Case Conference October 31st 2018

31-Oct-2018, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE October 31st2018

Mrs. H.Y, 43yo, 427-57-11

Cervical Cancer stage IIB  post chemoradiation with partial respone

 

 

 Objective Learning

To determine overall survival for palliative chemotherapy for cervical cancer post chemoradiation with partial respone .

 

 

I. Case Description

On April 3^rd , 2018 was diagnosed with cervical cancer stage IIB.  Patients were referred from PELNI Hospital with cervical cancer. The main complaint of vaginal bleeding since 2 months before entering the hospital. Change sanitary pads 2-3x / day. History of PRC 6 colf transfusion.

Then patient received external radiation 25 times (02/05/2018 until 06/06/18), brachyterapy 3 times (27/06/18 until 12/07/18).

She routinely came to the hospital on schedule to control her condition. In Augustus 2018, she came to RSCM to do routine examination. There was  mass in the vagina suspected local reccurent. She underwent US examination and MRI with result of MRI compared to before, the mass of the uterine cervix was 5.5 x 6.8 x 7.8 cm (previously 5.2 x 6.2 x 4.9 cm), with extension to the uterine fundus, right & left parametrium, mesorectal and 1/3 proximal vagina.

 

 

II. Physical Examination on October 26^th, 2018

a. General status:

CM. BP: 120/75 mmHg, HR: 80 x/min, T: 36,5 C, RR: 20 x/min,

Head: Pale conjungtiva (-/-) icteric sclera (-/-)

Thorax: symmetry shape and movement of hemithorax;

Lung: vesicular breath sound on both lungs, no wheezing or rhales

Cardia: no murmur, no gallop

Abdomen: shifting dullness (-).

b. Gynecology examination:

Inspection: vulva and urethra was normal, no bleeding

RVT: there was a mass on the anterior portio cervix at the direction of 11-01 o'clock, sized 1,5 x 1 x 1 cm, adhered on anterior fornix vaginal.

Work Up

Pathology Anatomy Result from RSCM on March 23^rd 2018

Makroskopik

TUP :Diterima 1 Pot

Berisi jaringan ukuran 0,7 x 0,6 x 0,5 cm, pada pembelahan tampak warna putih kecoklatan, kenyal, padat.

Semua cetak……………………1 Blok

Mikroskopik

Sediaan berasal dari serviks menunjukkan jaringan massa tumor invasive terususun solid diantara jaringan ikat. Bentuk tumor menyerupai sel skuamosa dengan inti pleomorfik, hiperkromatik .Mitosis mudah ditemukan. Tampak sebukan ringan sel radang mendadak dan menahun.

Kesimpulan

 Karsinoma sel skuamosa tidak berkeratin berdiferensiasi sedang dengan sebukan ringan sel limfosit.

 

Ultrasound Result from RSCM on August 31^st 2018

Description: Normal corpus. The uterine cavity does not contain abnormal mass. Regular endometrial basal stratum, 3 mm thick. The cervix contains a solid mass of inhomogen with irregular shapes and edges, measuring 23 x 19 mm. active vascular mass derived from active malignancy mass (residif). Both parametria are free from invasion. There is no abnormal mass in both adnexes. There is no bilateral parailiac KGB enlargement. Liver and both kidneys are normal. There are no ascites.

Conclusion: Active cervical (residif) mass malignancy. Limited mass in the cervix.

 

 

Lower Abdomen/Pelvic with contrast MRI from RSCM on 13/10/2018

 

Technique: Pelvic MRI with intravenous 5 mL gadobutrol contrast Comparison: MRI Pelvis on 5 June 2018 Description: Heterogeneous solid mass is seen as an indeterminate boundary, irregular edge, slight hyperintense T2-FS, heterogeneous warmth post contrast with diffusion restriction, in the uterine cervix region measuring about 5.5 x 6.6 x 7.9 cm (previously 5.2 x 6 , 2 x 4.9 cm) in the largest dimension. The mass appears to extend to the left right parametrium and mesorectal fat, extending to the uterine fundus and 1/3 proximal to the vagina. There is no mass expansion to the pelvic wall.

There is no visible dilatation of the ureter at the visualized level. There was no sign of mass infiltration into the intraluminal bladder and rectum. There is also an enlargement of multiple lymph nodes in the obturatoria and the left iliac, the largest in the left obturator with a short axis diameter of 1.2 cm. The pelvic inlet appears normal, the os.ilium wing and miliopsoas are bilateral, symmetrical, good. The structure of the intestines does not appear to be abnormal, there are no signs indicating thickening of the intestinal wall or mass. Fluid collection is minimal in presacral space. Vesika urinaria looks distended and normal with walls that do not thicken. Minor pelvic vascular structure is good. The shape and articulation of the femoral head and acetabulum are normal, normal bone marrow. There were no abnormalities in subcutaneous soft tissue in the pelvic region.

