Postoperative Radiation for Cervical Cancer

Invasive Cervical Cancer Inadvertently treated with a Simple Hysteectomy

  • microscopic invasion
    • No need for adjuvant therapy
  • Deeper stromal invasion
    • Vaginal brachytherapy alone
  • Fully invasive cancer
    • PRT + T & O brachytherapy

Risk Grouping after Radical Hystectomy for Stage IB to IIB cancers.

High risk

  • based on SWOG 8797/Intergroup/GOG 109 (Peters)
  • IB or IIB patients initially treated with Radical Hysterectomy

Risk factors outside of the cervix

  • LN (+)
  • surgical IIB (Parametrial Involvement)
  • margin(+)

Intermediate risk

  • as defined in GOG #92
  • IB patients treated with radical Hysterectomy

Risk factors are confined to cervix

  • LVI(+)
    • (1) deep 1/3 invasion
    • (2) middle 1/3 invasion, clinical tumor ≥ 2 cm,
    • (3) OR superficial 1/3 invasion, clinical tumor >= 5cm,
  • LVI(-)
    • either deep or middle 1/3 invasion
    • AND clinical tumor >= 4 cm

Low risk none of the above

Treatment by Grouping

High risk chemoradiation

  • GOG #109 showed
    • 63% vs 80% progression free survival with post-op CRT (chemotherapy and radiation)
    • 71% vs 81% overall survival with post-op CRT
    • RR of death was reduced by 50%
    • Chemotherapy & Radiation: 4 field pelvis only with no brachytherapy
  • NCCN
    • Chemotherapy & Radiation: 4 field pelvis +/- brachytherapy

Intermediate risk radiation alone

  • GOG #92 (Sedlis)
    • Reduction in recurrence rate from 28% to 15%
    • Overall survival 21% vs 13%, significance not reported due to immature data
    • But 2% vs 6% Grade 3 and 4 GI toxicity
    • technique: pelvic radiation with no brachytherapy
  • ABS (American brachytherapy society recommends XRT alone/ no chemo needed for this group)

Low risk

  • none

Radiation Dose

  • External beam radiation: 45Gy/25 fx at 180 cGy/fx
  • vaginal cuff boost
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