Small Cell Cancer of Uterus

[Gfunk6]

I have a lady in her mid 50s who underwent a TAHBSO for what turned out to be a small cell carcinoma. Primary invaded through the entirety of the myometrium and into the cervical stroma. Omentum was removed and was negative. 2/9 pelvic LNs positive.

A post-op PET/CT showed a single internal iliac LN with borderline enlargement and FDG-avidity. My personal recommendation was to proceed with systemic chemotherapy and reserve XRT for local salvage (as would be recommended for a small cell cancer of the lung which was R0 resected). However, tumor board disagreed and felt that we should proceed with concurrent XRT + Cis/Etoposide.

That being the case, would you recommend taking the entire post-op volume to 54 Gy? With small cell, we usually don't does escalate to grossly positive disease, so I don't see the point in taking the single LN higher than 54 Gy.

Addendum: MRI Brain was negative

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[medgator]

We do offer port to N+ lung pts (albeit N2 specifically). Considering the locally aggressive nature of the disease (complete mm involvement with cervical stromal invasion), my gut reaction would be to offer post-op pelvic xrt as well.

It may be a difficult bx at point, so if it really is believed to be a residual +LN from small cell, I'd think 54-60 Gy with chemo would be necessary to eradicate it.

If someone with sclc had gross ece on lymphadenectomy or +margin after resection of a "coin" lesion where it was found after the fact, I'd boost that "gross" disease.

Interesting case

 

[Palex80]

I would irradiate too. I agree with medgator's arguments concerning pN2 in the mediastinum.
Plus only 9 nodes were removed in this patient, thus it doesn't sound like a proper pelvin lymph node dissection.
50-54 Gy seem reasonable for the pelvis, I would boost the node to 60 Gy.

I

 

[evilbooyaa]

Only similar case I've had is a small cell of the cervix, Ib2 with nodal involvement on PET/CT. Underwent definitive XRT with Cis/Etoposide, IMRT 45Gy to Pelvis, 55Gy SIB to FDG-avid lymph nodes, followed by Cervical Brachy, followed by adjuvant chemo

Just reviewed my cases - had another lady, incidental small cell of the cervix, post-op after simple TAH/BSO. Got adjuvant XRT with Cis/Etoposide, 3D 45Gy to pelvis, Vaginal brachy, adjuvant chemo.

Based off my institution, we'd probably do 45 to pelvis, SIB node to 55, with concurrent Cis/Etoposide. Cover to top of common iliacs. I've been told that small cell of the pelvis (uterus/Cervix/anus/prostate) doesn't necessarily require the exact same things SCLC does. Not sure how accurate that is, FWIW.

 

[seper]

For these cases, PCI is not needed as incidence of brain mets is pretty low

 

[medgator]

For these cases, PCI is not needed as incidence of brain mets is pretty low

Yeah, I can't remember where I found the paper, but I think below the diaphragm, you can skip it. small cell of larynx/lung, you would do it.

 

[McConaughey]

Cervix involved...+pelvic node on pet...if you treat, including para-aortic nodes to 45 is something to consider.


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[Palex80]

Cervix involved...+pelvic node on pet...if you treat, including para-aortic nodes to 45 is something to consider.


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This is going to be challenging, since the lady is going to get 4x EP as well. She needs that Cisplatin more than an elective irradiation of the paraaortic nodes. I agree with your point, that there is a chance of paraaortic microscopic disease but would say that the chance of an isolated paraaortic recurrence in case of not treating the paraaortic area is probably less than 5%. One should take that into consideration too. Perhaps treat just up to the kidney vessels as a compromise?

 

[seper]

Agree, I wouldn't do extended field. It is too toxic with EP (speaking from personal experience).

 

[evilbooyaa]

I don't think full blown extended field is necessary, but treating up to the bifurcation (at least) would be reasonable. Obviously IMRT given the small bowel sparing you'll be able to achieve.

We did one patient with IMRT extended field for small cell cervical cancer who got concurrent EP- she had pretty bad nausea but was able to be controlled with medications, minimal other symptoms