Cervix cancer panel discussion

1. Cervix cancer panel discussion
Dr Kanhu Charan Patro

2. Welcome to the panelists

6. About NCG
• Standard guidelines for the management of early and locally
advanced cervical cancer are available from various academic
consortiums nationally and internationally.
• However, implementing standard-of-care treatment poses unique
challenges within low- and middle-income countries, such as India,
where diverse clinical care practices may exist.
• The National Cancer Grid, a consortium of 108 institutions in India,
aims to homogenize care for patients with cervical cancer by
achieving consensus on not only imaging and management, but also
in addressing potential solutions to prevalent challenges that affect
the homogenous implementation of standard-of-care treatment.
• These guidelines therefore represent a consensus statement of the
National Cancer Grid gynecologic cancer expert group and will assist
in homogenization of the therapeutic management of patients with
cervical cancer in India

7. Comments about new cervix cancer
staging?

9. Comments about new cervix cancer
staging?
• Adopting the new cancer staging?[ Dr. Muralikrishna sir]
• Addressing to the patient? [ Dr. Ravishankar sir]
• Any change in practice? [ Dr. Umesh sir]

10. WHAT ARE THE OPTIMAL INVESTIGATIONS
IN CERVICAL CANCER?

11. THE BASICS
• BIOPSY
• USG A/P
• CT
• MRI[ Dr Bhattacharyya please]
• CXR
• CBP AND CREATININE
• Viral markers
• PET
• Bladder biopsy

12. USE OF MRI IN CERVICAL CANCER
• MRI of the pelvis is the most reliable imaging modality for staging,
treatment planning and follow-up of cervical cancer.
• Often complementary to clinical assessment, which currently remains
the reference standard.
• MRI can accurately evaluate the extent of disease because of its high
spatial and contrast resolution for pelvic tissues and organs.
• Since clinical implications and therapeutic strategies for cervical
cancer treatment vary tremendously according to the degree of
tumor extension, familiarity with relevant MRI findings is essential for
radiologists

13. Dr Ravishankar sir please
•PET CT can we make standard or specific
conditions?

14. What NCG guideline says

15. Dr. Murali Krishna Sir please
• COMMENTS ABOUT VAGINAL CUTOFF MARGIN?

16. Resection of VCL >2.0 cm in RH has a more favorable long-term outcome than
VCL ≤2.0 cm among patients with cervical cancer (FIGO stage IB–IIA); shorter
VCL resection was significantly associated with local recurrence, DFS, and OS;
thus, it can be considered as a prognostic factor for cervical cancer.

17. Indication of post op radiotherapy?
Dr Ravishankar sir please

18. What NCG guideline says

19. Indication for postoperative brachytherapy?
Dr Bhattacharyya please

20. What NCG guideline says

21. Adding concurrent chemotherapy to RT in
postop settings
Dr Vamshi Krishna please

22. What NCG guideline says

23. Adeno carcinoma cervix
• Different entity
• Poor prognosis
• Poorer outcome

24. Is treatment different from squamous?
Dr Umesh sir please

25. Risk stratification

27. • The histological type did not affect the outcome for patients with stage I
disease. However, in stage II disease, ADC was significantly worse prognosis
than SCC.
• Patient with SCC exhibited significantly higher lymph node involvement in
stage IB, but not in IB2 and II.
• Among patients with lymph node involvement patients with ADC exhibited a
significantly worse 5-year survival rate compared to those with SCC (46.4%
vs. 72.3%, respectively, P=0.0005).
• Among the patients receiving the adjuvant RT, those with ADC showed
higher recurrence rate of central recurrence (pelvic and stump) than those
with SCC (24.6% vs. 10.5%, P=0.0022).
• As for distant recurrence and paraaortic recurrence there was no difference
between histological subtypes.
• Okazawa et al. reported a retrospective study in patients with stage IB1–IIB
for efficacy of CCRT vs. RT as an adjuvant therapy for intermediate-risk or
high-risk.
• Both PFS and OS of CCRT were superior to those of RT.

28. GOG 263

29. GOG 263 WAITED

30. Chemotherapy IN cancer cervix
DR Praveen please
• Neoadjuvant settings

31. Cisplatin-based concomitant chemoradiation resulted in superior DFS compared
with neoadjuvant chemotherapy followed by radical surgery in locally advanced
cervical cancer

32. Dr Vamshi Krishna please
Dr Praveen please
Use of carboplatin in concurrent settings in
odd situation

34. Car-RT showed a poorer tumor response and a trend toward inferior survival
compared with CisRT in the treatment of cervical cancer. However, this evidence
was limited by the imbalance among studies. Due to the encouraging efficacy and
low toxicity, carboplatin is a suitable concurrent agent for patients with
contraindications to cisplatin

35. What should be the optimal management in
patients with involved PA nodes?
Dr Ravishankar sir please

36. NCG guidelines
• Patients with involved PA nodes should receive EFRT with concurrent
weekly Cisplatin 40 mg/m2, followed by BT.
• High acute (33% to 87%) and late (10% to 40%) toxicity have been
reported with conventional techniques
• IMRT studies report reduced acute (24% to 76%) and late (5%)
toxicity
• Select patients with bulky PA nodes (> 3 to 4 cm in size) may be
considered for neoadjuvant CT followed by EFRT and chemotherapy

37. When we should consider for interstitial
brachytherapy?
Dr Bhattacharyya please

40. Indications
• Difficult os
• More OAR dose
• Bulky residual
• Vaginal involvement
• Vault recurrences
• Stump recurrences
• Residual Para after EBRT

41. Management of stage IV A
Dr Umesh sir please

42. What NCG guideline says?

43. What should be the treatment of choice for
metastatic cervical cancer?
Dr Ravishankar sir please

44. What NCG guideline says?
• Platinum-containing combination regimens have demonstrated
improved progression-free survival.
• Patients with an isolated visceral metastasis may also be considered
for stereotactic radiation and palliative pelvic radiation therapy

45. Management of locally recurrent cancer
cervix?
Dr Umesh sir please

46. Types and options
• Central
• Vaginal
• Nodal
• Distant
• Surgery
• Nodal
• primary
• Brachytherapy
• chemotherapy

47. Reirradiation using high-dose-rate brachytherapy is feasible with acceptable
outcomes in isolated local recurrence deemed unsuitable for surgery. The
local and disease free survival is better with higher doses (40 Gy and
above).

48. Sir can you enlighten the exenteration surgery in
in primary and recurrent cancer cervix
Dr Murali Ksrishna sir please

49. Follow up policy
Dr Bhattacharyya please

50. What NCG guideline says?
• Post-op
• Patients should thereafter be scheduled for follow-up every 4 months
for up to 2 years, every 6 months for another 3 years, and yearly
thereafter.
• Cytologic evaluation should be considered optional.
• Follow-up imaging should be directed by symptoms and is not
recommended for all patients.
• Post RT
• Follow-up should include per-speculum and bimanual pelvic
examination every 4 months for 2 years, then every 6 months
thereafter with symptom-directed imaging as indicated.
• Routine cytologic evaluation is not recommended.

51. Thank you
• Panelists
• Dr Karthik
• You all