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Management of CA of cervix

Stage-Based Therapy:

Stage 0 cancer:

Carcinoma in situ (stage 0)
Local ablative or excisional measures
Cryosurgery, laser ablation, and loop excision
Surgical removal to rule out microinvasive disease

Stage IA1 cancer:

Total hysterectomy, radical hysterectomy, and conization
Lymph node dissection:Not required if the depth of invasion < 3 mm
NCCN guidelines:Pelvic radiation therapy →category 1 recommendation for women with stage IA disease and negative lymph nodes after surgery who have high-risk factors
To maintain fertility:Therapeutic conization with close follow-up, including cytology, colposcopy, and endocervical curettage

Stage IA2, IB, or IIA cancer:

2 Treatment options:
- Combined external beam radiation with brachytherapy
- Radical hysterectomy with bilateral pelvic lymphadenectomy

Radical vaginal trachelectomy with pelvic lymph node dissection is appropriate for fertility preservation in stage IA2 & stage IB1 (< 2 cm)

Stage IIB, III, or IVA cancer:

Locally advanced cervical carcinoma (stages IIB, III, and IVA), radiation therapy was the treatment of choice
External beam radiation to reduce tumor mass
Brachytherapy is delivered by means of afterloading applicators that are placed in the uterine cavity and vagina.
Consequently, the use of cisplatin-based chemotherapy
Ca cervix stage III B is treated with Intracavitary brachytherapy with external beam radiation

Stage IVB and recurrent cancer:

Individualized therapy is used on a palliative basis.
Radiation therapy is used alone for control of bleeding and pain, whereas systemic chemotherapy is used for disseminated disease
Treatment of pelvic recurrences after primary surgical management should:single-agent chemotherapy and radiation
Treatment for recurrences elsewhere should include combination chemotherapy
Central pelvic recurrence after radiation therapy, modified radical hysterectomy (if the recurrence is smaller than 2 cm) or pelvic exenteration
NCCN also recommends docetaxel, gemcitabine, ifosfamide, 5-fluorouracil, mitomycin, irinotecan, and topotecan as possible candidates for second-line therapy (category 2B recommendation), as well as pemetrexed and vinorelbine (category 3 recommendation).
Treatment with bevacizumab plus cisplatin and paclitaxel or topotecan and paclitaxel was approved by the FDA

CERVICAL CANER MANAGEMENT IN PREGNANCY:

Carcinoma in Situ (Stage 0) During Pregnancy

Usually, no treatment is needed for carcinoma in situ (stage 0) during pregnancy. A colposcopy may be done to check for invasive cancer.

Stage I Cervical Cancer During Pregnancy

Pregnant women with slow-growing stage I cervical cancer may be able to delay treatment until the second trimester of pregnancy or after delivery.

Pregnant women with fast-growing stage I cervical cancer may need immediate treatment. Treatment may include:

Conization.
Radical trachelectomy.
Women should be tested to find out if the cancer has spread to the lymph nodes. If cancer has spread to the lymph nodes, immediate treatment may be needed.

Stage II, III, and IV Cervical Cancer During Pregnancy

Chemotherapy to shrink the tumor in the second or third trimester of pregnancy. Surgery or radiation therapy may be done after delivery.
Radiation therapy plus chemotherapy. Talk with your doctor about the effects of radiation on the fetus. It may be necessary to end the pregnancy before treatment begins

BRACHYTHERAPY FOR CARCINOMA CERVIX:

Point-A:

2cm above the lateral fornix & 2 cm lateral to the cervical canal (external os).
Denotes the crossing of the ureter in the pelvis.
Corresponds to the anatomical location of ureter; hence a dose exceeding 8000 rads should not reach this point.

Point-B:

Maximally irradiated, located 5cm from the uterine axis, laterally & at the same level as Point-A & dose is 5000 rads.
Represents the lateral pelvic wall where the obturator gland is located.
Due to inverse square law, the radiation achieved over the lateral pelvic wall would be as low as 1000rads.

Maximum radiation dose to Point-A: 8000cGy; to Point-B: 4500cGy.

The element used for intracavitary RT in carcinoma cervix Caesium

Exam Important

A case of carcinoma cervix who earlier received radiotherapy, relapses with new lesion should be treated with Pelvic exenteration
Management of stage IIB cancer cervix is Radiotherapy with combination with chemotherapy
Ca cervix of stage between II – III should be treated with Radiotherapy and chemotherapy
Ca cervix stage III B is treated with Intracavitary brachytherapy with external beam radiation
Point B in treatment of Ca cervix corresponds to Obturator Lymph node
Treatment of carcinoma Cervix stage IIIB include Concurrent chemoradiation
80-85 and 85-90 gy. is the maximum radiation dose to point A for early and advanced Ca cervix

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Management of CA of cervix