Cervix cancer is the fourth most common gynecologic cancer in women. Screening through regular pap smears can lower the risk of cervix cancer by 80%. Treatment depends on the stage - early stages may be treated with surgery or radiation while more advanced stages involve radiation with chemotherapy. Radiation uses external beam radiation to the pelvis and internal radiation through brachytherapy applicators in the cervix and vagina. Side effects result from radiation to nearby organs like the bowel, bladder, and ovaries.

1. Robert Miller MD
www.aboutcancer.com
Cervix Cancer the Role of
Radiation

2. Most common gynecologic
cancers in women in 2012
Site Number
Breast 232,340
Uterus 49,560
Ovary 22,240
Cervix 12,340
Vulva 4,700

3. Median age at diagnosis for cancer of the cervix
uteri was 49 years of age (uterus 61, ovary 63,
vulva 68)
Lifetime risk is 0.66% or 1 in 151 of women born
today will be diagnosed with cancer of the cervix
Stage Distribution 5 Year
Survival
Local (confined site) 47% 91%
Regional (into nodes) 36% 57%
Distant (metastases) 12% 16%

4. •Avoidance of Human Papillomavirus Infection
(abstinence, or condoms (lower risk by 60%)
•HPV16/18 vaccination will lower the risk by
92%
•Screening (pap smear) will lower incidence and
mortality by 80%
•Smoking cessation (smoking cigarettes
increases the risk in HPV+ women by 2 to 3
times)

5. Importance of screening because
of disease progression
uterus
cervix
vagina
Spreading
cancer
parametrium
Into
vagina
Early Stage IA more advanced IA stage II

6. Work up or evaluation of a patient with
cervix cancer before deciding on therapy

7. biopsy

8. Pathology Report
• Invasive cancer or just dysplasia or in situ
• Histology or type of cancer
• Squamous cancer (69%)
• Adenocarcinoma (25%)
• Depth of invasion and lateral spread

9. Stages of Cervix Cancer
uterus
Cervix
cancer

10. Stage I = confined to the
cervix
IA = too small to see (found
only on microscope)
IA1 = no deeper than 3mm or
lateral than 7mm
IA2 = 3 to 5mm deep and
lateral up to 7mm
IB = visible or bigger than a IA2
IB1 = up to 4cm
IB2 = bigger than 4cm
Stages of Cervix Cancer

11. Stage II = beyond the cervix
IIA = onto the upper vagina
IIA1 = up to 4cm
IIA2 = over 4cm
IIB = parametrial invasion
Stages of Cervix Cancer

12. Stages of Cervix Cancer
Stage IIIA = lower third vagina
Stage IIIB = side wall or nodes +
Stage IVA = into bladder or rectum
Stage IVB = distant metastases

13. Cross section anatomy of the
female pelvis
bladder
rectum
cervix

14. Cross section anatomy of the
female pelvis
rectum
vagina
rectum

15. PET Scan = Cervix Cancer
Cancer cells use more glucose or sugar and so “light up” on a PET
scan which uses radioactive glucose

16. Lymph
Nodes
spread
from the
cervix

17. Frequency of
lymph node
metastases in
cervical
carcinoma.

18. Cervix cancer
that has
spread to
para-aortic
and pelvic
nodes as
seen on PET
scan

19. Internal view (cross section) from
PET

20. PET = Stage IIIB Cervix Cancer

21. Stage 5 Year Survival
IB 80%
IIA 63%
IIB 58%
III 30%
IVA 16%
Cervix Cancer Survival by
Stage

22. Stage Survival Survival
IA IA1 (97.5%) IA2 (94.8%)
IB IB1 (89.1%) IB2 (75.7%)
II IIA (73.4%) IIB (65.8%)
III IIIA (39.7%) IIIB (41.5%)
IV IVA (22%) IVB (9.3%)
Cervix Cancer Survival

24. NCCN.org

25. Treatment of cervix cancer
•Early stages: surgery (hysterectomy) or
radiation
•More advanced cases: radiation +/-
chemotherapy (cisplatin) then possibly
surgery

