Cervix Cancer the Role of

Radiation

Robert Miller MD
www.aboutcancer.com
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
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%

•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)
 Importance of screening because
of disease progression

uterus

parametrium
Spreading
cervix cancer

vagina Into
vagina

Early Stage IA more advanced IA stage II

Work up or evaluation of a patient with
cervix cancer before deciding on therapy
biopsy
 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
Stages of Cervix Cancer

uterus

Cervix
cancer
 Stages of Cervix Cancer
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
Stage II = beyond the cervix

IIA = onto the upper vagina

IIA1 = up to 4cm

IIA2 = over 4cm

IIB = parametrial invasion

 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
Cross section anatomy of the
female pelvis

bladder

rectum
cervix
Cross section anatomy of the
female pelvis

vagina

rectum
rectum
PET Scan = Cervix Cancer

Cancer cells use more glucose or sugar and so “light up” on a PET
scan which uses radioactive glucose
Lymph
Nodes
spread
from the
cervix
Frequency of
lymph node
metastases in
cervical
carcinoma.
Cervix cancer
that has
spread to
para-aortic
and pelvic
nodes as
seen on PET
scan
Internal view (cross section) from
PET
PET = Stage IIIB Cervix Cancer
Cervix Cancer Survival by
Stage

Stage 5 Year Survival

IB 80%
IIA 63%
IIB 58%
III 30%
IVA 16%
 Cervix Cancer Survival

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%)
NCCN.org
 Treatment of cervix cancer

•Early stages: surgery (hysterectomy) or

radiation
•More advanced cases: radiation +/-
chemotherapy (cisplatin) then possibly
surgery
Early Stages: Surgery or
Radiation
More Advanced Stages:
Radiation or Surgery
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
Advanced Stages: Radiation
plus Chemotherapy
5 Trials Demonstrating Improved Survival
with Chemo-Radiation compared to
Radiation Alone
 External Beam Radiation

Internal
Radiation
Applicators Radioactive source
CT scan is obtained at the
time of simulation

CT images are then

imported into the
treatment planning
computer
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
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
Normal structures identified on CT scans that
can be affected by radiation and cause side
effects
Normal Structures Identified on MRI

uterus cervix
uterus cervix

rectum rectum

vagina parametrium bladder vagina

Computer generated targets for IMRT Radiation for
advanced cervix cancer to treat pelvis plus para-aortic
lymph nodes
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)
 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
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
Internal
radiation
devices or
brachytherapy
Internal radiation devices
Tandem goes
into the uterus

Ovoids go into the

corners (fornices)
next to the cervix
Internal Radiation Devices
HDR = high dose rate machine that can run
radiation through a tube that reaches the
patient through vaginal applicators
HDR Cervix Applicators
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)
Vaginal cylinder is
inserted into the
vagina, the
radiation tube or
wire stays inside
the tube and
doesn’t touch the
patient’s skin
A Wire or Tube connects the vaginal or cervical
applicators to the machine that holds the
radioactive (Iridium) source
The woman lays on the radiation table and the
treatment usually takes about 5 minutes and then the
applicator is removed
 Radiation Para-
Fields and aortic
Side Node field
Effects

Pelvic field
Side Effects of Radiation are
Related to Organs that are near
the Cancer
Side Effects of Pelvic Radiation

ovary
Side Effects of Pelvic Radiation

Radiation fields

Radiation may hit the bowel causing some more

bowel frequency, cramps, diarrhea and fatigue
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
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)
Cervix Cancer the Role of
Radiation

Robert Miller MD
www.aboutcancer.com