Radiation Oncology/Cervix/IA

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Front Page: Radiation Oncology | RTOG Trials | Randomized Trials

Cervix: Main Page | Overview | Micro-invasive | Early Stage Non-Bulky | Early Stage Bulky | Locally Advanced | Brachytherapy | Cervix Randomized | GOG Trials | RTOG Cervix

Prognostic Factors[edit]

  • Depth of stromal invasion (measured from base membrane of cervical epithelium)
    • <3 mm (IA1): Parametrial invasion rate 0 - 2.3%, LN mets rate 0 - 5.3%
    • >3 mm (IA2): Parametrial invasion rate 0 - 3.3%, LN mets rate 1.3 - 13.8% (average ~8%)
  • Lymphovascular space invasion
    • Clinical significance is controversial
    • Strong correlation with depth of invasion and tumor volume; literature unclear if it is an independent prognostic factor
    • Nevertheless, many GYN/ONC do not consider patients with LVSI+ to be Stage IA (including SGO and JSOG definitions)
  • Tumor volume
    • Clinical significance is controversial in IA
    • Some data support volumetric measurement, but technique is slow and imprecise
  • Confluence of invasive foci
    • There appears to be no difference (FIGO vs. JSOG data)
  • Grade
    • Four studies did not find grade an independent prognostic variable


Treatment Overview[edit]

  • IA1 and LVSI-
    • Historically total hysterectomy a gold standard
    • Demonstration of minimal risk of parametrial spread and LN+, with significant morbidity, resulted in shift to conization
    • Cervical conization primary treatment today
    • Brachytherapy alone probably a reasonable option in non-surgical candidates, based on the 2 series below
    • NCCN.org:
      • Extrafascial hysterectomy or
      • Cone + observe if negative margins or
      • Modified radical + PLND if LVSI+
  • IA2 or LVSI+
    • Some form of hysterectomy to evaluate parametrial space and LNs
    • NCCN.org:
      • Radical hysterectomy + PLND +/- aortic LN dissection or
      • Pelvic RT + brachytherapy (75-80 Gy to Point A)
      • Radical trachelectomy + LND if fertility preservation desired

Surgical Series[edit]

  • Milan, 2005 (Italy) PMID 15670302 -- "Prognostic factors in microinvasive cervical squamous cell cancer: long-term results." (Raspagliesi F, Int J Gynecol Cancer. 2005 Jan-Feb;15(1):88-93.)
    • Retrospective. 67 patients with IA1 treated with conization. Mean F/U 10 years
    • Invasive recurrences: 4 patients (6%)
    • Predictive factors: LVSI+, cone apical margin distance <10mm
  • Italian CTF, 2003 (Italy) PMID 14658592 -- "The clinical outcome of patients with stage Ia1 and Ia2 squamous cell carcinoma of the uterine cervix: a Cooperation Task Force (CTF) study." (Gadducci A, Eur J Gynaecol Oncol. 2003;24(6):513-6.)
    • Retrospective, multi-institutional. 166 patients with IA (143 patients IA1, 23 patients IA2), treated with conization alone (18%, all IA1), total hysterectomy (49%), or radical hysterectomy (33%).
    • Pelvic LN status: 0/67 LN+
    • Recurrence: 5% intraepithelial and 2% invasive. IA1 recurrence 6%, IA2 recurrence 13%. Cone alone 10% (but none invasive), total hysterectomy 5%, radical hysterectomy 9%
    • Conclusion: Conization can be a definitive treatement for Stage IA1. For Stage IA2, extrafascial hysterectomy might be adequate, need for LN dissection is questionable
  • Oslo, 1989 PMID 2722048 -- "Follow-up study of 232 patients with stage Ia1 and 411 patients with stage Ia2 squamous cell carcinoma of the cervix (microinvasive carcinoma)." (Kolstad P, Gynecol Oncol. 1989 Jun;33(3):265-72.)
    • Retrospective. 643 patients with IA. Follow up 3-17 years
    • Surgery: recurrence 15/496 (3%). All salvaged with further surgery
    • Brachytherapy alone: recurrence 0/136 (0%)


Radiotherapy Series[edit]

  • Washington University, 1991 (1959-1986) PMID 1905690 -- "Radiotherapy alone for medically inoperable carcinoma of the cervix: stage IA and carcinoma in situ." (Grigsby PW, Int J Radiat Oncol Biol Phys. 1991 Jul;21(2):375-8.)
    • Retrospective. 21 patients with CIS and 34 patients with IA.
    • RT for IA: BT alone (13 patients) to average 55 Gy to Point A, BT + Whole Pelvis (21 patients) to 14 Gy WP + 23.5 Gy parametrial boost with midline block + BT to 52 Gy to Point A
    • Recurrence: 0/21 CIS, 1/34 IA in pelvis. No DM.
    • Toxicity: severe complications 6%, in those getting WPRT + BT
    • Conclusion: BT alone excellent treatment for both CIS and IA
  • Oslo, 1989 PMID 2722048 -- "Follow-up study of 232 patients with stage Ia1 and 411 patients with stage Ia2 squamous cell carcinoma of the cervix (microinvasive carcinoma)." (Kolstad P, Gynecol Oncol. 1989 Jun;33(3):265-72.)
    • Retrospective. 643 patients with IA. Follow up 3-17 years
    • Surgery: recurrence 15/496 (3%). All salvaged with further surgery
    • Brachytherapy alone: recurrence 0/136 (0%)


Review[edit]

  • Milan, 2003 PMID 14693337 -- "Microinvasive squamous cell cervical carcinoma." (Raspagliesi F, Crit Rev Oncol Hematol. 2003 Dec;48(3):251-61.)