icra 2021 cervical cancer

ICRA 2021Cervical Cancer

Sandeep R. Bhave, MD, MS, DABR

Radiation Oncologist, Cancer Care Group

Franciscan Health Cancer Center

©2011 Franciscan St. Francis Health

History of Present Illness

12/4/2019:•44 year old woman presented to her PCP for screening Pap smear •Showed atypical glandular cells with positive for HPV.

Past Medical Hx1. HIV on HARRT 2. Fatty liver disease

OB/GYN G6P6Screening: 1. 2014- PAP negative2. 2019 Mammogram BIRADS-1 neg

Past Surgical Hx- None


HPI cont.

1/9/20

•Colposcopy:

– examine entire cervix, especially squamocolumnar junction (SCJ)

•Cervical Bx- adenocarcinoma in situ

•Endocervical Bx adenocarcinoma


HPI cont.

3/13/20

•Exam Under Anesthesia

– 6.5 cm cervical tumor posterior lip 4-5 cm beefy hypervascular mass.

•Cold Knife Conization

– 3:00 margin of the endocervix and posterior lip.

– Pathology- g1/2 invasive adenocarcinoma.

– + surgical margins


Cervical Cancer

•14,500 new cases/ yr in USA

– 3rd most common GYN cancer

•90% are SCCa, 10% are adenocarcinoma

– Adenocarcinoma tend have worse outcomes

•90-95% are HPV mediated (70% HPV subtype 16/18)

•Sexual Activity: Earlier age, # partners, H/o STI,

•Early age of first birth

•# of children

• Immunosuppression- higher risk than general population, more aggressive screening

– HIV

– Transplant

– Inflammatory bowel disease

– Lupus

– Stem Cell transplant


PET/CT

•Circumferential uptake in the endocervical canal

•Activity greater on the left side

•SUV max of 4.1

•3.75 cm

•No distant uptake

•No nodal uptake


MRI

•Vaginal contrast

– Better assesses soft tissue extension

•86% accuracy

•Better assesses tumor invasion

–Uterine body

–Parametria

–Vaginal extension

•3.8 x 2.0 x 2.5 cm endocervical

•Lower uterine segment on left


FIGO Staging of Cervical Cancer

Stage 1• Confined to uterus • IA =

• Microscopic in uterus

• IA1 • <3mm deep,

• IA2 • 3.1-5mm deep

• IB = • Grossly visible

cervical lesion• > 5mm• IB1

• 5mm-<2cm,• IB2

• >2-4cm• 1B3

• > 4 cm



Stage 2•Beyond Cervix•IIA =

•invading upper 2/3 vagina

• IIA1 •< 4cm

• IIA2 •>4cm

•IIB = •Parametrium extension



Stage 3•Further invasion

• IIIA •Lower 1/3 vagina

• IIIB = •Sidewall •hydronephrosis/non-

fxn kidney•LN+

• IIIC1 •Pelvic LN only

• IIIC2 •PA LN



Stage IV• Stage IVA

Beyond true pelvisRectal invasionBladder invasion

• Stage IVBDistant Metastases


Clinical Summary

•44-year-old woman with h/o HIV on HAART who has FIGO 2A2 adenocarcinoma of the cervix

– Macroscopic tumor in the upper 2/3 of the vagina > 4 cm

– No parametrial involvement, no nodal involvement, no distant disease

•Recommendation

– Definitive concurrent chemoradiation

• 45 Gy in 25 fractions with weekly cisplatin

– Brachytherapy boost


Chemo-RT in Cervical SCCa

•Cat 1 NCCN

•Standard of care in FIGO 1B3 and greater

•Chemotherapy

– Meta-analysis: 6% 5yr OS benefit

•Why not surgery?

– Landoni (Milan)

• Phase 3 study

• RT vs. type 3 hysterectomy

• adj RT if pT2b+LN +SM

• IB-IIA; 63% of surgery pts had adj RT

•No diff OS, DFS; surgery tox worse;

• Conclusion: RT > surgery for old FIGO IB-IIA


External Beam RT Plan

45 Gy in 25 fractions Tomotherapy

Weekly 40mg/𝑚2 Cisplatin

Full bladder

Daily Image guidance

IMRT reduces toxicity

•Bone marrow

•GI

•GU


Case Presentation

Week 4 of RT

•MRI is obtained to evaluate:

– Treatment response

– Brachytherapy planning

– Anatomy• Fundal length

• Tandem angle

•Reduced size 3.8→2.3 cm


Brachytherapy

•Brachytherapy- use of sealed radioactive source near tumor

•Absolutely crucial aspect of definitive therapy

•Allows for curative dose of radiation to cervix

•Higher dose associated with better local control and survival

•Lower utilization of brachytherapy in USA 1

– 88% in 1988→ 58% in 2009

– Propensity matched cohort

• Brachytherapy had higher yr CSS and OS

1. Han et al. 2013 PMID 23849695


Brachytherapy

•OR Procedure:

– Exam under Anesthesia

– Sound length of uterus

– Place an intrauterine tandem

– Then, a ring or ovoid is placed

•Hybrid: interstitial catheters added

– Tumor > 4 cm

– Pelvic side wall invasion

– Lower vaginal involvement

– Obliterated cervical os


Case

•Tandem and ovoid brachytherapy •5 treatments •1-2 treatments/ week•After placement CT scan performed•High risk clinical target drawn

– Cervix and residual tumor

•Dose to rectum, small bowel, bladder, sigmoid evaluated

•Treatment delivered in Rad/Onc ~ Noon•Treatment lasts 5-10 min•Device removed•Pt departs around 2 pm


Her Treatment Course

•She completed treatment very well

•Grade 1 bladder urgency/frequency

•Completed treatment in < 8 weeks

– Completion in > 56 days associated with worse cancer specific survival1

1. Song et al. Cancer 2013, PMID: 22806897


Follow up imaging

3 mo PET/CT was obtained:

•Response associated with PFS and survival1

• In her case:

– SUV decreased 3.5

– No new areas

– NED on pelvic exam

1. Schwarz et al. JAMA 2007 PMID 18029833


Most Recent Follow Up

•H&P:

– 1mo after brachy

– 2 mo with PET/CT at 3 months post-tx

– Q 3 x 2yr,

– then q6m to yr 5

• Pap annually

• Otherwise imaging only as needed for sx eval

• Labs prn

• Use vaginal dilator


Toxicity

Acute

•Cystitis, diarrhea, vaginal discharge, dysuria, decreased counts

Late• 18% risk of G3 and 5% risk G4

•Vaginal- stenosis stricture, fibrosis, thinning mucosa, dyspareunia

•Ureteral stricture, cystitis

• Bowel: obstruction, RT proctitis

•Ovarian failure

• Femoral neck Fracture Embrace 1, Potters et al. Lancet Oncology 2021 PMID: 33794207


Prognosis

Embrace 1, Potters et al. Lancet Oncology 2021 PMID: 33794207


Case

Last seen: September 2021

– Doing well, clinically asymptomatic

– Pelvic exam: telangectasias noted. vaginal shortening and stenosis distally.

– No evidence of disease on exam

– Negative PAP smear


Summary:

•Cervical cancer is detected by screening PAP smear and most associated with HPV

•Definitive chemoradiation is standard of care treatment for FIGO 1B3+ Cervical Cancer

– External Beam RT to pelvis with concurrent chemotherapy

– Brachytherapy boost

•5 year local control is around 90%

•5 year DFS and OS is dependent on overall stage

•While acute/late toxicities do occur, the overall rate of severe morbidity is limited


Thank you!

•Questions?

icra 2021 cervical cancer

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