RADIOTHERAPEUTIC AND

ONCOLOGICAL
TREATMENT OF CANCER
OF THE CERVIX
BY
DR SHAGAYA U. N.
OUTLINE
 INTRODUCTION
 PRE TREATMENT EVALUATION
 STAGING
 TREATMENT OPTIONS
 RADIOTHERAPY
 CHEMORADIATION
 CHEMOTHERAPY
 COMPLICATIONS
 RECURRENT DISEASE
 PROGNOSIS
 CONCLUCION
INTRODUCTION
 A major health public health problem.
 About 0.5Million new cases occur annually
worldwide. WHO 2002.
 Vast majority occurs in the developing
countries.
 Commonest female genital cancer in
developing countries.
 Account for 231,000 deaths annually .
 80% occurs in developing countries.
 Parkin et al 2000.
 Over 25,000 new cases are seen in Nigeria
annually i.e. 480cases per week.
 SolankeT.F.1996.
 At the UCH Ibadan 2-5 new cases are seen
weekly
 Edozien &Adewole 1993
AETIOLOGY
 INFECTIOUS AGENTS
üLargely regarded as STD
üSexually transmitted Human papilloma virus
(HPV) implicated Types 16 and 18 (associated
with 70-80% of cervical cancers)
üHIV infection
 Associated with faster progression of pre
invasive disease.
Smoking


 Radiation therapy [XRT] is a clinical modality
dealing with the use of ionising radiation in
treatment of patients with malignant
neoplasia’s and occasionally benign dx.
 The aim of XRT is to deliver a precisely
measured dose of irradiation to a defined
tumour volume with as minimal damage as
possible to surrounding healthy tissue
resulting in eradication of the tumour, high
quality of life &prolongation of survival at
competitive cost.
 In addition to curative effort XRT plays a
major role in cancer mgt in effective
palliation or prevention of symptoms of
disease.
 The biologic effects of ionizing radiation are
largely the result of DNA damage, which is
caused directly by ionization within the
DNA molecule or indirectly from the action
of chemical radicals formed as a result of
local ionization in water.
 Following exposure to radiation cells may
die attempting the next mitosis [mitotic
death] or they may die programmed cell
death [apoptotic death]
PRE TREATMENT
EVALUATION
 History and physical examination
 For stage II B, III or IV A disease or for
symptoms perform cystoscopy,
sigmoidoscopy and/or barium enema
 Labs
 Imaging

STAGING -FIGO
 STAGE I-Confined to the cervix STAGE IA-
Invasive carcinoma diagnosed microscopically only
max depth 5mm max width 7mm STAGE IB-
Macroscopic tumour size>IA
 STAGE II-Invades beyond the cervix to upper 2/3rd of
the vagina STAGE IIA-No
parametrial involvement STAGE IIB-With
parametrial involvement
 STAGE III- Extends to lower 1/3rd of the vagina, pelvic
side wall, causes hydronephrosis or non-functioning
kidney
STAGE IIIA-Extends to the lower third of vagina
but not to the pelvic side wall STAGE
IIIB-Extends to pelvic side wall or causes
hydronephrosis or non-functioning kidneys
STAGING
 STAGE IV-Extends beyond the true pelvis or
has clinically involved the mucosa of the
bladder or rectum STAGE IVA-
Spread to adjacent organs bladder/rectum
STAGE IVB-Spread to distant
organs
TREATMENT OPTIONS
RADIOTHERAPY

 Indication for XRT
 -Goal of XRT
 -Planned TX volume
 -Planned technique
 -Planned TX dose


 Simulation – position, field and borders

RADIOTHERAPY
 External beam radiotherapy
 Treat with 4 field or AP/PA technique
 Borders -Superior =L4/5, Inferior=3cm below
most inferior vaginal involvement,
Lateral=2cm lateral to pelvic brim,
posterior=include entire sacrum, anterior=
1cm anterior to pubic symphsis
 Dose -40Gy in 20# AP/PA, 14Gy in 7# lat
using photons
 EFRT for Para aortic nodes
BRACHYTHERAPY
 Radiation treatment with source placed
close to the tumour
 Proceed when tumour is <4cm so Pt A dose
will cover it
 LDR- Cs 137 at 0.4-0.8Gy/hr
 HDR- Ir 192 high activity source at 12Gy/hr
 Point A-2cm superior to ext cervical os and
2cm lateral to central canal/tandem
 Point B- 3cm lateral to point A
 Point C – 4cm lateral to point A
 E.g. applicator type Fletcher-Suit
CHEMORADIATION
 Chemo radiation- Cisplatinum, 5-FU
with/without Mitomycin C
 In hypoxic or oxygenated cells free radicals
with altered binding of platinum to DNA
are formed at the time of irradiation
 Interaction inhibits repair of sub lethal
damage
CHEMOTHERAPY
 Cisplatinum, Vinblastine, doxorubicin,
methotrexate [MVAC]
 Cisplatinum /topotecan
 Paclitaxel /Cisplatinum
 Irinotecan / Topotecan
 Vinorelbine
 Gemcitabine


COMPLICATIONS
 ACUTE SEQUELAE
 Diarrhoea, abd cramping, rectal
discomfort/bleeding
 Dysuria, frequency and nocturia
 Erythema and dry or moist desquamation
 Thromboembolism
 Uterine perforation
 Rare –sepsis, pulmonary dx, arterial
hypotension, change in mental status and
myocardial infarction
COMPICATIONS 2
 LATE SEQUELAE
 Fistulae
 Proctitis
 Cystitis
 Stricture
 Vaginal stenosis /adhesions
 Femoral neck fracture
 Intestinal obstruction
 Rare-post op pelvic abscess, pulm
embolism, haemorrhage, neuritis
RECURRENT DISEASE
 Chemotherapy
 Radiotherapy

PROGNOSIS
 Prognostic factors
 Age
 Race/socioeconomic status
 Anaemia and tumour hypoxia
 Tumour volume
 Histology

CONCLUSION
 Radiotherapy is a main mode of
management of ca cervix
 Not enough radiotherapy centres
 Hope for improvement
 HPV vaccine
THANK YOU FOR
LISTENING
.
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