Adjuvant RT for early stage adenocarcinoma of the cervix

[Kroll2013]

---

Members don't see this ad.

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

 

[CaesarRO]

Beyond Sedlis-A novel histology-specific nomogram for predicting cervical cancer recurrence risk: An NRG/GOG ancillary analysis - PubMed

Current treatment standards are based on the Sedlis criteria, specifically derived from data on SCC. However, risk factors for recurrence differ for squamous cell and adenocarcinoma of the cervix. Histology-specific nomograms accurately and linearly represent risk of recurrence for both SCC and...

pubmed.ncbi.nlm.nih.gov

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

 

[thecarbonionangle]

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.

 

[Kroll2013]

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?

 

[thecarbonionangle]

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.

 

[ramsesthenice]

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.

 

[evilbooyaa]

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)

 

[Palex80]

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.

Tailoring adjuvant radiotherapy for stage IB-IIA node negative cervical carcinoma after radical hysterectomy and pelvic lymph node dissection using the GOG score - PubMed

Our study confirms the utility of the GOG score to tailor radiotherapy for this cohort of patients. This has been proven to be high in efficacy and low in morbidity.

pubmed.ncbi.nlm.nih.gov

 

[seper]

2 cm size, middle 3d invasion - not wrong to offer EBRT. ultimately up to patient to decide. it’s a tossup