1.
**What is your specialty?
• 1-Gynecologist (general)
• 2-Gynecologic oncologist
• 3-Surgical Oncologist
• 4-Radiation Oncologist
• 5-Medical Oncologist

2.
Post-operative Cervical Ca
35 yo
– Pap smear + ASCUS, HPV DNA+
– Colposcopy/biopsy: invasive squamous
cell ca
– Exam: no visible lesion
– Radical hysterectomy with bilateral
complete lymphadenectomy
– Final path: 2cm inv sq cell ca, extensive
LVI+, 1.5 cm deep stromal invasion
– Staging: Chest X-ray, PET/CT, MRI
(optional < Stage IB1)

3.
Post-operative Cervical ca
Intermediate Risk Factors
• Pelvic RT: EB 45 Gy
– Prone, belly board
– IMRT, supine
– No VB necessary after a rad hyst (only
after a simple hyst)
• Concurrent chemotherapy:
– weekly cis 40 mg/m2
RTOG trial: concurrent cisplatin, post-RT
carbo/taxol x 4

4.
Management of IB1:
Radical Hysterectomy
Viswanathan ASTRO 11/3/09

5.
Radiation or hysterectomy
Landoni et al. Lancet 350: 535, 1997
• Randomized trial of 469 patients
• IB or IIA cervical cancer
• Median f/u: 87 months
• 54% of IB1 & 84% of IB2 surgical pts
had adjuvant radiation for high risk
features
Viswanathan ASTRO 11/3/09

6.
Radiation or Hysterectomy
5 year OS DFS Rec tox
RT 83% 74% 25% 12%
Surgery 83% 74% 26% 28%
(p=0.0004)
SBO risk increased with LND
Viswanathan ASTRO 11/3/09

7.
Post-operative RT : GOG 92
Intermediate risk factors
• Indications (Sedlis et al. GOG92 Gynecol Oncol 73:177-
183)
– LN+, LVI+
– any 2 other factors including >1/3
stromal invasion, large tumor size
Viswanathan ASTRO 11/3/09

8.
GOG 92 update IJROBP 65(1):169-176, 2006
• Median f/u 10 years
• 46% reduction in risk
of recurrence (HR
0.54)
– 42% reduction in risk of
progression/death
– Reduction in adenoca
8.8% vs. 44%
– 30% improvement in
overall survival (p=0.07)
– Increases Grade 3/4
toxicity by 4.5%
Upcoming RTOG trial
Viswanathan ASTRO 9/25/08

9.
Post-op Chemo-RT: SWOG 8797
High-risk patients
• + LN
• + Margins
• + Parametria
• 4 yr PFS
– 63% vs. 80%
(p=0.003)
• 4yr OS
– 71% vs. 81%
(p=0.007)
Upcoming GOG trial Viswanathan ASTRO 11/3/09
Peters et al. JCO 2000

10.
Other considerations for post op RT
– Close margins, 2x local recurrence rate
– Simple hysterectomy

11.
Para-aortic node positive
• 45 yo, 4 cm exophytic, friable mass
• EUA: R sidewall extension, L parametrium +
• Biopsy: invasive squamous cell ca
• PET/CT: positive 2 cm LN level renal hilum
• Hematocrit 25, normal WBC, platelets,
BUN/Cr, AST, ALT

12.
PAN + Treatment
• Extended field RT
– 4F vs. IMRT
– 45 Gy/1.8 Gy/fraction
– IMRT Nodal boost 18-25 Gy w small bowel limit
5cc < 55 Gy;
– 4F nodal boost limit 54Gy
• Concurrent weekly cisplatin 40 mg/m2 x 6 cycles
(last inbetween brachy fractions)
• HDR: 5.5Gy x 5 fractions 3D planning; LDR: 40 Gy
to point A

13.
Common iliac node positive
• 28 yo known high risk HPV+
• Routine annual exam 4cm protuberant
cvx
• Exam: L>R parametrial extension
• MRI: Bilateral parametrial extension,
1.5cm common iliac LN+
• PET: +uptake common iliac LN, no
other LN involved
• FIGO Stage IIB

14.
Common iliac LN+ Treatment
• Consider prophylactic coverage with an
extended field
• IMRT para-aortics and full pelvic field (at
least 3 cm margin on cervix and uterus)
• 45 Gy entire field
• Nodal boost IMRT + 18 Gy = 63 Gy
• Concurrent weekly cisplatin 40 mg/m2 x 6
• HDR Brachytherapy 5.5Gy x 5 3D

15.
Stage IB1
• 72 yo w vaginal spotting
• Exam: 5mm red polyp at os, firm
cervix, no PM extension
• MRI: 10 cm fibroid uterus, tumor
extending along endocervical canal,
tumor 3 cm height, 2cm width
• Biopsy: endocervical adenocarcinoma

16.
Stage IB1
• Options: Radical Hysterectomy
(robotic) with complete
lymphadenectomy, but….
• Post-op EBRT: toxicity increases
• External beam radiation with
concurrent chemotherapy (no hyst)
best option
• Followed by brachytherapy

17.
Vulvar Carcinoma Case
• 50 yo with long hx of
lichen sclerosus
• 6 month hx of scant
bleeding
• Seen for year exam
• Bx mod differentiated
squamous cell ca
• Physical exam reveals
right inguinal node 2.5
cm

18.
**You would recommend:
1- Obtain PET/CT to assess disease
extent and distant metastatic
disease
2- Send immediately for radiation +/-
chemo treatment
3- Aspirate enlarged node
4- Proceed directly to radical surgery
5- Initiate Aldara cream

19.
Preop Workup
• CT/PET: High FDG uptake in right
vulva, right inguinal node and lesser
FDG uptake in nodes bilaterally in groin

20.
PET

21.
Vulvar cancer.
MRI
McMahon C J et al. Radiology 2010;254:31-46
©2009 by Radiological Society of North America

22.
Surgical Approach and final
pathology
• Bilateral inguinal dissection with removal of
enlarged lymph nodes
• Partial radical vulvectomy with removal of
clitoris and upper vulva (bilateral)
• Pathology: 2.5 cm moderately differentiated
squamous cell ca invasive, closest margin
4mm to urethra, + LVI, Right inguinal node
(1)/3 positive, 0/5 Left inguinal

23.
**For the next step, you would
recommend:
1- Re-excise close margin
2- Send for radiation therapy alone
3- Give chemotherapy with radiation
therapy
4- Follow patient for recurrence
5- Refer to urologist

24.
Vaginal cancer
• 65 yo hysterectomy for benign fibroids
20ya
• No pap smears for 20 years
• Vaginal spotting
• Exam: friable mass upper L fornix
extending to L introius @6cm
• Biopsy: invasive squamous cell
carcinoma