1. Management of nodal recurrence from cervical cancer involves assessing whether the recurrence is isolated or metastatic. 2. Salvage concurrent chemoradiation provides good survival for isolated para-aortic lymph node recurrence, with a 5-year survival of 51.2% in one study. 3. Stereotactic body radiotherapy (SBRT) is a treatment option for recurrent pelvic nodes that offers high local control with acceptable toxicity, even in previously irradiated areas.

1. Management of Infield and outfield
Nodal Recurrence- cervix cancer
DR KANHU CHARAN PATRO
1

2. 2

3. 3

4. Common recurrences
Central recurrence
Para aortic node recurrence Pelvic node recurrence
Lateral pelvic wall
4

5. SCENARIO
1.post-RT [PA nodal]recurrence
2.Post-op iliac nodal recurrence
3.post-RT iliac node recurrence
5

6. PA nodal recurrence is called outfield recurrence
ILLIAC nodal recurrence is called infield recurrence
6

7. SUSPECTING NODAL RECURRENCE
• BACK PAIN/SCIATICA
• LIMB EDEMA
• DVT
• ABDOMINAL DISCOMFORT
• LIMPING/ FLEXON DEFORMITY
• HYDRONEPHROSIS
7
IF PATIENT PRESENTING WITH DVT PRESENCE
THINK THAT THERE IS A NODAL RECURRENCE

8. IF THERE IS NODAL RECURRENCE
DOING PET IS NOT AN OFFENCE
IT WILL GIVE THE SYSTEMIC CLEARANCE
THEN YOU CAN DECIDE WITH SOME SUBSTANCE
8

9. • 53-year-old female who presented in MAY 2014 with vaginal spotting and
discharge for 3Mo.
• Physical exam identified a 6 x 5 cm ,mass with medial parametrial involvement,
and biopsy returned positive for invasive squamous cell ca.
• CT also noted several prominent RT. iliac lymph node 2 CM, AJCC Stage IlB,
• She underwent IMRT F/B boost to enlarged RT external iliac node with weekly
cisplatin 40 mg/m2.
• Additionally, she received intracavitary brachytherapy to 7Gy /# for 3
• She tolerated treatment well with occasional nausea, vomiting, and diarrhea
controlled with Lomotil and Imodium as needed.
• ON REGULAR F/UP AT 2YEARS AND 3 MONTHS- PRESENTED WITH BACK PAIN WITH
ECOG-1
• X-RAY AP/LAT D/L SPINE-NORMAL
• USG ABD/PELVIS-MULTIPLE PA NODES
• PET-CT demonstrated an increased FDG uptake in multiple lower para-aortic nodes
of SUV-12.max size was 2.8cm
CASE -1
9

10. 10

11. HOW TO PLAN THE RECURRENT PALN
• PALLIATIVE VS CURATIVE
• BSC
• RT ALONE
– CONVENTIONAL
– STEROTAXY
– BRACHY
• CONCURRENT CT-RT
• NACT-RT
• RT-ADJ.CT
• CHEMO ALONE
• IS Sx IS AN OPTION?
11

12. TREATMENT RECEIVED
• Her case was discussed in Tumor Board with
the decision to proceed with reirradiation for
curative intent.
• She was planned for 45 Gy in 25# daily
fractions with IMRT to the involved para-
aortic lymph nodes without chemotherapy,
• She tolerated treatment well with increasing
loose stools managed with Imodium.
• FOLLOW UP AT 3M-IS NORMAL-USG/SYMPTOM FREE
12

