This document discusses staging and treatment of locally advanced cervical cancer (LACC). It summarizes a study evaluating survival outcomes of LACC patients who underwent laparoscopic para-aortic lymph node staging after having no para-aortic uptake on PET-CT imaging. The study found that half of patients with false-negative PET-CT results had lymph node metastases under 5mm. Patients with small (<5mm) solitary para-aortic metastases who received extended chemoradiation had similar survival to those without metastases, but survival remained poor for those with larger metastases despite extended treatment.
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic cancer.
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic cancer.
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
While the role of radiation therapy in carcinoma cervix management is undauntable for all stages. Recurrent carcinoma cervix need a lot of personalisation
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
While the role of radiation therapy in carcinoma cervix management is undauntable for all stages. Recurrent carcinoma cervix need a lot of personalisation
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
Original StudyType of Breast Cancer Diagnosis, Screening,a.docxvannagoforth
Original Study
Type of Breast Cancer Diagnosis, Screening,
and Survival
Carla Cedolini,1 Serena Bertozzi,1 Ambrogio P. Londero,2 Sergio Bernardi,3,4
Luca Seriau,1 Serena Concina,1 Federico Cattin,1 Andrea Risaliti1
Abstract
Organized, invitational breast cancer screening in our population succeeded in detecting early-stage tumors,
which have been consequently treated more frequently with breast and axillary conservative surgery, com-
plementary breast irradiation, and eventual hormonal therapy. The diagnosis of invasive cancer with screening
in our population resulted in a survival gain at 5 years from the diagnosis.
Introduction: Breast cancer screening is known to reduce mortality. In the present study, we analyzed the prevalence
of breast cancers detected through screening, before and after introduction of an organized screening, and we
evaluated the overall survival of these patients in comparison with women with an extrascreening imaging-detected
breast cancer or those with palpable breast cancers. Materials and Methods: We collected data about all women
who underwent a breast operation for cancer in our department between 2001 and 2008, focusing on type of tumor
diagnosis, tumor characteristics, therapies administered, and patient outcome in terms of overall survival, and re-
currences. Data was analyzed by R (version 2.15.2), and P < .05 was considered significant. Results: Among the 2070
cases of invasive breast cancer we considered, 157 were detected by regional mammographic screening (group A),
843 by extrascreening breast imaging (group B: 507 by mammography and 336 by ultrasound), and 1070 by extra-
screening breast objective examination (group C). The 5-year overall survival in groups A, B, and C were, respectively,
99% (95% CI, 98%-100%), 98% (95% CI, 97%-99%), and 91% (95% CI, 90%-93%), with a significant difference
between the first 2 groups and the third (P < .05) and a trend between groups A and B (P ¼ .081). Conclusion: The
diagnosis of invasive breast cancer with screening in our population resulted in a survival gain at 5 years from the
diagnosis, but a longer follow-up is necessary to confirm this data.
Clinical Breast Cancer, Vol. 14, No. 4, 235-40 ª 2014 Elsevier Inc. All rights reserved.
Keywords: Breast cancer, Breast cancer screening, Invasive breast cancer, Mammographic screening, Overall survival
Introduction
Because of the detection of early-stage tumors, breast cancer
screening reduced breast cancer mortality in Europe by 25%-31%
in patients who were invited for screening and by 38%-48% in
those who were actually screened during the last decade of the
twentieth century and the first decade of the twenty-first.1 In our
region of Italy, an organized breast cancer screening was firstly intro-
duced in 2005, but despite the high compliance of invited women
1Clinic of Surgery
2Clinic of Obstetrics and Gynecology
University of Udine, Udine, Italy
3Department of Surgery, Ospedale Civile di Latisana, Udine, Italy
4 ...
Scans and Ovarian Cancer: Everything You Want to Knowbkling
When you’re diagnosed with ovarian cancer, scans become an inevitable part of life. But what are the differences between the imaging tests? When should which scans be used? What about the pros and cons of each test? Join Dr. Kevin Holcomb, Vice-Chair of Gynecology and member of the Division of Gynecologic Oncology at Weill Cornell Medicine, and Dr. Elisabeth O’Dwyer, Instructor in Radiology at Weill Cornell Medicine and Assistant Attending Radiologist at NewYork-Presbyterian Hospital-Weill Cornell Campus, as they help make sense of it all.
