2. CASE
• 52yr old Female
• Normotensive, nondiabetic,
• Post Menopausal
• Obstetric History : P4L4
• LCB : 24yrs back
• Full term normal vaginal home deliveries
• No Relevant family History
3. Chief complaints ---
• Painless blood stained discharge P/V since
one month and a half
• Bleeding P/V- since one month
.
4. Clinical examination
• Average built, mild pallor.
• B/L Breasts, abdomen, Chest-- normal
• PS/PV/PR—
Foul smelling blood stained discharge seen
Large Growth occupying the entire Cervix,
growth involving the upper third of the vagina.
Right parametria involved, but not reaching
the pelvic side walls
6. What Next?—
Work up Investigations?
EUA ?
Biopsy / PAP ?
For local imaging- CT ?
MRI?
PET Scan?
Any role of Cystoscopy? Sigmoidoscopy?
HPV ?
7. MRI PELVIS
• Diffuse infiltrative mass lesion, 5APx4.5TRx8.6CC cm involving
the entire thickness of the cervix, causing cervical stenosis and
distension of the upper endometrial cavity with fluid collection.
• Involving lower 2/3rd of the uterine corpus and upper 1/3rd of
vagina.
• Right parametrial fat stranding/extension not reaching up to the
pelvic side wall.
• Multiple enlarged necrotic lymphnodes along the bilateral
common iliac, internal and external iliac vessels, Largest-
3.2x2.5cm
8.
9.
10. Biopsy
• HPE: Sections shows poorly differentiated
carcinoma with high N:C ratio and
hyperchromatic nuclei suggestive of poorly
differentiated Ca.
• IHC S/O CK Positive, P40 Positive
13. Whole body PET-CT
• FDG avid heterogeneously enhancing infiltrating
soft tissue lesion involving lower 2/3rd of uterine
body cranially and upper 1/3rd of vagina caudally
5.6x6.5x7.7cm, SUV max 16.9
• Few FDG avid aortocaval, retrocaval, precaval,
paraaortic, bilateral common iliac and bilateral
external iliac lymphnodes, largest - 2.6x2.2cm,
SUV max 11.3.
15. Plan Of Treatment?
• Surgery vs Radiochemotherapy?
• Role of Chemotherapy?
• How would RT be Planned—Dose?
Conventional? Conformal? Field?
16. Treatment Received
• IMRT on 6MV Linac, SIB To Nodes,
Extended field including Para-
aortic nodes
• Dose- PTV- 50Gy in 25
fractions ,
PTV NODE-- 55Gy in 25
fractions
Para Aortic LN--45Gy in 25
fractions
• Along with weekly cisplatin
based concurrent chemotherapy
17. Pre ICRT MRI
• Near complete regression.
She Underwent--3 Sessions of ICRT @ 7.5 Gy Per Fraction
18. How To Plan follow up?
• Follow-up:
- Clinical examination and SCC each three
months
- Abdominal US each six months
- Thorax- abdomen and pelvis CT scan
each year
20. 1. Radiotherapy
2. Chemotherapy ( paclitaxel/cisplatin)
3. Chemotherapy (Carboplatin/ Paclitaxel and bevacizumab)
4. Concurrent chemo-radiation
5. Surgery
6. Enrolment in a clinical trial
What is the best treatment?
21. 6 cycles
Paclitaxel 175 mg/m2 - Cisplatin 75 mg/m2- bevacizumab q3wks
Negative CT scan (performed at the end of chemo)
22. GOG-169: Phase III study of cisplatin with or
without paclitaxel in stage IVB, recurrent, or
persistent squamous cell carcinoma of the
cervix
32. Patient selection for Bev+CT:
Moore’s Criteria
1) Race (African ancestry or not),
2) ECOG PS (1 or 0)
3) Measurable disease in the pelvis
(yes/ no)
4) Prior platinum as a radiation
sensitizer (yes/ no)
5) PFS(≤365 days or >365 days)
LOW RISK 0-1 INTERMEDIATE RISK 2-3
HIGH RISK 4-5
33. Successive improvement in median overall
survival among women with advanced cervical
cancer.
Krishnansu S. Tewari et al. Clin Cancer Res 2015;21:5480-5487
201
7
34. Bevacizumab is more effective in cervical cancer
than in ovarian cancer
Ca Ovary
• Only PFS Benefit
• genomic instability
• heterogeneous
disease
Ca Cervix
• OS & PFS benefit
• HPV oncogene driven
angiogenesis
• homogeneous tumour
35. cough
Thorax TC scan: bilateral lung metastases
Biopsy of lung lesion: metastasis of squamocellular tumour
After 5 months
36. 1. Chemotherapy with bevacizumab
2. Radiotherapy
3. Supportive care
4. Topotecan
5. Weekly paclitaxel
6. Carboplatin
What is the next step?
37. The patient received 3 cycles of chemotherapy with topotecan
But … after three cycles, CT scan showed a progression of disease
(multiple lesions in the lung, lomboaortic nodes and in the pelvis)
After 4 months
Patient died after receiving supportive care
