Advances in Cervical Cancer Advances in Cervical Cancer Akila Viswanathan, MD MPHAssociate Professor of Radiation Oncology
ManagementManagementAssociate Professor of Radiation Oncology
BWH/Dana-Farber Cancer InstituteHarvard Medical School
April 14, 2012
DisclosuresDisclosures
• No financial disclosuresNo financial disclosures
• Board member of American Brachytherapy SocietySociety
Learning Objectives:Learning Objectives:
1. Early stage cervical cai di i-Post operative radiation
2. Locally advanced cervical cancer- External beam w conc chemo
3. Brachytherapyy py
Viswanathan ASTRO 2012
Presentation• Vaginal bleedingVaginal bleeding
• Discharge
B k i• Back pain
• Superficial ulceration
• Exophytic tumor
• May spread to the vaginal fornices,May spread to the vaginal fornices, parametria, bladder or rectum
Viswanathan ASTRO 2012
Diagnostic work-up
Visible lesion:
• EUA• EUA
• Chest X-ray, CBC, Labs, Urinalysis
• Stage > 3: Cystoscopy, Rectosigmoidoscopy
• Optional: MRI, PET, CT, US, IVP
• Lymphangiogram not in U.S.
Viswanathan ASTRO 2012
Manual Examination
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FIGO Staging System
• Studies permitted by FIGO for staging:– EUA, colposcopy, endocervical curettage, hysteroscopy,
cystoscopy, proctoscopy, IVP, CXR, skeletal x-raycystoscopy, proctoscopy, IVP, CXR, skeletal x ray
• Studies not permitted but often obtained in the U.S.: CT, MRI pelvis, PET
• If there is disagreement about parametrial invasion, the earlier stage should be chosen.N LN i l d d i FIGO t i• No LN included in FIGO staging
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2009 Staging revision2009 Staging revision
• Stage IIA1: upper 2/3 vag involvement with size < 4cm
• Stage IIA2: upper 2/3 vag involvement with size > 4cm
Prognostic FactorsPrognostic Factors
• FIGO Stage• Tumor Size• Lymph node status• HistologyHistology• Smoking• Hemoglobin ? (> 10) • Post hysterectomy• Post-hysterectomy
- Lymphovascular invasion- Percent stromal invasion
Parametrial extension- Parametrial extension• Others: SCC-Ag, Age• Predictive factors: duration
of treatment use of chemoof treatment, use of chemo-RT, brachytherapy
PET at diagnosis: Detection of Nodal Metastases
Rule of 15Rule of 15
Stage 5 yr survival %+ pelvic LNStage 5 yr survival %+ pelvic LN
I 85 15
II 70 30II 70 30
III 55 45
Prophylaxis of para-aortic LN? Not standardized
If + pelvic LN large tumor size LVI prophylactic PAN RTIf + pelvic LN, large tumor size, LVI - prophylactic PAN RT
Resect or boost LNs >3cm
PET + LN predict survivalPET + LN predict survival
• 513 patients513 patients
• Stage independent
• Positive pelvic LNPositive pelvic LN
better than PAN
Post-treatment PET predicts survivalPost treatment PET predicts survival
Schartz et al. JAMA 21;298(19):2289-95
Locally advanced casesMR: Sag and Axial T2-weighted
ImagesImages
Predictive value of MRIWang et al. Cancer 2010; 116(21):5093-101
• MRI at diagnosis, 2-3 k i EBRT fweeks into EBRT; after
45Gy, 1-2 mo post Tx
R i ti• Regression ratio predictive of recurrencerecurrence
• Initial MR Volume 40 cc and ratio:cc and ratio:
• post-EB vol/initial vol <20%– significantly lower LC
and DSS
Management of Stage IA
• Cryotherapy
• Laser Conization or AblationAblation
• Cold Knife Conization
• Loop Electrosurgical p gExcision Procedure (LEEP)
• If LVI+: Radical h t thysterectomy
• Trachelectomy
• Simple Cone + LND
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• Simple Cone + LND
Management of IB1: RadicalManagement of IB1: Radical Hysterectomy
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Radiation or h sterectomRadiation or hysterectomy Landoni et al. Lancet 350: 535, 1997
• Randomized trial of 469 patients
• IB or IIA cervical cancer• 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 2012
Radiation or Hysterectomy
5 year OS DFS Rec tox
RT 83% 74% 25% 12%RT 83% 74% 25% 12%
Surgery 83% 74% 26% 28%
(p=0.0004)
SBO risk increased with LND
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Post-operative RT : GOG 92I t di t i k f tIntermediate risk factors
Sedlis et al. 1999;73:177-83.
