Cervical Ca with PA nodes and isolated Left Supraclav Met

[Mandelin Rain]

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How would you approach such a case? Tumor was initially bulky with perimetrial and potentially bladder invasion. I'm seeing her after induction chemo with good (read: complete) CT response, both in the nodes and primary. I'm ordering a PET.

Would you treat in a "definitive" type manner with EBRT to extended field followed by brachy? Concurrent chemo? Nix brachy and just boost primary with beam? What about the supraclav node? Just do 30Gy to pelvis? Wait until recurrence/symptomatic?

Really not sure what the right answer is, but my main thought is her local disease is her most likely to cause her morbidity and potentially mortality. It'd be nice to have a durable control there.

 

[medgator]

If she's young and healthy, go for broke, I've heard anecdotal stories of the L scv being a common spread pathway after the pa nodes with some long term survivors after aggressive tx to all areas.

Brachy vs beam is a tough call here in a technically M1 setting. I'll let others chime in, my gut reaction is just beam and platinum

 

[nkmiami]

agree with the above- what is the role of adjuvant chemo after the radiation? There was an interamerican trial that suggested a benefit.

 

[Mandelin Rain]

Thanks for the responses, that was my initial inclination. What dose would you take it to if just beam?

 

[seper]

After chemo, it would hard for her to tolerate to tolerate more than 45/25fx to truly extended field (decreased counts, diarrhea). I'd start out with that.

 

[Boston Red]

There is (limited) data supporting the definitive treatment of these patients. As mentioned about, counts tend to be the main issue. I agree that 45/25 is a good way to start, and then see what happens with the counts before deciding if to boost.

 

[seper]

I now often see > 2 years relapse-free survival for widely metastatic cervical patients who receive chemo alone incorporating Avastin... These Korean numbers are not impressive.

There is (limited) data supporting the definitive treatment of these patients. As mentioned about, counts tend to be the main issue. I agree that 45/25 is a good way to start, and then see what happens with the counts before deciding if to boost.

 

[thecarbonionangle]

get a PETCT, if PET-CT confirms not widely metastatic disease, supraclav node is direct from PA nodes. Would treat "definitively", use IMRT with SIB to involved nodes or sequential boost, would treat involved supraclav as well, boost node to 66. Near the end of EBRT, can re-stage. If nothing major has changed, would do brachy. As stated above, if patient is healthy would treat aggressively.

 

[Radiator20]

Largely agree with thecarbonionangle. Agree with PET to start; would also get post-chemo pre-beam MRI pelvis if not already done. If isolated SCV met, and otherwise healthy and motivated patient, I think one could consider definitive treatment along the following lines:

-pelvis + PA + SCV to 45 w/concurrent cis. Might plan to 50 and decide along the way whether to stop at 45 based on how she's doing. (If treating PA and SCV, interesting to reflect on why not treat mediastinum -- one would think that is in the pathway of spread from PA to SCV but I believe mediastinal failures are quite rare)
-SIB (or sequential boost if you must) to post-chemo residual gross disease outside potential brachy field. 66 to SCV gross disease seems reasonable; if PA nodes, then dose as limited by duodenum (V55<5cc), and less importantly small bowel.
-post-beam MRI, and could consider PET restaging too
-brachy, with technique as indicated by that MRI

Did med onc already give all the systemic chemo they intend to, or are they planning more after you're done?

 

[seper]

Noble goals of aggressive local therapy, but the patient's well-being almost invariably gets on the way. What's-his-name said? Do no harm.

 

[Palex80]

(If treating PA and SCV, interesting to reflect on why not treat mediastinum -- one would think that is in the pathway of spread from PA to SCV but I believe mediastinal failures are quite rare)

It's not if it goes through the Ductus lymphaticus dexter or sinister.

 

[Radiator20]

It's not if it goes through the Ductus lymphaticus dexter or sinister.

Right, I guess I would just think you could see failures along the course of the thoracic duct, not just on either end of it. But I guess not.

 

[Reaganite]

I struggle with these. I think we all had that 1 patient in residency who presented with sclav mets and had extended dfs with aggressive treatment but all the patients ive treated in practice just with pa mets have developed widespread mets within less than a year of treatment. The last two patients I treated with PA mets only developed peritoneal mets within 3 months of treatment.

I don't know if anyone has looked at this, but I have started to consider the "bulk" of disease in these patients in deciding how aggressively to go after mets. If I have a person with a bullky primary tumor and tons of bullky nodes up and down the pelvis and paraaortics, I don't think these patients are curable. They are very likely widely seeded with micromets. If you look at the solitary brain met data in lung CA, for example, the patients with extended DFS are the ones with small primary tumors (T1N0s); patients with advanced primary tumors and nodal disease have the same survival curves as other M1 patients. I think with these eary stage lesions perhaps there was just a fluke clonogen that mutated much faster than all the other cells and seeded a distant site. This is a lot different than a patient with bulky primary and nodal disease likely with multiple clonogens seeding distant sites. I guess all of this being said, I'd consider being aggressive if the disease burden elsewhere is low.

 

[thecarbonionangle]

any debate on if these patients are "curable" is largely anectodotal. The literature says that many of them are not but it's hard to interpret this data, given the heterogeneity. I personally have multiple patients who I have treated, seen at follow up years later with disease burden similar or worst to the one you describe and are NED years later ( of course I have ones who did bad, all comes down to biology at the end). The biggest determinant if you will be able to cure them (or at least give them a shot) in some of them is how far you are willing to push bowel to boost nodes. I think if you are not getting at least 60s to the lymph nodes, all you are doing is palliating. I would say 66 is optimal, 60 is a minimum. Prefer SIB approach as it is much easier to do a sequential boost to make up what is left, rather than try to boost an entire 20Gy to a node sequentially. Even then, they of course have a high chance of distant progression, but you still gave them local control, and death from pelvic progression and failure is one of the most morbid things ever. They may develop brain mets, liver mets, lung mets, eventually, but then you can hopefully do something for some of this and they can go on to receive adjuvant therapy as indicated.

 

[scarbrtj]

Radiotherapy Improves the Survival of Patients With Metastatic Cervical Cancer: A Propensity-Matched Analysis of SEER Database.

 

[evilbooyaa]

Radiotherapy Improves the Survival of Patients With Metastatic Cervical Cancer: A Propensity-Matched Analysis of SEER Database.

Similar results in NCDB: Definitive Pelvic Radiation Therapy and Survival Among Patients With Newly Diagnosed Cervical Cancer

Probably similar results in MOST metastatic cancer patients who get definitive therapy (selection bias, etc.) but you have low level evidence supporting it.