بسم الله الرحمن الرحيم ” قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم“

Agenda Epidemiology. Where do we stand? Management of Cervical Cancer. Radiotherapy Evolution: -From 2D to IMRT.

Epidemiology Globally, cervical cancer is also the second most common cause of cancer-related mortality causing approximately 234,000 deaths annually among developing countries yet only killing 40,000 women in developed nations. Parkin DM, Bray F, Ferlay J, et al: Global cancer statistics, CA Cancer J Clin 55:74-108,2005

Primary Prevention

Vaccination is currently approved for use in girls and women ages 9 to 26 years.

Secondary Prevention

Screening should begin at age 21 years. Cytology alone is recommended every 3 years for women years of age. For women years of age, cotesting every 5 years is recommended. If HPV testing is not available, cytology alone should be continued every 3 years. New Screenin guidelines Saslow D, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin Mar 14

Where Do We Stand Radiotherapy and Cervical Cancer

Radiotherapy For Early Stage Disease

Early Stage I &II Early Stages (I &II) Stage I A1 - A2 Stage I B1 - B2 Stage II A1 - A2 Stage II A1 - A2

Inoperable patients

Stage IB and IIA bulky

Reduction in the risk of recurrence by up to 50% in the postoperative setting

Which Way? TREATMENT

Early Stage I &II Late Stages IIIA &IIIB Stage IIIA = N2 disease or T3 N1 Stage IIIA = N2 disease or T3 N1 Late Stages IIIA &IIIB Stage IIIA&B Late Stages IIIA &IIIB Stage IVA Late Stages IIIA &IIIB Late Stages IIB, III &VIA Stage IIB

Green J, Kirwan J, Tierney J, et al. Concomitant chemotherapy and radiation therapy for cancer of the uterine cervix. Cochrane Database Syst Rev 2001:CD A meta-analysis that included 4580 patients from 19 randomized trials supported the NCI consensus and confirms that concurrent chemo-radiation is superior to radiotherapy alone in terms of higher local control and decreased incidence of distant relapses with both platinum and non-platinum chemotherapy. Absolute Benefit of 10 to 13% in OAS

FEAR of Radiotherapy

History William Roentgen discovered X-ray London 1902 Cobalt machine First Linear accelerator

TOXICTOXIC

Small Bowel Bladder Rectum Bone Marrow Two Dimension

MRI, SPECT, PET and PET-CT Fusion 3D CT-Simulator

Toxicity and Quality of Life

Intensity Modulated Radiotherapy

Low Dose Region High Dose Region

Clinical Data

Bone Marrow Sparing and better tolerability to chemotherapy

Brachytherapy

Brachytherapy Boost