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

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

4. 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, 2002. CA Cancer J Clin 55:74-108,2005

5. Primary Prevention

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

7. Secondary Prevention

8. Screening should begin at age 21 years. Cytology alone is recommended every 3 years for women 21-29 years of age. For women 30-65 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. 2012 Mar 14

9. Where Do We Stand Radiotherapy and Cervical Cancer

10. Radiotherapy For Early Stage Disease

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

12. Inoperable patients

13. Stage IB and IIA bulky

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

15. Which Way? TREATMENT

16. 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

17. Green J, Kirwan J, Tierney J, et al. Concomitant chemotherapy and radiation therapy for cancer of the uterine cervix. Cochrane Database Syst Rev 2001:CD002225. 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

19. FEAR of Radiotherapy

20. History William Roentgen discovered X-ray 1895. London 1902 Cobalt machine First Linear accelerator

21. TOXICTOXIC

22. Small Bowel Bladder Rectum Bone Marrow Two Dimension

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

24. Toxicity and Quality of Life

25. Intensity Modulated Radiotherapy

26. Low Dose Region High Dose Region

27. Clinical Data

29. Bone Marrow Sparing and better tolerability to chemotherapy

30. Brachytherapy

31. Brachytherapy Boost