Mortality Conference 22032012

8/2/2019 Mortality Conference 22032012

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Mortality Conference

22/3/2012

Departments of Radiation &Medical Oncology


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Case historyName: Mrs. MDB

Age: 50 years

Sex: Female

MR No: 80772

DOA: 3/2/2012

DOD: 6/2/2012


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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


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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


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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.


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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


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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


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Natural HistoryTumor extension (cont..)

Superior

Lower uterine segment

Inferior

Vagina Lateral

Broad ligaments uterine obstruction

Postero-lateral

Utero-sacral ligaments

Extension to bladder uncommon -


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Lymhatic Drainage


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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%


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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


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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


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Prognostic factors (cont.)Anemia - poor


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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%


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Chemo-RT protocol

CDDP - CisplatinExternal RT Weekly 5 fractions

Intracavitary brachytherapy


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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


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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


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Mortality Conference 22032012

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