26. Early Stages: Surgery or
Radiation

27. More Advanced Stages:
Radiation or Surgery

28. Indications for post-operative radiation
and or chemotherapy based on pathology
report after surgery
•Positive lymph node spread
•Positive surgical margins
•Invasion into the parametrium
•Other high risk features:
•Large primary tumor
•Deep stromal invasion
•Lymphovascular invasion

29. Advanced Stages: Radiation
plus Chemotherapy

30. 5 Trials Demonstrating Improved Survival
with Chemo-Radiation compared to
Radiation Alone

31. External Beam Radiation
Radioactive sourceApplicators
Internal
Radiation

32. CT scan is obtained at the
time of simulation
CT images are then
imported into the
treatment planning
computer

33. In the simulation
and treatment
planning process
the CT and PET
scan images are
used to create a
“target” for the
radiation and a
computer plan is
generated

34. During the treatment
lasers are used to line
up the beam and the
patient receives the
radiation treatment
External beam
radiation is usually 5
to10 minutes, Monday
though Friday, 5 days
a week for 5 to 30
treatments

35. Normal structures identified on CT scans that
can be affected by radiation and cause side
effects

36. Normal Structures Identified on MRI
uterus
uterus
cervix cervix
vagina vagina
rectum
rectum
bladderparametrium

37. Computer generated targets for IMRT Radiation for
advanced cervix cancer to treat pelvis plus para-aortic
lymph nodes

38. Combine a CT scan and linear accelerator to ultimate
in targeting (IGRT) and ultimate in delivery (dynamic,
helical IMRT) ability to daily adjust the beam (ART or
adaptive radiotherapy)

39. Radiation for cervix
cancers
•External beam irradiation (daily for 5 weeks)
sometimes combined with chemotherapy (e.g.
cisplatin)
•Low dose radiation (LDR) Internal radiation (radium or
cesium implants, in hospital for 2-3 days
•High dose rate radiation (HDR) with Nucletron
(Iridium) once a week for 3-5 weeks as an outpatient

40. Radiation Dose Techniques
•External beam 45Gy (40-50Gy) plus possible
sidewall boost of 10-15Gy
•Brachytherapy: Point A total dose of 30-40Gy
(LDR or 6Gy X 5 with HDR) to 80- 85Gy total
dose

41. Internal
radiation
devices or
brachytherapy

42. Internal radiation devices
Tandem goes
into the uterus
Ovoids go into the
corners (fornices)
next to the cervix

43. Internal Radiation Devices

44. HDR = high dose rate machine that can run
radiation through a tube that reaches the
patient through vaginal applicators

45. HDR Cervix Applicators

46. Internal radiation devices
Procedure can be performed in
hospital and the patient stays over
night using a Cesium isotope
applicator or the procedure can be
done as an outpatient with a faster
technique (called high dose rate or
HDR) using an Iridium isotope
source (Iridium 192 with half life of
74 days)

47. Vaginal cylinder is
inserted into the
vagina, the
radiation tube or
wire stays inside
the tube and
doesn’t touch the
patient’s skin

48. A Wire or Tube connects the vaginal or cervical
applicators to the machine that holds the
radioactive (Iridium) source

49. The woman lays on the radiation table and the
treatment usually takes about 5 minutes and then the
applicator is removed

50. Radiation
Fields and
Side
Effects
Pelvic field
Para-
aortic
Node field

51. Side Effects of Radiation are
Related to Organs that are near
the Cancer

52. Side Effects of Pelvic Radiation
ovary

53. Side Effects of Pelvic Radiation
Radiation may hit the bowel causing some more
bowel frequency, cramps, diarrhea and fatigue
Radiation fields

54. Side Effects of Pelvic Radiation
Radiation fields
Radiation may hit the
bladder and rectum causing
urinary burning or frequency
and rectal irritation as well
as vaginal irritation
Patients may benefit from
Imodium, cranberry juice,
skin creams and rectal
ointments

55. Long Term Side Effects of
Pelvic Radiation
•Chronic bowel irritation (looseness or bleeding)
•Chronic bladder irritation (more frequency or
burning)
•Sexual dysfunction (more vaginal dryness or
fibrosis)
•Ovarian dysfunction (normal pelvic radiation doses to
the ovaries will cause menopause)
•Osteitis of the bone (more brittle bones)

56. Robert Miller MD
www.aboutcancer.com
Cervix Cancer the Role of
Radiation