8/2/2019 Mortality Conference 22032012
1/20
Mortality Conference
22/3/2012
Departments of Radiation &Medical Oncology
8/2/2019 Mortality Conference 22032012
2/20
Case historyName: Mrs. MDB
Age: 50 years
Sex: Female
MR No: 80772
DOA: 3/2/2012
DOD: 6/2/2012
8/2/2019 Mortality Conference 22032012
3/20
Initial presentationDate of 1st visit: 7/12/2010
Complaints
Bleeding P/V
Diabetic
P5L5Examination
P/V
Growth replacing cervix
All fornices involved
L parametrium involved medially
Dx: Ca. Cervix IIB
8/2/2019 Mortality Conference 22032012
4/20
Initial presentationMRI pelvis: Large, hyperintense lesion on
T2W & STIR sequences is seen involvingthe endocervical canal and cervicalstroma. The mass is extending intoadjacent 1/3 of vagina. Mass measures6.5 4.7 cm
CXR Normal
CUE Normal
CBP Normal
Sr. Creatinine Normal
RBS - Normal
8/2/2019 Mortality Conference 22032012
5/20
Initial presentationRT start date: 14/12/2010
PLAN: IMRT 5040 cGy @ 180 cGy/F 30
+ 2100 cGy ICR @ 700 cGy/F 3
+ 5 cisplatin 40 mg/m2 once a week
RT completion: 20/1/11, with no treatmentbreaks
ICRs: 2/2/2011, 9/2/2011, 16/2/2011
5 cycles weekly cisplatin 70 mg.
8/2/2019 Mortality Conference 22032012
6/20
8/2/2019 Mortality Conference 22032012
7/20
Natural HistoryMC site
Junction of endo & ecto-cervix (transformationzone)
Junction of columnar & squamous epithelium
Continuous metaplastic change Greatest
in utero
Puberty
First pregnancy
Decreases after puberty Greatest risk of viral induced neoplastic
transformation coincides with periods ofgreatest metaplastic activity
8/2/2019 Mortality Conference 22032012
8/20
Natural HistoryVery slow progression from CIN to
invasive cancer mean, 15 years
Tumor extension
Once breaks through basement membrane,
penetrates cervical stroma Directly
Through vascular channels
Exophytic tumors protrude into vagina Endocervical lesions massive expansion of
cervix despite normal appearing ectocervix
8/2/2019 Mortality Conference 22032012
9/20
Natural HistoryTumor extension (cont..)
Superior
Lower uterine segment
Inferior
Vagina Lateral
Broad ligaments uterine obstruction
Postero-lateral
Utero-sacral ligaments
Extension to bladder uncommon -
8/2/2019 Mortality Conference 22032012
10/20
Lymhatic Drainage
8/2/2019 Mortality Conference 22032012
11/20
Positive pelvic nodesStage I 11 to 18%
II 32 to 45%
III 46 to 66%
Depth of Invasion 3mm 20mm 22.6%
T - size 0.1 to 1.0cm 12.7%
2.1 to 3cm 16.3%
>3cm 23 to 42%
Grade 1 9.7%
2 13.9%
3 21.8%
Lymphovascular spaceinvasion Absent 8.2%Present 25.4%
8/2/2019 Mortality Conference 22032012
12/20
Natural HistoryMetastatic progression
Orderly pattern
Pelvic echelon nodes para-aortic nodes distant sites
Even in locoregionally advanced diseasehematogenous mets rare
MC sites of distant mets
Lung
Extra-pelvic LN
Liver
Bone
8/2/2019 Mortality Conference 22032012
13/20
Prognostic FactorsClinical tumor diameter
Lymph node mets Size of largest LN
Number of involved pelvic LN
Lympho-vascular invasion - poorDeep stromal invasion - poor 10mm or >70%
Parametrial extension poor
Strong inflammatory response in stromagood
Adenocarcinoma poor
Stage IB2 poorer
8/2/2019 Mortality Conference 22032012
14/20
Prognostic factors (cont.)Anemia - poor
8/2/2019 Mortality Conference 22032012
15/20
TreatmentStage Primary Therapy 5 Year OS
IA1 1. Cone biopsy2. Simple hysterectomy3. Brachytherapy
> 98%
IA2 1. Radical hysterectomy + pelvic nodedissection (PND)
2. Irradiation (RT)
95%
IB1/ limited IIA1 1. Radical hysterectomy + PND2. RT
90%
IB2/ Larger IIA1/ IIA2 1. ChemoRT 80 85%
IIB 1. ChemoRT 70 75%
III 1. ChemoRT 50%
IV A 1. ChemoRT2. Selective exenteration
15 25%
IV B 1. Chemotherapy
2. Palliative RT
0%
8/2/2019 Mortality Conference 22032012
16/20
8/2/2019 Mortality Conference 22032012
17/20
Chemo-RT protocol
CDDP - CisplatinExternal RT Weekly 5 fractions
Intracavitary brachytherapy
8/2/2019 Mortality Conference 22032012
18/20
RadiotherapyTumor burden Vs Radiation dose needed
for control
Microscopic disease 45 to 50 Gy1 to 2 cm 60 to 70 Gy
2 to 3+ cm 70 to 90 Gy
8/2/2019 Mortality Conference 22032012
19/20
RT doseExternal RT
Total dose50 Gy
Mid line block at40 Gy
Brachytherapy
Intracavitary added to EBRT
With MLB21Gy
Without MLB18 Gy
Post operative15 Gy Intersitital
8/2/2019 Mortality Conference 22032012
20/20