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Ca Cervix Dr Naresh Jakhotia
- 1. Non surgical management ofCarcinoma Cervix Dr Naresh Jakhotia Radiation Oncologist BMCHRC
- 4. FIGO staging -2009 Evaluation procedures – Colposcopy Biopsy Conization of cervix - invasiveness Cystoscopy Proctosigmoidoscopy CXR-PA view Intravenous Pyelography Barium enema Complex radiologic and surgical staging – not addressed.
- 5. Directly alignswith AJCC staging No Stage 0 in FIGO Regional LN mets not included Not altered by LVSI FIGO Staging – intended for comparison purposes only Not as a guide for therapy FIGO staging - 2009
- 6. • In UnitedStates, modalities used to guide treatment options and design – CT MRI PET-CT Surgical staging
- 7. WORK-UP History PhysicalExamination CBC RFT/LFT CXR-PA view CT PET-CT MRI Imaging – optional for stage ≤ IB 1 Cystoscopy & Proctoscopy – if bladder or rectal extension is suspected May aid in treatment planning Not accepted for formal staging purposes
- 8. NCCN panel Uses FIGO definitions as stratification system for guidelines Imaging studies (CT & MRI) - used to guide treatment options and design MRI – To rule out disease high in endocervix To guide b/w fertility-sparing v/s non-fertility-sparing treatment approaches. To determine soft tissue and Parametrial involvement in advanced tumors
- 9. Management Surgery – Early stage disease Smaller lesion – stage IA, IB1, selected IIA1 Concurrent Chemoradiation – Stage IB2 to IVA Not medically fit for hysterectomy Invariably lead to ovarian failure in premenopausal women Ovarian transposition Before pelvic RT Select F < 45 yr, with Sq. cell cancer
- 10. Stage Fertility SparingNon- Fertility sparing I A1 (No LVSI) Cone biopsy ( Negative margin) Extrafascial / Modified radical Hysterectomy ± Pelvic LN dissection ( SLN mapping) I A1 ( with LVSI) & IA2 •Cone Biopsy with Negative margin + Pelvic LN dissection ± Para- aortic LN sampling •Radical trachelectomy + Pelvic LN dissection ± Para- aortic LN sampling ( SLN mapping) •Modified Radical Hysterectomy + Pelvic LN dissection ± Para- aortic LN sampling ( SLN mapping) • Pelvic RT + Brachytherapy (70-80 Gy • A) I B1 & II A 1 (selected) •Radical Trachelectomy +Pelvic LN dissection ± Para- aortic LN sampling ( SLN mapping) (< 2cm) • Radical Hysterectomy + Pelvic LN dissection ± Para- aortic LN sampling ( SLN mapping) • Pelvic RT + BT ± CCT (80-85 Gy • A)
- 11. Stage IB2& II A2 - Definitive Pelvic RT + CCT + BT ( Total dose • A ≥ 85 Gy) – (Category 1) Radical Hysterectomy + Pelvic LN dissection ± Para- aortic LN sampling ( category 2B) Stage IIB, IIIA, IIIB, IV A – Definitive Pelvic RT + CCT + BT Para-aortic LN +ve – Extended-field RT
- 13. Randomized study ofradical surgery v/s radiotherapy for stage Ib-IIa cervical cancer: Lancet 1997 Only prospective trial comparing radical surgery with radiotherapy Design Surgery EBRT+ICR pT2b , <3 mm margins, positive margins, positive pelvic node, parametria l extn. Post op RT IB and IIA 343
- 14. Results Median follow-up of87 months Worse morbidity seen in combined modality Treatment modality 5-year overall and disease- free survival Toxicity Surgery 83% & 74 % 25% 28% Radiotherap y 83 % & 74% 26% 12% Local recurren ce P=0.004
- 15. Non randomized comparativestudies study Stage of ca cervix Outcome Results Kielbinska et al STAGE 1 n=792 survival, general health, incidence of recurrent carcinoma Equivalent results Piver et al Stage IB N=103 5-year disease-free survival 92.3% for the surgical group and 91.1% for the radiation therapy group Perez et al 118 patients with stage IB or IIA 5-year tumor-free survival Stage IB=80% and 82% stage IIA= 56% and 79% Perez et al 415 patients with stage IB or limited stage IIB 10-year cause- specific survival rate 61% and 68% for non bulky tumors
- 17. N =10,933 - Largest patterns-of-care analysis to date evaluating patients with local EOD IB-IIB cervical cancer Use of different treatment modalities over a 26-year time period - from 1983 to 2009 AIM - To reduce treatment related morbidity without compromising outcomes.