LVI Stromal invasion Tumor size
+ D 1/3 A+ Deep 1/3 Any
+ Middle 1/3 > 2cm
+ Superficial 1/3 > 5cm
-- Deep or middle 1/3 > 4cmDeep or middle 1/3 4cm
N d 2 f 3 f tNeed 2 of 3 features
GOG 92 update IJROBP 65(1):169-176, 2006
• Median f/u 10 years• 46% reduction in risk of
recurrence (HR 0 54)recurrence (HR 0.54) – 30% improvement in
overall survival (p=0.07)Increases Grade 3/4– Increases Grade 3/4 toxicity by 4.5%
– 42% reduction in risk of progression/deathprogression/death
– Reduction in adenoca 8.8% vs. 44%
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Accruing GOG 263: concurrent weekly Cisplatin vs. no chemo
Post-op Chemo-RT: SWOG 8797Post op Chemo RT: SWOG 8797High-risk patients
• + LN• + Margins• + Parametria• 4 yr PFS
– 63% vs. 80% (p=0.003)
• 4yr OS 71% 81% ( 0 007)– 71% vs. 81% (p=0.007)
Peters et al. JCO 18:1606-13, 2000
A i RTOG 0724 dj C b /T l
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Accruing RTOG 0724: adj Carbo/Taxol
Locally Advanced Cervical Locally Advanced Cervical Cancer Cancer
Viswanathan ASTRO 2012
Chemo-sensitizationChemo sensitization
MM G1
RT sensitiveTaxol
Cell cycleTaxol
SG2 Cis-platinumHydrea
RT resistant
CisplatinumCisplatinumcis-Diammine dichloroplatinum[II]
• Cytotoxic and supra-additive with RT
• Inhibits repair of sublethal and potentially lethal b s epa o sub e a a d po e a y e aRT injury
• Toxicities: renal, hematologic, GI, g ,– Check Creatinine – stent if obstructed
– CBC – transfuse if Hct <30
– Caution low performance status, medical comorbidities, nutritional status (cardiac, pulmonary)
Randomized trials of cisplatin-containing CT-RT leading p g gto NIH clinical alert in April, 1999
ailu
ree
risk
of fa
Rel
ativ
e
CT-RT of Cervical CancerCT-RT of Cervical CancerCT RT of Cervical CancerSettings in which chemoradiation has
demonstrated advantage over RT alone
CT RT of Cervical CancerSettings in which chemoradiation has
demonstrated advantage over RT alone
• Locally-regionally advanced (PAN -)• Locally-regionally advanced (PAN -)Locally regionally advanced (PAN )– IB2-IVA disease
• Pre operative (bulky IB)
Locally regionally advanced (PAN )– IB2-IVA disease
• Pre operative (bulky IB)• Pre-operative (bulky IB)
• Post-operative, high risk
• Pre-operative (bulky IB)
• Post-operative, high risk– Positive nodes, margins, parametria – Positive nodes, margins, parametria
RT versus RT and chemotherapyRT versus RT and chemotherapyRTOG 90-01: Morris et al.