13. Was it adequate?
13

14. 14

15. 15

16. 16

17. 17

18. 18

19. 1. 876 patients who received pelvic RT after the diagnosis of cervical carcinoma,
2. 26 were found to have isolated PALN recurrence as the first recurrent site, and
these patients enrolled in this study.
3. Only those with primary-site carcinoma controlled and who were free of other
distant metastases were eligible.
1. 19 of the 26 patients accepted salvage therapy.
2. 14 patients accepted concurrent chemoradiation (CCRT),
3. 1 accepted radiation to the paraaortic region
4. 4 accepted chemotherapy ALONE
4. Evaluatation included tumor markers (SCC and CEA) and image studies.
5. Results: Seven of the 26 patients were alive and disease-free.
6. All 7 survivors had salvage treatment with radiation to the paraaortic region
and concurrent cisplatin-based chemotherapy.
7. None of the patients receiving chemotherapy or radiation alone enjoyed long-
term, disease-free survival.
8. The 5-year survival rate for isolated PALN recurrence of the 14 patients who
accepted salvage concurrent chemoradiation (CCRT) was 51.2%.
9. The presence of a clinical symptom at the time of PALN recurrence was
analyzed. Seven of the 12 asymptomatic patients and none of the 14
symptomatic patients survived without disease after salvage treatment.
19

20. 5 YEAR SURVIVAL DATA
20

21. Secondary recurrence site
Do they need adjuvant /extra chemo?
21

22. 22

23. 23

24. 24

25. 25

26. 26

27. 27

28. 28

29. 29

30. 30

31. HANDLING PA NODAL RECURRENCE
PA-NODE RECURRENCE
SYSTEMIC EVALUATION
LOCALIZED DISEASE METASTATIC DISEASE
NON BULKY BULKY
RT/CT+RT NACT
RT/CT+RT+ ADJ CT
+ADJ CT
GOOD GC POOR GC
CHEMO BSC
PALL.RT1. CONSOLIDATED RT
2. PALL.RT
31

32. SUMMARY FOR PA NODAL
RECURRENCE
• Mostly it is outfield recurrence
• It is salvageable
• Systemic evaluation needed before definitive
treatment.
• Good survival with concurrent chemo- radiation
• Post RT adjuvant chemo is required?
• Single isolated recurrence brachy is an option
32

33. DO NOT TREAT ISOLATED PA NODAL RECURRENCE AS
PALLIATIVE.
5 YEAR SURVIVAL DATA WITH CONCURRENT CTRT SHOWS IT IS
CURATIVE
33

34. • 28-year-old female who initially presented in October 2012 with
post-coital bleeding.
• Colposcopy identified a friable 2 cm mass on the cervix.
– BIOSY- sq CA,
– NO NODE OR HYDRONEPHROSIS ON IMAGING
• She underwent TAH BSO
– TUMOR SIZE 1.2 X 1.8CM
– WD/sq CARCINOMA
– WITH 0.3 CM STROMAL INVASION,
– NO LVI
– PARA-VE, CM-VE AND NODE NEGATIVE
– KEPT ON OBSERVATION
Case-2
34

35. I. Patient presented with left sided lower limb DVT after 1 nad ½
year.
II. Follow-up PET-CT demonstrated increased FDG uptake in lt. iliac
node. FNAC of node was positive for viable carcinoma cells in the
background of extensive necrosis.
III. After DVT management she was discussed at Tumor Board with
the decision to treat with RT for curative iliac node. She was
treated with IMRT (45 Gy in 25#) without chemotherapy,
completed treatment in October 2014
IV. Acute side effects from RT included mild fatigue and increasing
non-bloody bowel movements controlled with Imodium as
needed.
V. Following completion of RT, she was planned for adjuvant chemo.
VI. Repeat exam and imaging in November 2015 showed no evidence
of disease, and at her last F/U ,
VII.Her bowel movements had returned to baseline with no new late
treatment-related toxicities (> one-year post-treatment).
35

36. 36

37. ISSUES
1. Was concurrent chemo missed during
radiotherapy?
2. TTD [Target, technique, dose-fractionation]
PARAMETERS?
3. Was there any need of adjuvant chemo in
this patient?
37