- 18. For StageIB-IIA cancers, definitive radiation has 5-year overall & disease specific-survival rates equivalent to surgery with radiation given for risk factors, with a reduction in grade 2 or 3 morbidity of greater than 50% for patients undergoing RT alone. Careful selection of patients for radical hysterectomy should be done to prevent increased toxicity of multiple therapies. Improved imaging technology –better pretreatment evaluation.
- 19. Preoperative nodalassessment - most challenging pretreatment evaluation. High sensitivity and specificity of PET for pelvic LN detection compared to other imaging modalities. Algorithm for LN positivity – Age < 50 yrs Tumor size Grade 2 and 3 disease Local extent of disease IB2, IIA, and IIB Depth of invasion LVI Parametrial extension
- 20. Decision tree forpretreatment evaluation of cervical cancer
- 21. GOG -92 Protocol- stage IB – Adjuvant T/t
- 22. Intergroup Gynecologic Oncology Group(GOG) Trial 109 ( Adj. RT v/s Adj. CTRT)
- 23. American Brachytherapy Society– Recommends primary therapy should avoid routine use of both Radical surgery and RT to minimize morbidity related to multimodality therapy. Overall treatment time should be ≤ 8 weeks.
- 24. Treatment of StageIIB–IVA Cervical Cancer
- 26. CTRT resultsin 30-50 % decrease in risk of death compared with RT alone. These trials established role for con. Cisplatin-based chemoradiation. Long term follow-up of 3 of these trials confirmed that concurrent cisplatin-based chemoradiation improves progression-free survival (PFS) and overall survival, compared with RT with (or without) hydroxyurea.
- 32. NCI - ALERT Strong consideration should be given for using concurrent chemoradiation instead of RT alone in cervical cancer
- 33. Chemoradiotherapy leadsto 6% improvement in 5- year survival Hazard ratio – 0.81 P<0.001
- 34. N= 4069 Confirmed that chemoradiotherapy improved outcomes when compared with RT alone
- 35. Radiation Treatment Planning CT-based treatment planning with conformal blocking and dosimetry – standard of care for EBRT CBCT – helpful in defining daily internal soft tissue positioning. Extending overall treatment time beyond 6 to 8 weeks can result in approximately 0.5 – 1 % decrease in pelvic control and cause specific survival for each extra day of overall treatment time. Entire RT course – should be completed within 8 weeks.
- 36. Brachytherapy Critical componentof definitive / adjuvant therapy Special shape of zone to be treated – Not symmetrical around the sources Considerable variation in size & shape of organs concerned Typically combined with EBRT in an integrated treatment plan
- 37. Approach – A) Intracavitary – intrauterine tandem and vaginal colpostats B) Interstitial – anatomy / tumor geometry C) Vaginal cylinder – selected post-hysterectomy cases. SBRT – not routine alternate to brachytherapy. Image-based volumetric brachytherapy Improve precision and quality of treatment
- 39. Paracervical triangle Aimof treatment : to raise to as high dose as can be tolerated to this thin triangle of tissue Important uterine arteries and ureter run through this Initial lesion of radiation necrosis due to high dose effects in the medial edge of broad ligament Radiation tolerance – limiting factor in treatment of ca cervix
- 40. Point A Representparacervical reference point At or near to point where uterine artery crosses ureter Most widely used, validated, and reproducible dosing parameter Point 2cm lateral to centre of uterine canal and 2 cm from mucous membrane of lateral fornix of vagina in plane of uterus
- 41. Recommended totaldose to point A- Small tumors – at least 80 Gy Larger tumors - ≥ 85 Gy Limitation – it does not take into account - 3-D shape of tumors, Individual tumor to normal tissue structure correlations.