NEJM 340:1137, 1999
• IB1, IB2, IIA (N+ or >5cm); IIB-IVA; PAN neg (lymphangiogram or surgery)
• 403 patients• Arm 1: Extended field RT (pelvic & PAN)
RT dose: 45Gy pelvis and PAN + 40 Gy point A• Arm 2: RT+CDDP 75 mg/m2 + 5FU 4g
d1 5 q3w x 3 cyclesd1-5 q3w x 3 cycles
RTOG 90 01: 8 yr updateRTOG 90-01: 8 yr updateJ Clin Oncol 22(5):872-880, 2004
8yOS DFS LRF DM PAN
RT+CDDP+5FU 67% 61% 18% 20% 9%RT+CDDP+5FU 67% 61% 18% 20% 9%
EF RT 41% 36% 35% 35% 4%
p= <0.0001 p=0.15
• Only trial with RT alone arm
• Largest RR reduction (0.48)
• G3+ toxicity: 13% vs. 12% (p=0.65)
• St IB-IIA (272 pts): 78% vs. 55% (p<0.001)
St III IVA (117 t ) 59% 47% ( 0 066)• St III-IVA (117 pts): 59% vs. 47% (p=0.066)
Weekly CDDP Chemoradiotherapy for CervicalWeekly CDDP Chemoradiotherapy for Cervical Cancer
GOG 120 526 (1999 2007) HU+RT +++
Trial Year Control Result
GOG 120 526 (1999, 2007) HU+RT +++
GOG 123 374 (1999, 2003) RT only +++
NCIC 259 (2002) RT only -
NCIC trial: why negative?y g
• Smallest # patients, lowest % stage III-IVp g
insufficient power to detect difference
• Shortest treatment duration
– Improved outcome in both arms
• Anemia higher in chemotherapy armAnemia higher in chemotherapy arm
• Para-aortic LN staged CT only
• Only squamous cell caOnly squamous cell ca
• Variable brachytherapy (HDR, MDR, LDR)
d f / h d hStudies of CDDP/5FU Chemoradiotherapy
Trial Year Control Result
RTOG 90-01 (1999) RT (EF) +++
SWOG 87 97 (2000) RT (postop) +++SWOG 87-97 (2000) RT (postop) +++
GOG 85 (1999) HU + RT +
Plat/5FU never compared directly with weekly CDDPPlat/5FU never compared directly with weekly CDDP
Weekly CDDP Chemoradiotherapy as the standardWeekly CDDP Chemoradiotherapy as the standard arm
GOG 165 316 (2005) PVI 5FU ++
Trial # Year Control Result
(terminated early 35% failure rate)
Conclude: 5FU alone inferior to weekly CDDP
J Clin Oncol 2005;23(33):8289-95
Meta-AnalysisGreen JA et al, Lancet 358: 781, 2001
• Review of 19 randomizedReview of 19 randomized Trials of CT+RT for cervical cancer (1981-2000) – 4580 pts randomized,4580 pts randomized,
3656 evaluable• 16% absolute improvement
in PFS (47% to 63%)( )– Benefit both local control
and distant failures• 12% absolute improvement12% absolute improvement
in survival (40% to 52%)– Greater benefit for St IB-
IIB• Increased acute toxicity with
CT+RT, but not late toxicity
LDR Treatment SchemaLDR Treatment SchemaT/O #1T/O #1 T/O #2T/O #2CDDP
1 2 3 4 5 6 7 8 wks1 2 3 4 5 6 7 8 wks
T/O #1T/O #1 T/O #2T/O #2CDDP
1 2 3 4 5 6 7 8 wks
E t l b
1 2 3 4 5 6 7 8 wks
E t l b
40-45 Gy Boosts
External beam External beam
HDR Treatment SchemaHDR Treatment Schema#1#1 #2#2CDDP
HDR Treatment SchemaHDR Treatment Schema#3#3 #4#4 #5#5
40-45 Gy Boosts1 2 3 4 5 6 7 8 wks1 2 3 4 5 6 7 8 wks
Viswanathan ASTRO 9/25/08
y oosts
