**What is your specialty?

• 1-Gynecologist (general)

• 2-Gynecologic oncologist

• 3-Surgical Oncologist

• 4-Radiation Oncologist

• 5-Medical Oncologist

Post-operative Cervical Ca35 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)

Post-operative Cervical caIntermediate 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

Viswanathan ASTRO 11/3/09

Management of IB1: Radical Hysterectomy

Viswanathan ASTRO 11/3/09

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

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

Post-operative RT : GOG 92Intermediate 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 9/25/08

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 11/3/09

Post-op Chemo-RT: SWOG 8797High-risk patients

• + LN• + Margins• + Parametria• 4 yr PFS

– 63% vs. 80% (p=0.003)

• 4yr OS – 71% vs. 81%

(p=0.007)

Peters et al. JCO 2000Upcoming GOG trial

Other considerations for post op RT

– Close margins, 2x local recurrence rate

– Simple hysterectomy

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

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

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

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

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

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

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

**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

Preop Workup

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

PET

Vulvar cancer.

McMahon C J et al. Radiology 2010;254:31-46

©2009 by Radiological Society of North America

MRI

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

**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

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