Cervical

Question 1

HPV 16 and 18 - involved in what % of cervical cancer -1

Answer 1

70%

Question 2

screening - <21yo

Answer 2

none

Question 3

screening - 21-29yo

Answer 3

cytology alone q3y

Question 4

screening - 30-65yo

Answer 4

preferred: HPV DNA (looks at 16 and 18) and cytology “co-testing” q5y
acceptable: cytology alone q3y (NOT annual)

Question 5

screening - >65yo

Answer 5

none

Question 6

screening - guidelines

Answer 6

after hysterectomy for benign dz - no screening

if HPV vax - follow std screening, no difference

if abnormal test result - follow NCCN cervical screening guideline

Question 7

tx - basic concepts -surgery -4

WHEN IS CURE POSSIBLE?

Answer 7

primary tx,

varies with stage of dz and desire for fertility (determines surgery type),

MAJOR role in early stage (stage Ia-b, IIa) - GOAL CURE

preferred over XRT as less tox

Question 8

tx - basic concepts -XRT -4

MAJOR OR MINOR ROLE?

Answer 8

MAJOR role in locally adv to advanced dz,

also in adjuvant setting for pts with high risk of recurrence

external beam: outside going in

internal beam: probe in cervix (can not give external beam at doses higher enough to not damage bowel and bladder) (also called intracavitary) VERY IMPT!

Question 9

tx - basic concepts -chemo -3

COMMON OR LIMITED ROLE?

WHEN WOULD YOU USE CHEMO ALONE?

Answer 9

limited role,

1. concurrent with XRT for currative tx,
2. palliative tx for advanced or recurrent dz

NOT used alone in absence of metastatic dz

Question 10

tx - adjuvant XRT by stage Ia-IIa -3

SURGERY THEN +/- ADJ

Answer 10

node neg, positive LVSI, tumor >4cm: 
adj XRT (cat 1) +chemosensitization (cat 2b)

LN (+) and/or +surgical margins and/or +parametria:
adj XRT +chemosens (cat 1) +/- vaginal brachy

adenosquamous OR neuroendocrine small cell histology (THESE ARE RARE):
adj XRT

Question 11

primary tx - advanced stage IB2-IVA - XRT + chemosens - SOC -4

NO SURGERY BECAUSE NOT AN OPTION

WHAT SIZE IS TOO LARGE?

Answer 11

lesion too large to surgically resect, >4cm

external beam pelvic radiation (40-60 Gy) + vaginal brachytherapy (80-85 Gy Point A) + concurrent cis 40 mg/m2 weekly

adding chemo reduced death by 20%, 6% improvement in 5yr OS

can also use 5-FU, mitomycin, and paclitaxel (also effective) for women who can not tolerate cis (those with renal dysfunction) (NOTE ALL RADIOSENSITIZING DRUGS)

Question 12

staging - effect of size and location of dz -2

Answer 12

> 4cm

III: if dz outside cervical area LIKE HYDRONEPHROSIS

Question 13

cisplatin chemoXRT concepts

Answer 13

Goal 6 wks of XRT without breaks with 5-6 doses of cis (OS improves with at least 5)

start cis within 24-48h of XRT

Question 14

cisplatin chemoXRT acute ADR -5

Answer 14

myelosuppression,

diarrhea,

electrolyte abnormalities (mostly from diarrhea),

anemia,

N, V

Question 15

cisplatin chemoXRT long term ADR -3

Answer 15

vaginal stenosis (vaginal dialators),

menopause,

bowel obstruction / fistulas (FROM XRT FIBROSIS)

Question 16

cisplatin chemoXRT monitoring -3

Answer 16

labs: CBC, chem, pt wt

others: 
pain scores (local tissue swelling can make worse prior to getting better), 

analgesic use in pts with large tumors

Question 17

recurrence - general principles (5pts)

OPTIONS ARE LIMITED

Answer 17

cure unlikely (especially if recurrence in field that was previously radiated)

XRT +/- cis if recurrence isolated AND outside the previously irradiated field

FOR ISOLATED LOCALIZED RECURRENCE ONLY: pelvic exenteration (massive procedure, not common) surgery for highly selected pts

palliative chemo if not candidate for XRT or surgery

single agent tx or BSC appropriate for recurrence within previously irradiated field as responds poorly to chemo

Question 18

recurrence - salvage chemo (3pts)

WHAT IS TOC?

Answer 18

cisplatin 50mg/m2 historic TOC, OS 6-7mo, results prior to common use of concurrent XRT-cis,

last decade -> platinum-based doublets is TOC -> trend favors pac-cis doublet, improves OS by 4 months over cis alone

gem-cis doublet least toxic (less leukop, neutrop, anemia, infx)

Question 19

advanced (metastatic) OR recurrent - NCCN 1st line (4pts)

WHICH 3 ARE CAT 1?

Answer 19

cis 50 +pac 135 over 3h (cat 1, even though no data) or over 24h (not preferred)

cis 50 D1 +topot 0.75 D1-3 (cat 1, vs cis alone only study to show OS improvement, BUT pac-cis still preferred, no hair loss BUT less convenient)

pac 175 +carbo 6 (cat 1, but phase III study in progress)

cis 50 D1 +gem 1000 D1, 8 (cat 2B, acceptable if pre-existing neuropathy)

Question 20

advanced (metastatic) OR recurrent - NCCN 1st line FOR PTS THAT CAN NOT TOLERATE 2 DRUGS (3pts)

ALSO FOR recurrence within previously irradiated field as responds poorly to chemo

MANY PTS CAN NOT TOLERATE DOUBLETS

Answer 20

cis 50

pac 135-175

carbo 5-6

Question 21

advanced (metastatic) OR recurrent - 2nd line -10

Answer 21

#bev
#doce
#5FU
#ifos
#irino
#mitomycin
#pemetrexed
#topot
#venorelbine