External beam External beam
Management of IB2-IVA
• Concurrent chemotherapy (Cisplatinum 40 mg/m2 weekly) and radiation therapy
• RT – pelvic and brachytherapy• Pelvic – APPA or 4F, 180cGy/fraction, 45Gy,Pelvic APPA or 4F, 180cGy/fraction, 45Gy,
15-18 MV. • Boost parametria, sidewallBoost parametria, sidewall• Brachytherapy TD 80-90 Gy
Outback ChemotherapyDueñas-González A et al. JCO 2011;29:1678-1685
Outback Chemotherapy
• Concurrent Cis + RTConcurrent Cis + RT versus
• Concurrent Gem/Cis
Kaplan-Meier estimates of (A)
/plus outback Gem/Cis
progression-free survival (PFS) and (B) overall survival
for patients who were prandomly assigned to arm A or arm B. PFS at 3 years is shown by the dotted black y
lines and was 74.4% for arm A and 65.0% for arm B (P = .029)
TECHNIQUES
Bowel sparing simulation
Supine ProneSupineIntact cervix Post-op pelvis
Radioth Oncol 2005;74:267-74
Cervical Cancer Simulation
Superior L4-5
APPA Most inclusive
Viswanathan ASTRO 9/25/08
Lateral DRR
Could miss external iliac, pre-sacral, peri-rectal andrectal and internal iliac LN posteriorly
Viswanathan ASTRO 9/25/08
IMRThttp://www.rtog.org/gynatlas/mai
n.htmln.html
Viswanathan ASTRO 2012
MOVEMENTMOVEMENT
Heisenberg’s Uncertainty PrincipleHeisenberg s Uncertainty Principle
• The more precisely the p yposition is determined,
the less precisely the momentum is known inmomentum is known in
this instant, and vice versa.
--Heisenberg, Uncertainty paper,
19271927
Heisenberg ≅ 4D RT• Locate the target• Locate the target
• But as soon as you locate it, it moves
• Vaginal, parametrial mobility
• How much over-contouring is necessary to g ycompensate ‘uncertainity’
• A sim CT is a STATIC imageA sim CT is a STATIC image
Variation in Vaginal PositionBladder Full vs. Empty
Parametria & changeParametria & change depending on volume of bladderof bladder
PTV: 1-4 cm
Courtesy of Karen Lim, Princess Margaret
RTOG IMRT AtlasRTOG IMRT Atlas
• Obturator nodal contours /inferior extensionObturator nodal contours /inferior extension
• Vaginal ITV
i l i• Parametrial tissues
• Uterosacral ligaments/parametria
/PET/CT Fusion Nodal Contour
N d l b 4 6 GNodal boost 54-65 Gy
Location of Dose Limiting Structures
P tiPara-aortics
Small Bowel
Bone Marrow
Viswanathan ASTRO 2012
IMRT looks like an attractive option…
Disadvantages of IMRT
C iContouringNeed accurate contouring to avoid misses
ImmobilizationPatient setup must be accurate and reproducible
Knowledge of Internal Motion
Margins could vary greatly depending on organ motion
Viswanathan ASTRO 2012
Disadvantage…..
• Underdosing a critical region….– Uterosacral ligamentsUterosacral ligaments
– Parametrial tissues
– Uterine cavity– Uterine cavity
• ConsequenceR l– Relapse
– DEATH
Viswanathan ASTRO 2012
Can IMRT replace Can IMRT replace brachytherapy?brachytherapy?
