Transcript PowerPoint 프레젠테이션

Ch. 31.
Cervical and Vaginal Cancer
부산백병원 산부인과
R1 손영실
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# Treatment
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INDEX
1. Postoperative Radiation
2. Chemotherapy
3. Radiation
4. Concurrent Chemoradiation
5. Patient Evaluation and Follow-up after Therapy
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Postoperative Radiation
• Recommended for patients
- metastasis to pelvic lymph nodes
- invasion of paracervical tissue
- deep cervical invasion
- positive surgical margins
→ in an effort to improve survival rates
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Postoperative Radiation
• Necessary in the presence of positive surgical margins,
but, use of other risk factors is controversial
• Rationale for treatment
: pelvic node dissection does not remove
all of nodal and lymphatic tissue
→ radiotherapy can sterilize cancer
in pelvic lymph nodes.
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Postoperative Radiation
• Based on retrospective studies,
postoperative radiation therapy for positive pelvic LN
- can decrease pelvic recurrence
- does not improve 5-year survival rates
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Postoperative Radiation
• Study of 60 pairs of irradiated and nonirradiated
women of positive nodes after radical hysterectomy
① no significant difference in 5-year survival rate
- 72% for surgery alone
- 69% for surgery plus radiation
② significant decrease in pelvic recurrence
- 67% for surgery only
- 27% in treated with postoperative radiation
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Postoperative Radiation
• Location of LN metastases is relevant to
postirradiation recurrence rates.
• As the number of positive pelvic LN increase,
the percentage of positive common iliac
and low paraaortic nodes increases.
→ extended-field radiotherapy is recommended to
patients with positive pelvic LN in an attempt to
treat undetected extrapelvic nodal disease
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Chemotherapy
• Chemotherapy in cervical carcinoma is limited
in part by the success of surgery or radiation therapy.
• However, neoadjuvant chemotherapy has been used to
shrink the tumor before radical hysterectomy or
radiotherapy
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Chemotherapy
• Neoadjuvant chemotherapy
- achieve a 22% to 44% CR rate
- decrease the number of positive pelvic LN
- improve the 2- and 3-year disease-free survival
rates, particularly in patients with stage Ⅰ or Ⅱ
disease
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Radiation
• Radiotherapy can be used to treat all stages of
cervical squamous cell cancer.
• Cure rate of about
- 70% for stage Ⅰ
- 60% for stage Ⅱ
- 45% for stage Ⅲ
- 18% for stage Ⅳ
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Radiation
• Comparison of Surgery versus Radiation
for Stage Ⅰb/Ⅱa Cancer of the Cervix
Surgery
Survival
Serious
complications
Vagina
Ovaries
Chronic
Effects
Applicability
Surgical
mortality
85%
Urologic fistulas 1%~2%
Initially shortened, but may
lengthen with regular intercourse
Can be conserved
Bladder atony in 3%
Radiation
85%
Intestinal and urinary strictures
and fistulas 1.4%~5.3%
Fibrosis and possible stenosis,
particularly in postmenopausal
patients
Destroyed
Radiation fibrosis of bowel
and bladder in 6%~8%
Best candidates are younger
than 65 years of age.
<200lb, and in good health
All patients are potential
candidates
1%
1% (from pulmonary embolism
during intracavitary therapy)
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Radiation
• Radiation treatment plan generally consist of a
combination
- external teletherapy to treat regional nodes
to shrink the primary tumor
- intracavitary brachytherapy to boost
the central tumor
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Radiation
• The treatment sequence depends on tumor volume
① Stage Ⅰb lesions smaller than 2cm
: treated first with intracavitary source to treat the
primary lesion, followed by external therapy to
treat the pelvic nodes
② Larger lesions
: require external radiotherapy first to shrink the
tumor and to reduce the anatomic distortion
caused by the cancer
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Radiation
• Patients will have “geographic” treatment failure
if standard pelvic radiotherapy ports are used.
→ Thus, treatment plans are individualized based on
CT scans and biopsy of the paraaortic LN.
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Radiation
A. Surgical “Staging” before Radiation
→ designed to discover the presence of positive nodes
• Survival appears to be related to the amount of
disease in the paraaortic nodes and to the size of
the primary tumor.
