A 4.5 cm Cervical Cancer With a Single Pelvic Node
A 46-year-old woman, never screened, presents with 2 months of postcoital and intermenstrual bleeding. Examination shows a 4.5 cm exophytic cervical mass that does not involve the parametria or vaginal wall. Biopsy shows HPV-16-positive squamous cell carcinoma. PET/CT demonstrates an FDG-avid cervical mass (SUVmax 14), a single 1.2 cm right external iliac node, and no para-aortic or distant uptake. Creatinine is 0.8 mg/dL, hemoglobin 10.1 g/dL, and she smokes. She is anxious about 'losing the uterus' and asks whether surgery would be quicker, and she is worried about sexual function afterward. She has completed childbearing.
1. Assign stage, justify the treatment recommendation, and explain why surgery is not the preferred route here.
Read the worked answer
The tumor is 4.5 cm and confined to the cervix; with the single external iliac node, the stage is IIIC1 (node-positive). Even without the node, a 4.5 cm cervical tumor is stage IB3, for which definitive chemoradiation is preferred over radical hysterectomy.
- Oncologic reasoning: randomized comparison of radical surgery versus radiotherapy in early-stage disease showed similar survival, but surgery for tumors above 4 cm frequently requires adjuvant radiotherapy, and combined modality increases fistula, lymphedema, and bladder dysfunction without a survival gain.
- Node positivity: surgery cannot adequately treat a metastatic pelvic node; chemoradiation with a nodal boost addresses both the primary and the node.
- Her concerns: chemoradiation takes about 5-6 weeks of external beam therapy followed by brachytherapy, which is comparable to the recovery from radical hysterectomy plus adjuvant therapy. It avoids surgical menopause and operative morbidity.
- Sexual function: counsel proactively about vaginal stenosis, dilator use, lubricants, and topical estrogen after treatment; this is manageable and should be discussed before therapy begins, not after.
- Fertility: not a consideration here; if she had a small tumor and a strong desire for fertility, radical trachelectomy would be the discussion.
Smoking cessation should be addressed now because it worsens radiation toxicity and outcomes.
2. Write your radiation plan: external beam dose and fields, concurrent chemotherapy, brachytherapy technique, target doses, and organ-at-risk constraints.
Read the worked answer
External beam: 45 Gy in 25 fractions of 1.8 Gy, five days per week, to the pelvis using IMRT/VMAT with daily image guidance. The involved external iliac node receives a simultaneous integrated boost to roughly 55-57.5 Gy EQD2. Para-aortic nodes are not treated because PET is negative.
Concurrent chemotherapy: weekly cisplatin 40 mg/m2 (maximum 70 mg), five cycles, with hydration, magnesium replacement, and creatinine monitoring. Consider carboplatin if renal function declines.
Brachytherapy: MRI-based image-guided adaptive brachytherapy with a tandem and ring or ovoids, 4-5 fractions, delivered within 1-2 weeks of completing external beam. Prescribe to the high-risk clinical target volume with a D90 of at least 85 Gy EQD2 (targeting 90 Gy or more).
Organ-at-risk limits (D2cc, EQD2): bladder 90 Gy or less, rectum 70-75 Gy or less, sigmoid 75 Gy or less, bowel 70 Gy or less.
Overall treatment time: complete all therapy within about 56 days. Each additional day beyond that costs roughly 1% of local control per day; never sacrifice or delay brachytherapy to give more external beam. If the node still has residual uptake at brachytherapy, consider an additional boost.
3. After three cycles she has grade 3 neutropenia and platelets of 78,000/µL, and hemoglobin is 9.2 g/dL. She asks to 'take a break until counts recover.' How do you protect both her counts and her cure?
Read the worked answer
Treatment time is a therapeutic variable in cervix cancer, so the default is to continue rather than pause.
- Neutropenia: add granulocyte colony-stimulating factor and continue external beam and weekly cisplatin; isolated neutropenia without fever is not a reason to interrupt pelvic radiation.
- Thrombocytopenia: transfuse platelets if below about 20,000-30,000/µL or before brachytherapy, and continue. Brachytherapy should not be deferred for counts that can be supported.
- Anemia: transfuse to maintain hemoglobin around 10 g/dL; anemia worsens tumor hypoxia and radiation response. Investigate iron deficiency, which is common in this population.
- Cisplatin modifications: if creatinine rises or neuropathy or ototoxicity develops, switch to carboplatin rather than omitting radiosensitizing chemotherapy entirely; a delay without chemotherapy is worse than a change of agent.
- Brachytherapy: protect it above all. If she needs a short break, keep it to the minimum and compensate by treating on weekends if the department can.
- Smoking: offer cessation pharmacotherapy; continued smoking increases toxicity and may reduce efficacy.
Explain to her that the break she is requesting is the one intervention most likely to reduce her chance of cure, and that the team will manage the counts rather than the calendar.