2. Cervical Cancer
Most common gynecologic malignancy
worldwide and the second most common
cancer in women in the world
Since the advent of cytologic screening in
the 1940s, the incidence of cervical cancer
has been decreasing
However, a steady increase in the
incidence of preinvasive and locally
invasive disease of the cervix has occurred
3. FIGO Staging
Stage Description
0 Carcinoma in situ
I Strictly confined to cervix
IA Micro-invasive carcinoma
IA1 Invasion of stroma ≤ 3mm depth; ≤ 7mm width
IA2 Invasion of stroma ≤ 5mm depth; ≤ 7 mm width
IB Clinical lesions confined to cervix
IB1 Clinical lesion </= 4 cm
IB2 Clinical lesion > 4 cm
II Clinical lesions extending beyond cervix, but not to the pelvic wall
IIA No obvious parametrial involvment
IIB Obvious parametrial involvment
III No extension to pelvic wall, involvment lower 1/3 of vagina
IIIA Extension to pelvic wall or hydronephrosis or nonfunctioning kidney
IIIB Beyond true pelvis/clinically involving mucosa of bladder or rectum
IVA invades mucosa of the bladder or rectum, and/or extends beyond true pelvis
IVB Distant metastases
5. Management of cervical cancer
determined primarily by the stage and
extent of disease
0, IA1: conservative surgery (excisional
conization or extrafascial/simple
hysterectomy)
IA2: Modified radical hysterectomy
IB1: -radical surgery (radical/modified
radical hysterectomy)
-radiation alone
-chemoradiation
6. Management of LACC??
Controversy still surrounds the optimal
management of these bulky tumors at
the primary site
Triple modality treatment often
employed
Metastatic disease in the regional
nodes: important factor for tumor
recurrence
7.
8. Introduction
Incidence of extrapelvic disease at the
time of initial management of locally
advanced cervical cancer (LACC) is
high
10 to 30%
para-aortic (PA) nodes and/or the chest
9. Introduction(contd)
Chemoradiotherapy(CRT) is considered
the standard treatment for LACC
Newer radiotherapy modalities have
been useful for local control
However, rate of nodal and/or distant
failure remains a major problem, raising
the question of the early detection of
such potentially occult disease missed
on conventional imaging
10. Introduction(contd)
PET/CT : improves the rate of detection
of extracervical disease; but carries a
false-negative results of upto 12%
Purpose of the study: evaluate the
survival of patients with LACC without
uptake in PA nodes on PET-CT who
were thus submitted to PA staging
surgery
11. Aim of the study
to evaluate the therapeutic impact of
laparoscopic PA lymph node staging in
patients with locally advanced cervical
cancer with negative PET imaging
outside the pelvic area
12. Patients and Methods
Prospective Multicenter Series
Three French comprehensive cancer
centers
Similar strategy employed at all these
centers for the staging procedures and
treatment of LACC
13. Eligibility Criteria
Stages IB2 to IVA cervical cancer (as
per the FIGO 2009 classification)
Adenocarcinoma, squamous cell
carcinoma, or adenosquamous subtypes
No extrapelvic disease on conventional
imaging(abdominopelvic MRI or CT
scan and pelvic MRI)
No PA (or extrapelvic) uptake on initial
PET-CT imaging
14. Additional Criteria
First, PA staging surgery performed
using a laparoscopic extraperitoneal or
transperitoneal approach
removal of PA nodes from the aortic
bifurcation to the left renal vein(PA,
preaortic, superficial intercavoaortic and
precaval groups)
Pelvic nodes not resected, because they
will subsequently be included in the RT
field
15. Additional Criteria(contd)
Second, no macroscopic extrapelvic
disease should be present during the
laparoscopic peritoneal exploration
Patients with limited pelvic peritoneal
carcinomatosis and/or ovarian
metastasis were excluded from the
study
16. Additional Criteria(contd)
Third, the cervical tumor was treated (if
no PA node involvement after staging
laparoscopy) with pelvic external
radiation therapy (45 to 50 Gy)
Concomitant platinum-based
chemotherapy( Cisplatin @ 40
mg/m2/week)
17. Few patients at the end of this study underwent
IMRT, subsequently completely by uterovaginal
brachytherapy
In patients with initial parametrial and/or suspicious
pelvic nodes on PET/CT imaging, an additional boost
EBRT of upto 60 Gy given optionally
Completion surgery only if -brachytherapy not
technically feasible or
-in clinical and radiologic
(using MRI exam) residual disease 6 to 8 weeks
after the end of brachytherapy
18. Additional Criteria(contd)
Finally, patients with histologic PA node
metastasis after staging laparoscopic
surgery were treated using pelvic and
PA CRT (45 to 60 Gy) with concomitant
cisplatin chemotherapy (40 mg/m2 per
week)
19.
20.
21. Morbidities
Patients were evaluated weekly with a clinical
examination, a blood count, and renal function tests
during treatment
Morbidities related to the laparoscopic surgical procedure
(within 60 days after the staging surgery) - Clavien-Dindo
classification
Morbidities during and/or after CRT - National Cancer
Institute Common Terminology Criteria for Adverse Events
(CTCAE) classification (version 4; revised in October
2009)
To have the most reliable reports on morbidities, grade 1
complications not evaluated
22.
