Management of carcinoma Cervix for all stages... Brief description about chemotherapy and radiotherapy

1. TREATMENT FOR CA CERVIX
~R.NAJESH,
II unit, B batch, Final Year
STAVERGONZ-13

2. CRITERIA FOR DECISION MAKING
• Age
• Menopausal Status
• Stage of Disease
• Size of Tumour
• Comorbidities - older age, DM, HT

3. TREATMENT MODALITIES
• Surgery
• Radiotherapy
• Chemotherapy
• Combined

4. STAGE IA1
Younger women Older women
Conisation Simple Hysterectomy
• Squamous cervical cancers with stromal invasion <1 mm have a 1% risk of
nodal metastasis, with 1 to 3 mm of stromal invasion
carry a 1.5% risk.

5. SIMPLE HYSTERECTOMY
(TYPE I)
Also known as EXTRAFACIAL HYSTERECTOMY.
Uterus and cervix are removed but not the parametrium or the paracervical tissue

6. STAGE IA2
younger women Older women
Radical trachelectomy modified Radical hysterectomy
+ pelvic lymphadenectomy + pelvic lymphadenectomy
• 7-percent risk of lymph node metastasis, and
• 4-percent risk of disease recurrence

7. MODIFIED RADICAL HYSTERECTOMY
(TYPE II)
• Also known as EXTENDED HYSTERECTOMY, WERTHEIM’S hysterectomy.
• Uterus ,cervix ,vaginal cuff are removed with the parametrium and paracervical
tissue medial to ureters.

8. RADICAL TRACHELECTOMY
• Removal of cervix upto internal os along with paracervical tissue medial to ureter•

9. PELVIC LYMPHADENECTOMY
• Removal of parametrial,obturator ,internal iliac, external iliac,sacral ,and common
iliac nodes.

10. STAGE IB AND IIA
Stage IB1 and IIA – Radical hysterectomy with pelvic lymphadenectomy / Radiotherapy.
Oophorectomy not essential.

11. BULKY IB2
Higher chances of LN metastasis and recurrence.
TREATMENT OPTIONS:
 Radical Hysterectomy with Pelvic Lymphadenectomy and Postoperative Radiation-
treatment of choice.
Radiation followed by Simple Hysterectomy,
Chemoradiation followed by Simple Hysterectomy,
Neoadjuvant Chemotherapy followed by Radical Hysterectomy.

12. RADICAL HYSTERECTOMY
(TYPE III)
• MEIG’s modification of WERTHEIM’s Hysterectomy.
• Uterus, cervix ,vaginal cuff,parametria upto pelvic side wall and paracervical tissue
are removed.

13. Gross surgical specimen following radical hysterectomy.
The specimen includes the uterus, parametria (arrows), adnexa, and 2 cm of proximal vagina.

14. Diagrammatic representation of types of Hysterectomy

15. STAGES IIB TO IVB
• IIB to IVA : Chemoradiation
• IVB : Palliative chemotherapy
and/or
Palliative radiotherapy
and
Supportive care

16. RADIOTHERAPY
• External irradiation- EBRT
• Intracavitary radiation
• Interstitial Brachytherapy
point A- 2cm above external os and 2cm lateral to cervical canal (corresponds
to the point where uterine artery and ureter cross).
point B - 3cm lateral to point A .(corresponds to obturator nodes in pelvic side
wall)

17. EXTERNAL IRRADIATION
Deliveres uniform dose of radiation to the tumour and entire pelvis
Administered in fractions- 5 days/week for 5 weeks.

18. INTRACAVITARY RADIATION
• Delivered using TANDEMS inserted into uterus and VAGINAL OVOIDS inserted
into vagina.
• Delivers maximum dose to the tumour, parametrium, and paravaginal tissue, and
diminishes towards the lateral pelvic wall.
• Traditional methods: Stockholm technique, Manchester technique.

19. INTERSTITIAL BRACHYTHERAPY
• Supplementary dose following EBRT in patients with advanced parametrial disease,
distorted anatomy or recurrences.
• Afterloading transperineal perforated templates with iridium-192 and
iodine-125 are used.
Syed-Neblett perineal template brachytherapy with iridium-192 source for advanced stage cancer of the cervix

20. CHEMORADIATION
• Chemotherapy:
Cisplatin 40mg/M2 weekly for 4 weeks
• External radiation:
start along with chemotherapy
daily for 5 days /week for 5 weeks
• Intracavity radiation:
LDR- Caesium-137, 36-48hrs
HDR-Iiridium-192, once a week for 2-3 weeks
• Total dose:
point A :80-85Gy
point B : 55-65Gy

21. Radical surgery
• Ovaries preserved
• No vaginal narrowing/shortening
• Sexual function can be preserved
• Difficult in women with obesity, IHD etc.
• Complications
 Hemorrage
 Ureteric injury
 Thromboemblism
 Lymphocyst formation
Radiotherapy
• Ovaries irradiated
• Vaginal stenosis common
• Dyspareunia common
• Indicated in women with comorbidities
• Complications
 Radiation proctits
 Vaginal stenosis
 Radiation cystitis
 Fistula formation

24. ADENOCARCINOMA
• 15-20% of all cervical cancers
• 70-80% caused by HPV
• More radioresistant than squamous cell cancers
• Currently treated the same way as squamous cell carcinoma, stage by stage.

25. REFERENCES
• WILLIAM’S Gynecology
• SHAW’s textbook of Gynaecology
• JEFFCOAT’s principle of Gynecology
• BEREK & NOVAK’s Gynecology