38. NODAL RECURRENCE AFTER SX
38

39. 39

40. 40

41. 41

42. 42

43. CONCLUSION
43

44. POST-OP ILIAC NODAL RECURRENCE
ILIAC NODE RECURRENCE
SYSTEMIC EVALUATION
LOCALIZED DISEASE METASTATIC DISEASE
NON BULKY BULKY
RT/CT+RT NACT
RT/CT+RTADJ CT
ADJ CT
GOOD GC POOR GC
CHEMO BSC
PALL.RT1. CONSOLIDATED RT
2. PALL.RT
44

45. Case-3
• 35-year-old female who initially diagnosed with carcinoma cervix lllB
• She then received 50.4 Gy in 28 daily fractions IMRT F/B brachytherapy 7 Gy x3 # with
concurrent weekly cisplatin 40 mg/m2.
• At 2 and half year follow-up patient presented with abdominal discomfort,
• USG abdomen finding was 2cm RT. EXTERNAL ILLIAC NODE
• PET-CT demonstrated increased FDG uptake in rt external iliac node.
• Fine-needle aspiration (FNA) node was positive for viable carcinoma cells
• She was discussed at Tumor Board with the decision to treat with RERT for curative intent
external iliac node.
• She was treated with nodal IMRT (45 Gy in 25#) without chemotherapy, completed
retreatment in July 2016.
• Side effects from RT included mild fatigue and increasing non-bloody bowel movements
controlled with Imodium as needed.
• Following completion of RT, she was planned for adjuvant chemo.
• Repeat exam and imaging in April 2017 showed no evidence of disease, and at her last
follow-up,
45

46. ISSUES
• Was concurrent chemo missed during
radiotherapy?
• TTD [Target, technique, dose, fractionation]
PARAMETERS?
• Was there any need of adjuvant chemo in this
patient?
46

47. POST-RT ILIAC NODAL RECURRENCE
ILIAC NODE RECURRENCE
LOCALIZED DISEASE
NON BULKY BULKY
RT/CT+RT NACT
RT/CT+RTADJ CT
ADJ CT SBRT
Large
volume
Small
volume
IMRTSBRT
Large
volume
Small
volume
IMRT
47

48. 48

49. 49

50. SBRT
50

51. 51

52. SBRT works at
more than 4R of
radiobiology
Already irradiated
tissue less sensitive
to RE-RT because of
hypoxia, accelerated
repopulation
SHOOTER
SBRT differs from
IMRT mainly in that
SBRT uses higher
dose per fraction
SMALLER volume
No delay in
chemotherapy if it
was preplanned for
adjuvant
WHY SBRT FOR PELVIC RERT?
SHARPER dose fall
reduces dose to
OARS
SHORTER
duration of
treatment
TOXICITY IS ALMOST
SIMILAR WITH
CONVENTIONAL
superior
results
52
There is greater
precision

53. 53

54. 54

55. Axial view of a radiosurgical treatment plan for one of the patients treated in the study.
The structure outlined in white is the tumor volume. The gray and the black lines
represent the 50%, and the 95% isodose lines, respectively.
55

56. 56

57. 57

58. 58

59. 59

60. 60

61. 61

62. 62

63. In conclusion, SBRT for recurrent or metastatic uterine
cervical cancer resulted in excellent local control and this
tended to be more evident in the group of patients with a
long disease-free interval (more than 36 months) and
treatment with a high BED. This promising local control was
achieved with acceptable toxicities, regardless of previous
irradiation history. Therefore, SBRT can be considered as a
primary therapeutic option for recurrent or oligometastatic
cervical cancer
63