Conclusion: Follow-up status e.c. ca cervix, compared to before the mass in the uterine cervix increases in size, with an extension to the uterine fundus, left right parametrium, mesorectal and 1/3 proximal to the vagina. Obturator and left iliac lymphadeopathy.

 

 

 

Introduction

Patients with cervical cancer may develop pelvic recurrence, distant metastases, or a combination of both. A 10%- 20% recurrence rate has been reported following primary surgery or radiotherapy in women with stage IB-IIA cervical tumors with no evidence of lymph node involvement, while up to 70% of patients with nodal metastases and/or more locally advanced tumors will relapse.

Most women with metastatic cervical cancer or local recurrence after radiotherapy are candidates for palliative chemotherapy. Historically, cisplatin has been considered the most active agent. Although cisplatin plus paclitaxel has shown no significant overall survival (OS) advantage compared with cisplatin alone, this combination has resulted in a doubling of both response rate (RR) and median progression-free survival (PFS) and had tolerable toxicity.

 

PROBLEM TO BE DISCUSSED

 

How is overall survival for palliative chemotherapy for cervical cancer post chemoradiation with partial respone ?

 

What question did the study ask?	PICO Analysis
Population	cervical cancer post chemoradiation with partial respone
Intervention	Palliative chemotherapy
Comparison	Observation
Outcome	Overall survival

 

METHODS

Search strategy

In order to answer the question above, we conduct a searching in PubMed site by using keywords “ cervical cancer post chemoradiation with partial respone AND palliative chemotherapy AND observation AND Overall survival”. The search was conducted with Pubmed search on October 26^th, 2018. We found none result.

Then, we reduced the keyword in to “advanced cervical cancer”, “ management”,metastasis”,“original article”, “systematic review”, “meta-analyses”  and “guidelines”.

The two articles found, one was original report  and one guidelines. All were appraised according to the corresponding type article, comprising its validity, importancy, and applicability.

 

Figure 1. Flowchart of search strategy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Critical appraisal

The three articles found, two wasoriginal report . and one guidelines. All were appraised according to the corresponding type article, comprising its validity, importancy, and applicability (table 2).

 

 

Table 2. Critical appraisal of the article

Study                 Criteria	Kitagawa (2015)
Validity
Randomisation	Yes
Intention to treat analysis	Yes
Blinding	Yes
Equal treatment besides experiment	Yes
Similiarity of groups	Yes
Importance
Control event rate (CER)	Can’t be calculated
Experimental event rate (EER)	Can’t be calculated
Relative risk reduction (RRR)	Can’t be calculated
Absolute riskreduction (ARR)	Can’t be calculated
Number needed to treat (NNT)	Can’t be calculated
Aplicability
Can the results help the patient?	Yes
Potential benefit of therapy	Yes
Patient satisfaction	Yes

 

 

DISCUSSION

Ryo Kitagawa et al evaluated the clinical benefits of carboplatin-based regimen. Kitagawa et al specifically only assigned whether it was primary, persistent or recurrent.

Eligible patients had metastatic or recurrent cervical cancer and had one platinum-containing treatment and no prior taxane. Patients were randomly assigned either to conventional paclitaxel plus cisplatin (TP; paclitaxel 135 mg/m2 over 24 hours on day 1 and cisplatin 50 mg/m2 on day 2, repeated every 3 weeks) or paclitaxel plus carboplatin (TC; paclitaxel 175 mg/m2 over 3 hours and carboplatin area under curve 5 mg/mL/min on day 1, repeated every 3 weeks). Primary end point was overall survival (OS). Planned sample size was 250 patients to confirm the non inferiority of TC versus TP with the threshold hazard ratio (HR) of 1.29.

Median PFS was 6.9 months (95% CI, 5.7 to 7.9 months) in the TP group and 6.2 months (95% CI, 5.5 to 7.2 months) in the TC group (HR, 1.041; 95% CI, 0.803 to 1.351). Complete response rate was 3.9% in the TP group and 7.1% in the TC group.

Treatment-related grade 3 or 4 adverse events occurring in more than approximately 5% of patients in either treatment group . Incidences of grade 4 neutropenia (75.0% v 45.2%; P<0.01), grade 3 to 4 febrile neutropenia (16.0% v 7.1%; P <0 .031), creatinine elevation (2.4% v 0.0%; P<0 .122), and nausea/ vomiting (6.4% v 3.2%; P <0.254) tended to be higher in the TP group, whereas incidences of thrombocytopenia and sensory neuropathy tended to be higher in the TC group.

Kitagawa concluded that TC was noninferior to TP and should be a standard treatment option for metastatic or recurrent cervical cancer. However, cisplatin is still the key drug for patients who have not received platinum agents. 

 

 

CONCLUSION

Based on the articles, patient has two option for the next treatment. One is chemotherapy and other is palliative supportive. Either one she will choose, any treatment is palliative, aiming to prolong survival but also to maintain quality of life. 

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