Adjuvant RT for early stage adenocarcinoma of the cervix

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what is the best adjuvant treatment

  • observation

    Votes: 3 100.0%
  • EBRT pelvis only

    Votes: 0 0.0%
  • brachy only

    Votes: 0 0.0%
  • EBRT pelvis + brachy

    Votes: 0 0.0%

  • Total voters
    3

Kroll2013

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Dear colleagues,
i need your expert opinion concerning my patient:

44 years old young female, preMNP, with no particular medical or surgical history, who underwent TAH-BSO for endocervical adenocarcinoma (clinically papsmear twice negative, menometrorrhagia)
pathology showed:
- Well differentiated adenocarcinoma of the cervix, invasive (pattern A), confined to the cervix.
- Tumor 2cm ulcerates the mucosa and invades the wall DOI 1.5 cm over 4cm uterine thickness, so <50%
- LVI -
- Free surgical margins / free parametria
- Absence of adnexal lesion.
- Right iliac lymph nodes: Absence of nodal metastasis (0/3).
- Left iliac lymph. nodes: Absence of nodal metastasis (0/5)

as per Sedlis criteria, she does not need RT, but those sedlis was mainly designed for Squamous.

pleas advise
 

Updated data on Sedlis that is histology specific.

Your case looks like it's right on the cusp. Per table 3 the AC likelihood of recurrence is 14% at 2cm with everything else negative vs 5% for SC
 
as you say it does not meet Sedlis. I’m guessing no LVSI. It does look like greater than 1/3 stromal invasion, however?. The Sedlis and Peters papers which established indications for adjuvant radiation and chemoxrt in cervix both had subset analysis showing that adenos and adenosquamous benefited from the experimental intervention at the time. So i know some people argue that adeno or adenosquamous can be a “soft” criteria. You could consider it although as you say, it is not a hard indication.
 
as you say it does not meet Sedlis. I’m guessing no LVSI. It does look like greater than 1/3 stromal invasion, however?. The Sedlis and Peters papers which established indications for adjuvant radiation and chemoxrt in cervix both had subset analysis showing that adenos and adenosquamous benefited from the experimental intervention at the time. So i know some people argue that adeno or adenosquamous can be a “soft” criteria. You could consider it although as you say, it is not a hard indication.
so in this case yes for EBRT , not necessarily brachy?
 
so in this case yes for EBRT , not necessarily brachy?
I dont see any indication for brachy only. No i would likely not treat. I would closely observe. You could consider treating if you really felt you might not see the patient again. I don’t see strong indications.
 
My answer depends on what surgery they did. If they didn't realize she had a cervical primary and did a simple hyst instead of a rad hyst, her risk of local recurrence would be high enough that I would treat. If they did a radical hyst, you could argue for observation.
 
Did patient get a radical or modified radical hysterectomy? TAH/BSO generally means no, just a simple hysterectomy for the uterus. SHAPE trial does apply here given only ~60% were pure squams but only if tumor was < 2cm (IB1).

If < 2cm and got a simple hysterectomy then observe in absence of other risk factors.
If > 2cm and got a simple hysterectomy then discuss role of adjuvant therapy vs completion parametrectomy (if your surgerons offer that). At my institution, adjuvant therapy would be the full gamut - post-op chemoRT + cuff brachy boost. It's rare, but very unfortunate for patients who were hoping to skip the modified radical and end up with tri-modality therapy on the back end, but my tumor board is very conservative on these things. I think EBRT +/- brachy without chemo would be reasonable as well.
If > 2cm but got an at least modified radical hysterectomy then does not meed Sedlis criteria - higher risk of adenos failing but not entirely clear that adj. RT with that alone as a risk factor is warranted despite adenocarcinoma being a risk factor for recurrence (unclear if independent, or if adenos are more likely to otherwise meet Sedlis criteria)
 
First point:
8 resected LNs are not a lot. This was not SLNB, right?

Second point:
The GOG score seems to be around 65 or so?
One could opt for a smaller volume and not treat the entire pelvis. There is some data for that approach too.
 
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2 cm size, middle 3d invasion - not wrong to offer EBRT. ultimately up to patient to decide. it’s a tossup
 
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