After 45 Gy EBRT• Complex internal
organ motion• Complex internal
organ motion
After 45 Gy EBRT
– Brachy fixed to target• Tumor response
– Brachy fixed to target• Tumor response• The proximity of
critical structures l littl f
• The proximity of critical structures l littl fleaves little room for error in EBRT planningleaves little room for error in EBRT planning
Brachy better than IMRTBrachy better than IMRTyy
BrachytherapyBrachytherapy IMRTIMRTMoves with patientMoves with patient Does not move with patient
Difficult to adjust with responseDoes not move with patientDifficult to adjust with response
y pyy py
Does brachytherapy increase local control and increase survival?
Viswanathan ASTRO 2012
Brachytherapy is Necessaryy py y• Brachytherapy: internally delivered radiation using
radioactive sourcesS l t t l b• Supplements external beam
• Tumor control probability correlated with RT dose and cervix ca volume Fletcher, J Radiol Electrol 56:383-400, 1975
External beam only
External Beam + brachytherapyonly brachytherapy
4 y Pelvic Control
45%
19%
67%
46%Control
4 y SurvivalLanciano JROBP 20:95, 1991
19% 46%
Local Control Montana Cancer 57:148, 1986
40% 52%
Individual Patient Assessment• Where is the diseaseWhere is the disease• What is the patient’s anatomy
– MRI– Clinical exam
• Preparation for the OR– Ante vs. retroversion– Os visible or palpable– Inferior extent of disease– Inferior extent of disease– Proximity of posterior uterus to both rectum and
small bowel
Viswanathan ASTRO 2012
– Bladder
Applicators for BrachytherapyApplicators for Brachytherapy
A B C
INTERSTITIAL Tandem and Tandem and Ring Ovoids
Interstitial BrachytherapyInterstitial Brachytherapy
Fistula
Interstitial BrachytherapyInterstitial Brachytherapy
Postop recurrenceExtensive distal vaginal involvementCervical stump CaCervical stump Ca
IMAGING
Plain x rayComputed
Tomography Magnetic
Resonance ImagingPlain x ray g p y(CT)
Resonance Imaging (MRI)
-International standard-BWH until 2002
2002-2011 2002-2006 0.5T2011- 3.0T
-prescribe to points2011 3.0T
Ultrasound for Dilation
• Suspected uterine preforation
• Retroverted uterus
• Absence of endocervical canal
• Extreme anteversion of uterus
Viswanathan ASTRO 2012
What might appear acceptable on Xray, may not be acceptable in 3D
Posterior placementPosterior placement
Proper placement
Viswanathan ASTRO 9/25/08
RTOG O116/0128: Brachy QualityRTOG O116/0128: Brachy QualityRTOG O116/0128: Brachy QualityRTOG O116/0128: Brachy Quality
ff idid•• Asymmetry of Asymmetry of ovoidsovoids
•• Displaced Displaced ovoidsovoids
•• Inappropriate packingInappropriate packing
Viswanathan et al. IJROBP 2012; Viswanathan et al. IJROBP 2012; 22(1):12322(1):123--3131
Unacceptable TandemUnacceptable Tandempp
Midline on lateral filmMidline on lateral film Bisecting ovoidsBisecting ovoids
Local RecurrenceLocal Recurrence
Parameter*HR†
(95% C.I.) p-valueSymmetry of Ovoids to Tandem
2.61(1.05, 6.45) 0.039
Displacement of Ovoids in Relation to Cervical Os
2.54(1 11 5 80) 0 027Relation to Cervical Os (1.11, 5.80) 0.027
Position of Tandem in Mid-Pelvis on Lateral Film
