16. Cervix cancer - The GEC-ESTRO Handbook of Brachytherapy

Cervix cancer

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THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 01/09/2023

are better assessed on clinical examination (Figure 2b). Transvaginal or transrectal ultrasound (US) has been shown to be as sensitive as MRI for detecting parametrial disease in expert hands. Computed tomography (CT) is less useful than clinical examination for assessing local tumour extent but is equal to MRI for assessing LN involvement. Positron emission tomography (PET) in combination with MRI or CT has been shown to have greater sensitivity and specificity for detecting LN metastases than MRI or CT alone. Comparison of the different imaging modalities is shown in figures 3 and 4. The clinical findings and imaging findings should be accurately and systematically recorded by the examining physician. Examples of diagrams developed for this purpose are shown in figure 5. The FIGO staging system is the first staging system developed to compare treatment results of cervical cancer. Traditionally, it was mainly based on clinical findings by gynaecological examination and did not consider LN status. In 2018, the FIGO system was revised [2, 3] to include any LN involvement regardless of local tumour extent as substages of Stage III disease (Table 1); however, in doing so, some information about local tumour extent has been obscured. The TNM classification defines the status of the primary tumour and LN separately unlike the FIGO staging system but up to now, has not been extensively used making it less useful for comparisons with historical results. The T score is a new proposal for assessing the primary tumour burden involving a simple scoring system which integrates the findings from clinical examination

and MRI [4]. Evidence from the EMBRACE-I study [5] has shown that this system provides additional prognostic information on local control and survival based on the pattern of local spread at diagnosis and the degree of regression observed at the time of BT.

6. INDICATIONS

Guidelines for the multidisciplinary management of cervical cancer were issued by European Society of Gynaecological Oncology (ESGO), ESTRO and European Society of Pathology (ESP) in 2018 [6]. Definitive radiotherapy is recommended as the treatment of choice for all patients with advanced cervical cancer defined as local disease FIGO2018 IB3–IVA and/or LN involvement. Radiotherapy is also an effective alternative to surgery for patients with limited disease (IB, ≤4 cm). The combination of surgery with post-operative EBRT should be avoided as it has been shown to increase morbidity without improving survival. Brachytherapy alone is a curative option in patients with limited disease who are not suitable for surgery or EBRT. Preoperative BT followed by surgery is used in a limited number of centres and should only be used by teams experienced in this approach. The standard protocol for definitive radiotherapy is EBRT (preferably with intensity-modulated radiotherapy (IMRT)), with concomitant cisplatin chemotherapy followed by BT. Brachytherapy is crucial

Figure 3. Comparison of MRI, CT and PET-CT for primary tumour

Figure 4. Comparison of MRI, CT and PET-CT for involved node