- 42. Point B Dose– indicate rate of fall-off of dosage laterally Located at same level as Point A but 5 cm from midline Chosen because of proximity to obturator gland.
- 44. EBRT volume Grossdisease Parametria Uterosacral ligaments Sufficient vaginal margins from gross disease (3 cm) Presacral LN Other LN at risk Neg LN on surgical/radiologic staging – Obturator, Ext. & Int. iliac LN Higher risk of LN involvement ( bulky tumor, suspected/confirmed LN confined to true pelvis) Volume increased to cover common iliac LN also
- 45. For lowerone third vaginal lesion – Inguinal LN – must be treated Para-aortic LN (occult or macroscopic) – 45 Gy Bowel, spinal cord, renal tolerances Gross disease in parametria or unresected LN – boosted to 60-65 Gy SBRT – not considered routine alternate to brachytherapy
- 47. RADIOLOGICAL MARKINGS Superiorborder – At the L4-5 inter space to include external & internal iliac L.N. This margin must be extended to the L3-4 inter space if common iliac nodal coverage is indicated. Inferior border - at the inferior border of the obturator foramen. For vaginal involvement, lower border is 2-3cm below the lower most extent of disease tumours that involve lower third of vagina, inguinal nodes should be included in the fields Lateral borders - 1.5 - 2cm margin on the widest portion of pelvic brim
- 48. RADIOLOGICAL MARKINGS Anteriormargin - at the pubic symphysis Posterior margin – at S2 – S3 junction and it should extend to the sacral hollow in patients with advanced tumours Superior & inferior margins - same as that for AP/PA Fields
- 50. Composite of 6MVbeam 6MV color wash Composite of 15MV beam 15MV color wash
- 51. Documented commoniliac and/or para-aortic LN – Extended –field pelvic or para-aortic RT, upto level of renal vessels. EBRT dose to LN – Microscopic – 45 Gy Gross unresected – 10-15 Gy (Boost)
- 52. IMRT Minimize doseto bowel and other critical structures in post-op cases PALN Useful when high doses are required to treat gross disease in regional LN Not alternative to brachytherapy for treatment of central disease in intact cervix Very careful attention to detail and reproducibility required
- 54. Intraoperative Radiation Therapy Single, highly focused dose of radiation to – Tumor bed at risk Isolated unresectable residual disease, during surgery Esp. useful – recurrent disease within previously radiated volume Overlying normal tissue are displaced Delivered with pre-formed applicators – variable sizes.
- 55. Dose prescription pointsfor BT in cervical cancer
- 62. CONCLUSION These aresq. cell ca. that are moderately sensitive to radn. Radiation plays an important role in management of carcinoma cervix. Predictable pattern of spread helps in designing radn portals. Since tolerance of Cx is very high hence high dose can be delivered. Aim is to deliver curative dose of around Early stage - 80 - 85Gy to point A Advanced stage - 85-90Gy to point A
- 63. But thisdose can’t be delivered by EBRT alone because of presence of dose limiting structures like bladder & rectum in the beam path. To achieve tumor control – radiation is delivered by combined technique of EBRT & Brachytherapy.
- 64. The cervicalcancer has two components Central component - Disease confined to cervix , vagina & medial parametria- best treated by brachytherapy Peripheral component - Disease involving lateral parametria & lymph nodes-best treated by EBRT& brachytherapy as boost CONCLUSION
- 65. Patients withstage IA ca cx are managed by radical hysterectomy alone. If inoperable, then dose of approx.80 Gy is delivered by brachytherapy alone Patients with stage IB may be managed by a radical hysterectomy alone if the tumor is <4 cm in size with no other adverse features. Stage IB with tumor > 4 cm, and all patients with stage IIA, IIB, IIIA, IIIB, and IVA are managed with EBRT with concurrent chemotherapy and Brachytherapy. CONCLUSION
- 66.