Here are the key steps I would recommend based on the information provided: 1. Obtain imaging such as CT or MRI of the pelvis to evaluate extent of disease. 2. Perform cystoscopy and proctoscopy to evaluate for involvement of bladder or rectum. 3. Refer the patient to a radiation oncologist for consideration of concurrent chemoradiation as the primary treatment given the large primary tumor size and long time since last screening. 4. Discuss possibility of brachytherapy boost after external beam radiation is completed. 5. Recommend close follow-up after treatment completion to monitor for response and recurrence.

1. **What is your specialty?
• 1-Gynecologist (general)
• 2-Gynecologic oncologist
• 3-Surgical Oncologist
• 4-Radiation Oncologist
• 5-Medical Oncologist

2. Post-operative Cervical Ca
35 yo
– Pap smear + ASCUS, HPV DNA+
– Colposcopy/biopsy: invasive squamous
cell ca
– Exam: no visible lesion
– Radical hysterectomy with bilateral
complete lymphadenectomy
– Final path: 2cm inv sq cell ca, extensive
LVI+, 1.5 cm deep stromal invasion
– Staging: Chest X-ray, PET/CT, MRI
(optional < Stage IB1)

3. Post-operative Cervical ca
Intermediate Risk Factors
• Pelvic RT: EB 45 Gy
– Prone, belly board
– IMRT, supine
– No VB necessary after a rad hyst (only
after a simple hyst)
• Concurrent chemotherapy:
– weekly cis 40 mg/m2
RTOG trial: concurrent cisplatin, post-RT
carbo/taxol x 4

4. Management of IB1:
Radical Hysterectomy
Viswanathan ASTRO 11/3/09

5. Radiation or hysterectomy
Landoni et al. Lancet 350: 535, 1997
• Randomized trial of 469 patients
• IB or IIA cervical cancer
• Median f/u: 87 months
• 54% of IB1 & 84% of IB2 surgical pts
had adjuvant radiation for high risk
features
Viswanathan ASTRO 11/3/09

6. Radiation or Hysterectomy
5 year OS DFS Rec tox
RT 83% 74% 25% 12%
Surgery 83% 74% 26% 28%
(p=0.0004)
SBO risk increased with LND
Viswanathan ASTRO 11/3/09

7. Post-operative RT : GOG 92
Intermediate risk factors
• Indications (Sedlis et al. GOG92 Gynecol Oncol 73:177-
183)
– LN+, LVI+
– any 2 other factors including >1/3
stromal invasion, large tumor size
Viswanathan ASTRO 11/3/09

8. GOG 92 update IJROBP 65(1):169-176, 2006
• Median f/u 10 years
• 46% reduction in risk
of recurrence (HR
0.54)
– 42% reduction in risk of
progression/death
– Reduction in adenoca
8.8% vs. 44%
– 30% improvement in
overall survival (p=0.07)
– Increases Grade 3/4
toxicity by 4.5%
Upcoming RTOG trial
Viswanathan ASTRO 9/25/08

9. Post-op Chemo-RT: SWOG 8797
High-risk patients
• + LN
• + Margins
• + Parametria
• 4 yr PFS
– 63% vs. 80%
(p=0.003)
• 4yr OS
– 71% vs. 81%
(p=0.007)
Upcoming GOG trial Viswanathan ASTRO 11/3/09
Peters et al. JCO 2000

10. Other considerations for post op RT
– Close margins, 2x local recurrence rate
– Simple hysterectomy

11. Para-aortic node positive
• 45 yo, 4 cm exophytic, friable mass
• EUA: R sidewall extension, L parametrium +
• Biopsy: invasive squamous cell ca
• PET/CT: positive 2 cm LN level renal hilum
• Hematocrit 25, normal WBC, platelets,
BUN/Cr, AST, ALT

12. PAN + Treatment
• Extended field RT
– 4F vs. IMRT
– 45 Gy/1.8 Gy/fraction
– IMRT Nodal boost 18-25 Gy w small bowel limit
5cc < 55 Gy;
– 4F nodal boost limit 54Gy
• Concurrent weekly cisplatin 40 mg/m2 x 6 cycles
(last inbetween brachy fractions)
• HDR: 5.5Gy x 5 fractions 3D planning; LDR: 40 Gy
to point A

13. Common iliac node positive
• 28 yo known high risk HPV+
• Routine annual exam 4cm protuberant
cvx
• Exam: L>R parametrial extension
• MRI: Bilateral parametrial extension,
1.5cm common iliac LN+
• PET: +uptake common iliac LN, no
other LN involved
• FIGO Stage IIB

14. Common iliac LN+ Treatment
• Consider prophylactic coverage with an
extended field
• IMRT para-aortics and full pelvic field (at
least 3 cm margin on cervix and uterus)
• 45 Gy entire field
• Nodal boost IMRT + 18 Gy = 63 Gy
• Concurrent weekly cisplatin 40 mg/m2 x 6
• HDR Brachytherapy 5.5Gy x 5 3D

15. Stage IB1
• 72 yo w vaginal spotting
• Exam: 5mm red polyp at os, firm
cervix, no PM extension
• MRI: 10 cm fibroid uterus, tumor
extending along endocervical canal,
tumor 3 cm height, 2cm width
• Biopsy: endocervical adenocarcinoma

16. Stage IB1
• Options: Radical Hysterectomy
(robotic) with complete
lymphadenectomy, but….
• Post-op EBRT: toxicity increases
• External beam radiation with
concurrent chemotherapy (no hyst)
best option
• Followed by brachytherapy

17. Vulvar Carcinoma Case
• 50 yo with long hx of
lichen sclerosus
• 6 month hx of scant
bleeding
• Seen for year exam
• Bx mod differentiated
squamous cell ca
• Physical exam reveals
right inguinal node 2.5
cm

18. **You would recommend:
1- Obtain PET/CT to assess disease
extent and distant metastatic
disease
2- Send immediately for radiation +/-
chemo treatment
3- Aspirate enlarged node
4- Proceed directly to radical surgery
5- Initiate Aldara cream

19. Preop Workup
• CT/PET: High FDG uptake in right
vulva, right inguinal node and lesser
FDG uptake in nodes bilaterally in groin

20. PET

21. Vulvar cancer.
MRI
McMahon C J et al. Radiology 2010;254:31-46
©2009 by Radiological Society of North America

22. Surgical Approach and final
pathology
• Bilateral inguinal dissection with removal of
enlarged lymph nodes
• Partial radical vulvectomy with removal of
clitoris and upper vulva (bilateral)
• Pathology: 2.5 cm moderately differentiated
squamous cell ca invasive, closest margin
4mm to urethra, + LVI, Right inguinal node
(1)/3 positive, 0/5 Left inguinal

23. **For the next step, you would
recommend:
1- Re-excise close margin
2- Send for radiation therapy alone
3- Give chemotherapy with radiation
therapy
4- Follow patient for recurrence
5- Refer to urologist

24. Vaginal cancer
• 65 yo hysterectomy for benign fibroids
20ya
• No pap smears for 20 years
• Vaginal spotting
• Exam: friable mass upper L fornix
extending to L introius @6cm
• Biopsy: invasive squamous cell
carcinoma