1.01(0.43, 2.37) 0.98
T d Bi ti O id 0 68Tandem Bisecting Ovoids on Lateral Film
0.68(0.27, 1.67) 0.39
Appropriateness of Packing
1.66(0 73 3 77) 0 23Packing (0.73, 3.77) 0.23
*Model included pelvic/iliac, para-aortic node positive, FIGO stage
†This represents the HR of unacceptable/not evaluated scores compared to acceptable scores
Viswanathan et al. Int J Gyn Ca 2012; 22(1):123-31
DiseaseDisease--Free SurvivalFree Survival
Parameter*HR†
(95% C.I.) p-valueSymmetry of Ovoids to Tandem
1.43(0.73, 2.80) 0.29
Displacement of Ovoids in Relation to Cervical Os
2.12(1 16 3 89) 0 02Relation to Cervical Os (1.16, 3.89) 0.02
Position of Tandem in Mid-Pelvis on Lateral Film
1.15(0.63, 2.09) 0.65
T d Bi ti O id 0 79Tandem Bisecting Ovoids on Lateral Film
0.79(0.42, 1.48) 0.47
Appropriateness of Packing
1.95(1 08 3 55) 0 028Packing (1.08, 3.55) 0.028
*Model included pelvic/iliac, para-aortic node positive, and FIGO stage
†This represents the HR of unacceptable/not evaluated scores compared to acceptable scores† p p p p
Viswanathan et al. Int J Gyn Ca 2012; 22(1):123-31
Standard prescription: Point A
CT-detected perforation
Slide courtesy of Dr Beriwal
ABS SurveyyMethod used for dose specification to
the cervixthe cervix
10%
12%Point Amg/hours
2%
3%mg/hoursCTVGTV/CTV
73%
GTV/CTVOther
Point A vs. 3D
Narrow cervix Wide cervix
Therapeutic Ratio: Balance between tumor cure andbetween tumor cure and
complicationsyy
babi
lity
babi
lity
Prob
Prob Tumor
controlComplications
Poor anatomy
DoseDose
p
Viswanathan ASTRO 2012
DoseDoseSlide courtesy of Dr Eifel
GEC ESTRO recommended dose recording
Organs at risk: 0 1D0.1cc,
D2cc
Target: D90 V100D90, V100
@ 2cm difference ICRU Bladder and D2cc value
f fPlan required for each HDR fractionRadioth Oncol 81:269, 2006
NORMAL TISSUE VARIATION
CT versus MR contouringgViswanathan et al. Int J Radiat Oncol Biol 2007;68(2):491-498.
Bladder
• Width of contoured tumor larger on MRI
MR
Bladder
• OAR differences depend on filling status
HR-CTVCT • Nodal dose may be
estimated
Rectum• Point A constant
MR guided interstitial brachytherapybrachytherapyViswanathan et al. IJROBP 66(1):91-99, 2006
• Interstitial reconstruction CT vs. MR– Patients must be imaged with legs down
• Protection of bladder or rectum– No inadvertent insertion of interstitial catheter into bladder or
d CT f MRrectum noted on CT after MR
MR-Interstitial OutcomesMR Interstitial Outcomes
• 25 patients• 15 recurrent ca• Interstitial
brachytherapy• 0.5 T MR• No LR• 2 yr PFS 65%, • 2 yr OS 60%
Recommendations based on MR-imaging
• GTV – T2 bright areas g
• HR-CTV – cervix + visible/palpable IR CTVvisible/palpable disease at brachy
• IR CTV 1 cm margin
IR CTV
• IR-CTV – 1 cm margin around HR-CTV + initial sites of
GTVHR CTV
initial sites of involvement
Viswanathan ASTRO 2012
GYN GEC ESTRO Recommendations (I) Radioth.Oncol. 2005, 74:235-245
MR T/R Brachytherapy OutcomesRad Onc 2011:100:116-123Rad Onc 2011:100:116-123
• 156 patients• HistoricalHistorical
comparison• Med FU 42 mo• CR 97%• Significant ↑Significant ↑
– 3y OS 53 to 68%
– CSS 62 to 74%
