Small cell carcinoma of the uterine cervix

Question:
I'm wondering how you might approach consolidation radiation (with primary concurrent cis-plat/VP-16) for limited stage small cell carcinoma of the uterine cervix.  I'm calling this limited stage disease as the cervix/uterus is a bulky primary site while there are bilateral pelvic nodes from the ext iliac to the lower most common iliac, with no gross distant disease.  So I can encompass the entirety of the disease in "tolerable" ports, but what about dose?  I favor 45 Gy in 1.5 BID for LS lung, but can I use that here?  1.8 to 50.4?  Any thoughts.
 
Response # 1:
Personally I just give standard fields and dose/fractionnation. I understand your rationale  but probably no firm evidence either way.

We would obviously add brachy.

Rather than concomitant we would start with induction chemo and then proceed to CCRT but who is to say which approach is right!
 
Best Wishes
Nick Reed
 

Response # 2:
These are crude figures from my database. Follow-up may not accurate but general information is correct.

We have treated 29 patients with the diagnosis of small cell Ca Cx in the last 12 years. Fifteen of these patients with curative intent and the rest palliatively.

Of the 15 patients treated with curative intent, there were 9 - stage 1b, 5 – 2b and 1 – 3b.

Most of these received 2 cycles of Cis-plat/VP 16, then concurrent cisplat and RT (like ca cx) 40 Gy in 20 fx EBRT, if radiation field limited to pelvis or EFRT 45Gy in 1.8 fx + HDR conformal brachytherapy (4-5 fx) giving a total dose of 80 Gy (2 Gy equivalent) to the tumor (not point A).

If nodal disease was present (on PET), the nodal site was boosted to either 6 or 10 Gy EBRT boost in between brachytherapy treatment. This was followed by continued systemic chemo.

All except one had disease control at the primary site. The one who failed at the primary site also failed at multiple extra pelvic sites.

3 patients failed at distant sites only.

4 have failed in pelvis and at other sites.

3 have >10 years survival

1 > 3 years survival (no relapse yet)

3 were treated within the last 18 months, short follow-up.

I have assumed that you will give brachy boost to the primary site. I do not see any role of hysterectomy in these patients.

Kailash Narayan
 

Response # 3:
I forgot to mention that nodal boost was small postage stamp field covering each nodes separately, not  continuous single field encompassing all the involved nodal groups.

Kailash Narayan
 

Response # 4:
Limited stage small cell carcinoma almost always turns out to have metastasized without clinical signs at this moment. With that in mind, we would give chemo as for small cell ca of the lung to treat all. For local control after a good response,  RT and even surgery is an option for the pelvis.

We would not start with concomittent chemoradiation in such a case.

Cheers

Ruud L.M. Bekkers
 

Response # 5:
For the couple that I have treated I  started off with 2 cycles of carbo/etoposide and then gave RT concomitantly with cycle3. Used dose 50.4 Gy/28 fractions. Would feel very uncomfortable with BD farctionation here

Good luck
Mary McCormack