64. WHEN YOU ARE PLANNING FOR SBRT
KEEP THE MARGIN VERY TIGHT
THOUGH DATA IS SPARSE
YOU CAN EXPECT THE RESPONSE
64

65. To Summarize
• The decision of re-irradiation should be taken after
exploring all available options, benefits and toxicities.
• Maximum information from the previous treatment course
should be available.
• Brachytherapy remains the treatment of choice for isolated
single nodal recurrence.
• SBRT should be treatment of choice in nodal relapse .
• IORT- If experience and expertise available can prove as
important adjuvant of surgical treatment.
• Re-irradiation is an underutilized treatment.
• Evolving technologies, more published experience and
workshops in the re-irradiation will increase experience
and expertise in near future.
65

66. NORMAL FOLLOW-UP SYSTEM
66

67. THE ABCDE
EDEMA
DVT
Distant
node
Bleeding
Discharge
BACK PAIN
cough
Appetite loss
Abdominal pain 67

68. THE CHUP TEST
PHYSICAL EXAMUSGCXR
68

69. 69

70. ASYMPTOMATIC VS SYMPTOMATIC
70

71. WHY NOT DIAGNOSE EARLY
&
HOW TO DIAGNOSE EARLY
71

72. 72

73. 73
thanks

74. Local/Regional Recurrence: Therapy for Relapse
NCCN Guidelines® for Cervical Cancer (v.2.2015)
• No prior RT or failure outside of previously treated field (consider surgical
resection, if feasible)
– Tumor-directed RT + platinum-based chemotherapy ± brachytherapy
– For additional recurrence, consider clinical trial, or chemotherapy, or best
supportive care
• Previous RT
• For additional recurrence, consider clinical trial, or chemotherapy, or best
supportive care
– Noncentral disease: tumor-directed RT ± chemotherapy, or resection with
IORT for close or positive margins (category 3 for IORT), or clinical trial, or
chemotherapy, or best supportive care
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Cervical Cancer, version 2.2015.

75. Chemotherapy for Recurrent or
Advanced Cervical Cancer
• Recurrent or advanced cervical cancer has a
poor prognosis
• Since 1995, approximately 40 phase II GOG
studies have been published
– Results showed response rates < 10% in most
studies
Gien L, et al. GOG Symposium 2015.

76. Chemotherapy for Recurrent or
Advanced Cervical Cancer: Meta-analysis
• 35 phase II protocols
• N = 1348
• Only eligible and evaluated pts included (10%
excluded): N = 1237
• CR or PR: 154 (12.4%)
– CR: 34 (2.7%)
– PR: 120 (9.7%)
Gien L, et al. GOG Symposium 2015.

77. Chemotherapy for Recurrent or
Advanced Cervical Cancer: Results
• Sobering results with 11% PR among 1348 pts
• Factors significant for tumor response are
similar
– Performance status
– Prior platinum-based chemotherapy
– Relapse within 1 yr
– Black race
Gien L, et al. GOG Symposium 2015.

78. Recurrent or Metastatic Cervical Cancer:
Chemo ± Bevacizumab (GOG-240)
• Regimens
– Cisplatin/paclitaxel (CP)
– Topotecan/paclitaxel (TP)
• Bevacizumab associated with more toxicity: hypertension,
thromboembolic events, and gastrointestinal fistula
– Cisplatin/paclitaxel + bevacizumab
– Topotecan/paclitaxel + bevacizumab
Tewari KS, et al. N Engl J Med. 2014;370:734-743.
100
80
60
40
20
0
PFS(%)
0 6 12 18 24
Mos Since Randomization
HR: 1.39 (95% CI: 1.09-1.77; 2-sided P = .008)
Median PFS: 7.6 mos (CP) vs 5.7 mos (TP)
CP
with or without
bevacizumab
TP
with or without
bevacizumab
100
80
60
40
20
0
OS(%)
0 6 12 18 24
Mos Since Randomization
HR: 1.20 (99% CI: 0.82-1.76; 1-sided P = .88)
Median OS: 15.0 mos (CP) vs 12.5 mos (TP)
CP
with or without
bevacizumab
TP
with or without
bevacizumab
Cisplatin
Topotecan
Events,
n (%)
81 (35)
93 (42)