– Tumors > 5cm• OS 28 to 65% Pötter et al. Rad Oncol 2007
Tumor control related to doseDimopoulos JC et al. Int J Radiat Oncol Biol Phys. 2009 Sep 1;75(1):56-63
• D90 for HRCTV > 87 Gy y– LR 4% (3 of 68)
D90 f HRCTV < 87 G• D90 for HRCTV < 87 Gy – LR 20% (15 of 73)
• The effect was most pronounced in patients that had tumors >5cm w athat had tumors >5cm w a poor response
The OR and MR rooms of AMIGOAMIGO
Advanced Multimodality Image Guided Operating (AMIGO) SuiteP41 RR019703 – National Center for Image Guided Therapy (NCIGT) 2005-2015
Ferenc Jolesz, MD Clare Tempany, MD
3T MR Treatment Planning3T MR Treatment Planning
Standard vs Optimized PlanStandard vs Optimized Plan
Biologically Equivalent DoseE i l t D i 2 G F ti
Biologically Equivalent DoseE i l t D i 2 G F tiEquivalent Dose in 2 Gy Fractions
(EQD2)Equivalent Dose in 2 Gy Fractions
(EQD2)( )( )BED= nd(1+d/α/β )/(1+2/ α/β )
EQD2 BED/1 2
BED= nd(1+d/α/β )/(1+2/ α/β )
EQD2 BED/1 2EQD2= BED/1.2n = # fractions
d d /f
EQD2= BED/1.2n = # fractions
d d /fd = dose/fraction
α/β for tumor ~ 10
α/β for normal tissue ~ 3
d = dose/fraction
α/β for tumor ~ 10
α/β for normal tissue ~ 3α/β for normal tissue 3
Example:
α/β for normal tissue 3
Example:
Viswanathan ASTRO 9/25/08(5 fractions) x (5.5 Gy) x (1+5.5 Gy/10) / 1.2 = 35.5 Gy10(5 fractions) x (5.5 Gy) x (1+5.5 Gy/10) / 1.2 = 35.5 Gy10
HDR Doses (after 45 Gy EB)HDR Doses (after 45 Gy EB)HDR Doses (after 45 Gy EB)HDR Doses (after 45 Gy EB)
6 Gy x 56 Gy x 57 Gy x 48 Gy x 3
Consider lower doses with concurrent chemo
8 Gy x 3
5.0 Gy x 5 - small volume disease 5.5 Gy x 5 - large volume disease
Viswanathan ASTRO 2012
5.5 Gy x 5 large volume disease
Standard Fractionation and EQD2 lvalues
Fractional # EQD2 EB+EQD2Dose
9 Gy 2 28.5 73
8 Gy 3 36 80
7 Gy 4 39.7 847 Gy 4 39.7 84
6 Gy 5 40 84
5 5 Gy 5 35 5 805.5 Gy 5 35.5 80
6 Gy 4 32 76
DVH analysis and late side effects Georg et al. Int J Radiat Oncol Biol Phys. 2011 Feb 1;79(2):356-62
• Rectum: D2cc rectum >75 Gy predicted >Rectum: D2cc rectum 75 Gy predicted G2 side effects
• Sigmoid: No dose limit identified given low number of sigmoid specific sidelow number of sigmoid specific side effects
• Bladder: D2cc >95 Gy appeared to increase side effects though furtherincrease side effects though further analysis needed
Strategize your approachStrategize your approach
• Experience matters– Training programsTraining programs
• Follow guidelines
• Standardize approach• Standardize approach
Follow-UpFollow Up
• Pelvic examination and Biopsy if evidence of newPelvic examination and pap smears at regular intervals
Biopsy if evidence of new lesions or abnormal pap smearI i t di d d– Every 3 months for the
first 2 years
E 4 th th 3 d
Imaging studies as neededVaginal Dilator
– Every 4 months the 3rd year
– Every 6 months years e y 6 o t s yea s4th and 5th
– Yearly thereafter
Summary: Cervical Cancer
• Screening effective• Treatment effectiveTreatment effective
– Pre-invasive– Invasive– RT very effective
• Individualize careIndividualize care– Emphasizes role as a comprehensive
oncologist
Viswanathan ASTRO 2012
Thank you