Mortality Conference

22/3/2012 Departments of Radiation & Medical Oncology

Case history
Name: Mrs. MDB Age: 50 years Sex: Female MR No: 80772 DOA: 3/2/2012 DOD: 6/2/2012

Initial presentation
Date of 1st visit: 7/12/2010 Complaints
Bleeding P/V

Diabetic P5L5 Examination

P/V
Growth replacing cervix All fornices involved L parametrium involved medially

Dx: Ca. Cervix IIB

Initial presentation
MRI pelvis: Large, hyperintense lesion on T2W & STIR sequences is seen involving the endocervical canal and cervical stroma. The mass is extending into adjacent 1/3 of vagina. Mass measures 6.5 4.7 cm CXR Normal CUE Normal CBP Normal Sr. Creatinine Normal RBS - Normal

Initial presentation
RT start date: 14/12/2010 PLAN: IMRT 5040 cGy @ 180 cGy/F 30 + 2100 cGy ICR @ 700 cGy/F 3 + 5 cisplatin 40 mg/m2 once a week RT completion: 20/1/11, with no treatment breaks ICRs: 2/2/2011, 9/2/2011, 16/2/2011 5 cycles weekly cisplatin 70 mg.

Natural History
MC site
Junction of endo & ecto-cervix (transformation zone) Junction of columnar & squamous epithelium Continuous metaplastic change
Greatest
in utero Puberty First pregnancy

Decreases after puberty

Greatest risk of viral induced neoplastic transformation coincides with periods of greatest metaplastic activity

Natural History
Very slow progression from CIN to invasive cancer mean, 15 years Tumor extension
Once breaks through basement membrane, penetrates cervical stroma
Directly Through vascular channels

Exophytic tumors protrude into vagina Endocervical lesions massive expansion of cervix despite normal appearing ectocervix

Natural History
Tumor extension (cont..)
Superior
Lower uterine segment

Inferior
Vagina

Lateral
Broad ligaments uterine obstruction

Postero-lateral
Utero-sacral ligaments

Extension to bladder uncommon - <5% Involvement of rectal mucosa rare

Lymhatic Drainage

Positive pelvic nodes

Stage I II 11 to 18% 32 to 45%

III
Depth of Invasion 3mm 3 to 5mm 6 to 10mm 11 to 15mm 16 to 20mm >20mm T - size 0.1 to 1.0cm 2.1 to 3cm >3cm Grade 1 2 3 Lymphovascular space invasion Absent Present

46 to 66%
<1% 1 to 8% 15.1% 22.2% 38.8% 22.6% 12.7% 16.3% 23 to 42% 9.7% 13.9% 21.8% 8.2% 25.4%

Natural History
Metastatic progression
Orderly pattern
Pelvic echelon nodes para-aortic nodes distant sites

Even in locoregionally advanced disease hematogenous mets rare MC sites of distant mets
Lung Extra-pelvic LN Liver Bone

Prognostic Factors
Clinical tumor diameter Lymph node mets
Size of largest LN Number of involved pelvic LN

Lympho-vascular invasion - poor Deep stromal invasion - poor

10mm or >70%

Parametrial extension poor Strong inflammatory response in stroma good Adenocarcinoma poor
Stage IB2 poorer

Prognostic factors (cont.)

Anemia - poor

Treatment
Stage Primary Therapy 5 Year OS

IA1

1. Cone biopsy 2. Simple hysterectomy 3. Brachytherapy 1. Radical hysterectomy + pelvic node dissection (PND) 2. Irradiation (RT)

> 98%

IA2

95%

IB1/ limited IIA1

1. Radical hysterectomy + PND 2. RT

1. ChemoRT 1. ChemoRT 1. ChemoRT 2. Selective exenteration 1. Chemotherapy 2. Palliative RT

90%
80 85% 70 75% 50% 15 25% 0%

IB2/ Larger IIA1/ IIA2 1. ChemoRT IIB III IV A IV B

Chemo-RT protocol

CDDP - Cisplatin
External RT Weekly 5 fractions

Intracavitary brachytherapy

Radiotherapy
Tumor burden Vs Radiation dose needed for control
Microscopic disease 1 to 2 cm 2 to 3+ cm 45 to 50 Gy 60 to 70 Gy 70 to 90 Gy

RT dose
External RT
Total dose 50 Gy Mid line block at 40 Gy

Brachytherapy
Intracavitary added to EBRT
With MLB 21Gy Without MLB 18 Gy Post operative 15 Gy

Intersitital