23. Statistical Analysis and End
Points of the Study
Descriptive data were compared using the
Chi-square test or Fisher’s exact test for
proportions
primary end point – overall survival (OS):
time from the beginning of CRT to death
from any cause
secondary end point - event-free survival
(EFS): time from the beginning of CRT to
recurrence or disease progression or death
24. Patients with no event at the time of
analysis: censored at date of last follow-up
OS and EFS curves were calculated
using the Kaplan-Meier method
Median follow-up was estimated using
the Schemper method
25. All qualitative variables tested using the
log-rank test (univariate procedure)
Continuous variables (delays between
procedures) tested using a Cox
proportional hazards regression model
The hazard ratio (HR) and its 95% CI
were provided.
P=0.05 was set as the threshold for
statistical significance
26. Statistically significant factors
the presence and size of metastatic PA
nodes
a delay of 45 days between PET-CT and
the beginning of CRT
27.
28.
29.
30. Discussion
Addresses two important questions
Q1: accuracy of PET-CT imaging in LACC?
False-negative rate between 9% and 22%
Half of this group had a nodal metastasis
<5mm
5 mm cutoff: limit of PET-CT imaging for
accurately detecting tumor tissue is
approximately 5mm
31. Q2: impact of the PA node staging on survival in
LACC?
prognosis of patients with small PA metastasis
( ≤ 5 mm) after laparoscopic staging surgery
and were then treated with extended-field
CRT, was similar to that of patients without PA
metastasis
majority (10 of 13) of these patients also had a
single nodal metastasis
it is unclear whether the good prognosis
among these patients could be owed to the
solitary nature or the small size
32. The risk of distant metastasis was lower in this
subgroup compared with those with a PA node
measuring more than 5 mm.
The survival of this subgroup of patients
(lesion < 5 mm) was excellent and again
similar to that of patients without PA nodal
spread.
If nodal metastasis had not been detected
initially, this patient subgroup would have been
undertreated
33. Patients with PA nodal mets ≥ 5 mm?
Prognosis after laparoscopic staging
surgery remains poor, despite treatment
with extended-field CRT
34. Review of Literature:
PET/CT vs conventional
imaging
Yildirim et al, Gynecol Oncol. 2008 Jan:
Integrated PET/CT for the evaluation of para-aortic
nodal metastasis in locally advanced
cervical cancer patients with negative
conventional CT findings
The accuracy, sensitivity, specificity, PPV and
NPV of the PET/CT were 75%, 50%, 83.3%,
50% and 83.3%, respectively
The treatment was modified in four of sixteen
(25%) patients(EFRT in combination with
cisplatin chemotherapy instead of standard
pelvic field radiotherapy in combination with
cisplatin chemotherapy)
35. Chao A et al, Gynecol Oncol. 2008 Aug:
PET in evaluating the feasibility of curative
intent in cervical cancer patients with
limited distant lymph node metastases
Additional PET or PET/CT had positive
clinical impact in 21 (44.7%) of the 47
study patients, 23 had no impact, and three
had negative impact
Positive Clinical Impact: disclosing additional
curable sites (n=8), down-staging (n=6),
offering metabolic biopsy (n=4) or change
to palliation
36. Review of Literature:
Surgery vs conventional
imaging
Gold et al, Cancer. 2008 May:
Surgical versus radiographic determination of
para-aortic lymph node metastases before
chemoradiation for locally advanced
cervical carcinoma: a Gynecologic
Oncology Group Study
550 patients: S Group; 130 patients: R Group
R group was associated independently with a
poorer prognosis compared with the S
group(HR for progression – 1.35 and for
death – 1.46)
37. Delpech et al, Gynecol Obstet Fertil 2010
Jan:
Lymph node surgical staging for locally
advanced cervical cancer
Even if recent studies have reported
promising results with FDG PET/CT,
surgical staging remains the most accurate
procedure for evaluating LN metastases
Although laparoscopy allows an early start of
adjuvant treatment, due to doubts over its
survival benefits, needs to be validated
through randomized trials
38. Review of Literature:
Staging laporoscopy vs PET/CT
Mortier et al, Int J Gynecol Cancer. 2008
Jul-Aug:
Laparoscopic para-aortic lymphadenectomy
and PET scan as staging procedures in
patients with cervical carcinoma stage IB2-
IIIB (90 pts)
Lymphadenectomy showed metastases in
13% of the patients. In the subgroup with
negative PET scan, 11%(5 of 44) had
metastases
39. Conclusion
Staging laparoscopy has better
sensitivity to detect para-aortic nodal
metastases, owing to the poor spatial
resolution of PET/CT in identifying
metastases < 5mm in size
Staging laparoscopy fraught with peri-operative
and post-operative
morbidities(29/237, 12.2%)