Ch. 31. Cervical and Vaginal Cancer

1. Ch. 31. Cervical and Vaginal Cancer 부산백병원 산부인과 R1 손영실

2. # Treatment

3. INDEX 1. Postoperative Radiation 2. Chemotherapy 3. Radiation 4. Concurrent Chemoradiation 5. Patient Evaluation and Follow-up after Therapy

4. Postoperative Radiation • Recommended for patients - metastasis to pelvic lymph nodes - invasion of paracervical tissue - deep cervical invasion - positive surgical margins → in an effort to improve survival rates

5. Postoperative Radiation • Necessary in the presence of positive surgical margins, but, use of other risk factors is controversial • Rationale for treatment : pelvic node dissection does not remove all of nodal and lymphatic tissue → radiotherapy can sterilize cancer in pelvic lymph nodes.

6. Postoperative Radiation • Based on retrospective studies, postoperative radiation therapy for positive pelvic LN - can decrease pelvic recurrence - does not improve 5-year survival rates

7. Postoperative Radiation • Study of 60 pairs of irradiated and nonirradiated women of positive nodes after radical hysterectomy ① no significant difference in 5-year survival rate - 72% for surgery alone - 69% for surgery plus radiation ② significant decrease in pelvic recurrence - 67% for surgery only - 27% in treated with postoperative radiation

8. Postoperative Radiation • Location of LN metastases is relevant to postirradiation recurrence rates. • As the number of positive pelvic LN increase, the percentage of positive common iliac and low paraaortic nodes increases. → extended-field radiotherapy is recommended to patients with positive pelvic LN in an attempt to treat undetected extrapelvic nodal disease

9. Chemotherapy • Chemotherapy in cervical carcinoma is limited in part by the success of surgery or radiation therapy. • However, neoadjuvant chemotherapy has been used to shrink the tumor before radical hysterectomy or radiotherapy

10. Chemotherapy • Neoadjuvant chemotherapy - achieve a 22% to 44% CR rate - decrease the number of positive pelvic LN - improve the 2- and 3-year disease-free survival rates, particularly in patients with stage Ⅰ or Ⅱ disease

11. Radiation • Radiotherapy can be used to treat all stages of cervical squamous cell cancer. • Cure rate of about - 70% for stage Ⅰ - 60% for stage Ⅱ - 45% for stage Ⅲ - 18% for stage Ⅳ

12. Radiation • Comparison of Surgery versus Radiation for Stage Ⅰb/Ⅱa Cancer of the Cervix

13. Radiation • Radiation treatment plan generally consist of a combination - external teletherapy to treat regional nodes to shrink the primary tumor - intracavitary brachytherapy to boost the central tumor

14. Radiation • The treatment sequence depends on tumor volume ① Stage Ⅰb lesions smaller than 2cm : treated first with intracavitary source to treat the primary lesion, followed by external therapy to treat the pelvic nodes ② Larger lesions : require external radiotherapy first to shrink the tumor and to reduce the anatomic distortion caused by the cancer

15. Radiation • Patients will have “geographic” treatment failure if standard pelvic radiotherapy ports are used. → Thus, treatment plans are individualized based on CT scans and biopsy of the paraaortic LN.

16. Radiation A. Surgical “Staging” before Radiation → designed to discover the presence of positive nodes • Survival appears to be related to the amount of disease in the paraaortic nodes and to the size of the primary tumor. • In patients with - microscopic paraaortic LN metastases - tumor has not extended to the pelvic wall → 5-year survival rate improve to 20% to 50%

17. Radiation B. Supraclavicular Lymph Node Biopsy • Although not standard practice, supraclavicular LN biopsy has been advocated in patients - with positive paraaortic LN before extended-field irradiation - with central recurrence before exploration

18. Radiation C. Complications during Brachytherapy ① Perforation of the uterus may occur at time of insertion of the uterine tandem • Particularly for elderly patients who had a previous diagnostic conization ② Fever may occur after insertion of tandem and ovoids, if most often results from infection of the necrotic tumor and occurs 2 to 6 hours after insertion of the intracavitary system.

19. Radiation D. Acute Morbidity - are caused by ionizing radiation on the epithelium of the intestine and bladder. • Symptoms : diarrhea, abdominal cramps, nausea, frequent urination, and occasionally bleeding from the bladder of bowel mucosa

20. Radiation E. Chronic Morbidity - result from the induction of vasculitis and fibrosis - more serious than the acute effects - occur several months to several years after radiotherapy - bowel and bladder fistula, bowel bleeding, stricture, stenosis, or obstruction

21. Radiation F. Proctosigmoiditis - should be treated with low-residue diet, antidiarrheal medications, and steroid enemas - In extreme cases, a colostomy may be required, and resection of rectosigmoid must be performed. G. Rectovaginal Fistula - occur in fewer than 2% of patients

22. Radiation H. Small Bowel Complications • previous abdominal surgery → pelvic adhesions → sustain more radiotherapy in the small bowel • Symptoms : crampy abd. Pain, intestinal rush, small bowel obstruction, low-grade fever, anemia, small bowel fistula I. Urinary Tract - occur 1% to 5% of patients - vesicovaginal fistula, ureteral stricture, ureterolysis

23. Radiation J. Treatment of Stage Ⅱb to Ⅳb • Radiation therapy : traditional therapy for patients with stage Ⅱb or greater cervical cancer • urinary or rectal diversion is performed in stage Ⅳa, vesicovaginal or rectovaginal fistula • stage Ⅳb - considered candidates for palliative radiation therapy - control of symptoms with the least morbidity

24. Concurrent Chemoradiation • Emcompasses the benefits of - Regional therapy with radiation - Chemotherapy to sensitize cells to radiation → improve locoregional control • The 4-year survival rate (in GOG studies) - chemoradiation : 81% - radiation alone : 71% → Patients with these high-risk factors after radical hysterectomy for stage Ⅰa2, Ⅰb, and Ⅱa disease, chemoradiation is the postoperative treatment of choice.

25. Concurrent Chemoradiation • In the GOG protocol 85, patients with stage Ⅱb to Ⅳa who received concurrent chemoradiation and were treated with cisplatin and 5-FU had a statistically improvement in progression-free interval and overall survival than treated with hydroxyurea and radiation → Thus, cisplatin-based concurrent chemoradiation is the treatment of choice for patients with advanced-stage cervical cancer.

26. Patient Evaluation and Follow-up after Therapy → Tumors may be expected to regress for up to 3 months after radiotherapy • Pelvic exam → progressive shrinkage of the cervix and possible stenosis of the cervical os and upper vagina • Rectovaginal exam → palpation of the uterosacral, cardinal ligament for nodularity (most important)

27. Patient Evaluation and Follow-up after Therapy • FNA cytology of suspicious area • Supraclavicular and inguinal LN should be examined • Cervical or vaginal cytology should be perfomed - every 3 months for 2 years - then every 6 months for the next 3 years

28. Patient Evaluation and Follow-up after Therapy • Endocervical curettage should be performed in patients with large central tumors. • Chest x-ray may be obtained yearly (in advanced stage) - Lung metastasis : 1.5% - Solitary nodules : 25%

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