the utility of SLN mapping to uncover unusual lymph drainage patterns?
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SENTICOL
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What should you do if no sentinel node are detected on a given side of the pelvis?
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Perform and ipsilateral lymphadenectomy
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It is para-aortic lymph node involvement closely tied to?
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The presence of pelvic lymph node metastasis, large tumor size greater than 2 cm and metastasis to the common iliac notes
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What is better: surgical exclusion of para-aortic lymph node involvement or radiographic?
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And analysis of data from 555 women who participated in GOG 85, 120 and 165 revealed a more positive prognosis for patients who underwent surgical exclusion of PA lymph nodes and those who want radiographic determination of lymph node involvement
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What are the potential advantages associated with laparoscopic and robotic approaches?
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Decreased hospital stay and more wrap a patient recovery
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What is the LACC trial?
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- a randomized phase 3 trial comparing disease-free survival in more than 700 patients undergoing open radical abdominal is directly or total laparoscopic radical hysterectomy/total robotic radical hysterectomy.
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What is the primary treatment of early-stage cervical cancer?
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Either surgery or RT
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Who is surgically typically reserved for?
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Stage of these and smaller lesions
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Who is concurrent chemoradiation generally use for?
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The primary treatment of stages IB2 or IVA disease based on the results of five randomized trials
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How are adenocarcinomas of the cervix generally treated?
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Similar to squamous cell cancer of the cervix
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How can one preserve intrinsic hormone function in women with cervical cancer?
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Ovarian transposition maybe consider before public or tea for select women younger than 45 years of age with screams of cancer
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How does surgery compare to RT alone in patients with cervical cancer and stage IB-IIA?
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A randomized Italian study showed the patients treated with RT versus surgery with or without post op radiation had similar outcomes, but higher complication rates were noted for the combined modality approach
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Why are we now using chemoradiation?
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Because five randomized clinical trial revealed a 30 to 50% decrease in the risk of death compared with RT alone
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What can be done with patients with positive cone margins and the desire to have children with cervical cancer?
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Options include radical trachelectomy or repeat: biopsy
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For patients who have positive margins after a cone of the cervix what are the predictors of residual disease?
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Positive endocervical curettage, combined endocervical margin and endocervical curettage, volume of disease
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Do you treat patients with stage IA1 with LVSI that desire future fertility?
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radical trachelectomy and pelvic lymph node dissection
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What is also reasonable for patients with IA1 disease and LVSI?
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Cone and nodes with negative margins
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What should be recommended after childbearing is complete?
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Hysterectomy can be considered
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When is it appropriate to conserve ovaries and cervical cancer?
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; 45 years of age
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If childbearing is not an issue what is recommended for patients with positive margins for cancer?
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Modified radical hysterectomy with lymph node dissection
