# Radiation Oncology/Cervix/IA

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* Overview |
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* Cervix Randomized |
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* RTOG Cervix

## Prognostic Factors

* 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

* 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

* 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

* 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

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