• In patients with
- microscopic paraaortic LN metastases
- tumor has not extended to the pelvic wall
→ 5-year survival rate improve to 20% to 50%
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Radiation
B. Supraclavicular Lymph Node Biopsy
• Although not standard practice, supraclavicular LN
biopsy has been advocated in patients
- with positive paraaortic LN before extended-field
irradiation
- with central recurrence before exploration
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Radiation
C. Complications during Brachytherapy
① Perforation of the uterus may occur at time of
insertion of the uterine tandem
• Particularly for elderly patients who had a previous
diagnostic conization
② Fever may occur after insertion of tandem and
ovoids, if most often results from infection of the
necrotic tumor and occurs 2 to 6 hours after
insertion of the intracavitary system.
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Radiation
D. Acute Morbidity
- are caused by ionizing radiation on the epithelium
of the intestine and bladder.
• Symptoms : diarrhea, abdominal cramps, nausea,
frequent urination, and occasionally
bleeding from the bladder of bowel
mucosa
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Radiation
E. Chronic Morbidity
- result from the induction of vasculitis and fibrosis
- more serious than the acute effects
- occur several months to several years after
radiotherapy
- bowel and bladder fistula, bowel bleeding, stricture,
stenosis, or obstruction
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Radiation
F. Proctosigmoiditis
- should be treated with low-residue diet,
antidiarrheal medications, and steroid enemas
- In extreme cases, a colostomy may be required,
and resection of rectosigmoid must be performed.
G. Rectovaginal Fistula
- occur in fewer than 2% of patients
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Radiation
H. Small Bowel Complications
• previous abdominal surgery → pelvic adhesions
→ sustain more radiotherapy in the small bowel
• Symptoms : crampy abd. Pain, intestinal rush,
small bowel obstruction, low-grade
fever, anemia, small bowel fistula
I. Urinary Tract
- occur 1% to 5% of patients
- vesicovaginal fistula, ureteral stricture, ureterolysis
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Radiation
J. Treatment of Stage Ⅱb to Ⅳb
• Radiation therapy : traditional therapy for patients
with stage Ⅱb or greater cervical
cancer
• urinary or rectal diversion is performed in stage Ⅳa,
vesicovaginal or rectovaginal fistula
• stage Ⅳb
- considered candidates for palliative radiation
therapy
- control of symptoms with the least morbidity
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Concurrent Chemoradiation
• Emcompasses the benefits of
- Regional therapy with radiation
- Chemotherapy to sensitize cells to radiation
→ improve locoregional control
• The 4-year survival rate (in GOG studies)
- chemoradiation : 81%
- radiation alone : 71%
→ Patients with these high-risk factors after radical
hysterectomy for stage Ⅰa2, Ⅰb, and Ⅱa
disease, chemoradiation is the postoperative
treatment of choice.
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Concurrent Chemoradiation
• In the GOG protocol 85, patients with stage Ⅱb to
Ⅳa who received concurrent chemoradiation and
were treated with cisplatin and 5-FU had a
statistically improvement in progression-free
interval and overall survival than treated with
hydroxyurea and radiation
→ Thus, cisplatin-based concurrent chemoradiation
is the treatment of choice for patients with
advanced-stage cervical cancer.
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Patient Evaluation and Follow-up after Therapy
→ Tumors may be expected to regress for up to
3 months after radiotherapy
• Pelvic exam → progressive shrinkage of the cervix
and possible stenosis of the
cervical os and upper vagina
• Rectovaginal exam → palpation of the uterosacral,
cardinal ligament for
nodularity (most important)
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Patient Evaluation and Follow-up after Therapy
• FNA cytology of suspicious area
• Supraclavicular and inguinal LN should be examined
• Cervical or vaginal cytology should be perfomed
- every 3 months for 2 years
- then every 6 months for the next 3 years
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Patient Evaluation and Follow-up after Therapy
• Endocervical curettage should be performed in
patients with large central tumors.
• Chest x-ray may be obtained yearly
(in advanced stage)
- Lung metastasis : 1.5%
- Solitary nodules : 25%
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감사합니다.
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