cervix - XY Patient (Learning Plan)
onco
risk factors : Early age of sexual activity, smoking, multiple partners, south America/india, lower
socio economic status(HPV), smoking
biopsy- colposcopy(magnifying device of the vagina, cervix) , ultrasound, MRI(radiological extent
of disease)
Presentation: 4th decade, vaginal discharge and bleeding, pelvic pain and or lower back pain,
unilateral peripheral edema, rarely mets disease
spread- internal/external iliac, pre-sacral pelvic, common pelvic, and para-aortic
staging - stage 0 cancer cells only on surface of the cervix
stage 1- not beyond cervix, (1A, A<3mm, A2 3-5mm - size, 1B, B1 <4cm, >4cm B2)
stage 2- tumor spread to upper parts of vagina (2A, 2B)
stage 3- tumor extends to lower parts of vagina (3A, 3B)
stage 4- bladder rectum, distant (4A, 4B)
advanced cervical ca with lower vaginal involvement, not paired cervix uteri, unspecified
squamous cell carcinoma NOS(not otherwise specified) affirmed, 4*5cm uterus + bulky
obturator nodes 10*6mm + very small nodes in lung
pathology- SSC, adenocarcinoma, adenosquamous
tx
GTV- primary tumor in cervix/vagina
planni
CTV- primary tumor plus margin + pelvic nodes
ng
CT sim
TX
isocentre – mid separation 3cm sup of symphasis pubis
contouring – rectum, bladder, upper vagina, pelvis vessels, small bowel and CTV
IV contrast (magnetic properties of hydrogen nuclei) – omnipaque 300 (contraindications)
vaginal/cervical markers
- Vaginal rod/dummy
- Barium soaked tampon
lymphatic
- Surgical clips
recal barium, SBFT for small bowel, cystogram for bladder
early 1A – high grade intra-epithelial neoplasia (laser treatment), cone or simple hysterectomy ,
trachalectomy (fertility preservation)
1B1- radical trachelectomy and pelvic node dissection for fertility only, radical hysterectomy and
pelvic node dissection
** post op 4500-5000/25
stages 1B2, 2, 3, and 4A
- Concurrent chemo and radical RT will external beam and brachy
4500/18 four field + Brachy Ir 192 550cGy – intracavity 1-5days 15MV + weekly cisplatin BID
max 1 per week if needed
CISPLATIN- weekly for 5 weeks, start 1 week of RT, no chemo on brachy days, txs need to be
completed in 8 weeks
HDR- boost (2 times a week)
****4500-5000cGy/25# -/+parametrial boost with central 4cm block – 360cGy-900cGy/2#-5#
(bladder comfortably full)
4500-5040cGy/25#-28# +/-cx for cervix (pelvis 4fld box, pop bulky tumors, paraaortic nodes IMRT
optional boost to cervix HDR, boost to endo HDR- 550cGY/2or 3# vaginal vault applicator
brachy – point A (covers uterous, cervix, perimetrum, primary coverage) - 2 cm lateral and 2 cm
sup of cervical OS, point B (lateral pelvis wall)– 3cm lateral to point A (node baring tissue) ,
PTC
bladder point (post surface mid length of catheder ballon, rectum point- 0.5cm post to post
vaginal wall)
tendom plus a ring applicators
total dose A- 80Gy to 85Gy, total B - >55Gy
technique 2 field ant/post, 4 field – ant/post and 2 lateral, IMRT 6MV
---- intracavitary brachy Cs137, Ir192 HDR (irridates central disease, mucosa and submucosa of
cervix, and endometrium and upper vagina and medial parametria
treatment set up – supine, full bladder, leg immobilizer
treatment field – AP/PA sup L5-S1, inf – obturator foramin, lats – 2cm lat to pelvis for lateral
fields ant-symphysis pubis, s2/s3 (includes lymph nodes , 2-3cm post to known extent of
disease)
weekly image , with week 1 – 4 action is 0.5cm for shifts
radiation therapy:
early - fatigue, diarrhea, frequency, dysruia, urgency, skin erythema
late- menopause, chronic diarrhea, chronic frequency, vaginal stenosis, dyspareunia, bowel
obstruction, rectal bleeding, fistulae, 2nd cancer, bowel obstruction
chemotherapy – cisplatnum: nausea, vomiting, renal toxicity, hearing loss, peripheral neuropathy
Imodium – 2 initially, 1 every bowel movement to 8 in 24hrs, sitz bath – ½ cup baking soda and
5inch water, lomotil –1-2 every 4 hrs to 8 in 24hrs, kelpectate, ginger ale, pepto bismo , avoid
coffee, smoking, alcohol , spicy food, UTI checks mid urine test - medication flowmax (relax
smooth muscles, and relieve obstruction makes urination easier. Pyridum-relives pain