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Gynaecological Cancers CE/CME ACCREDITED Watch Time: 32 mins

touchMDT Shifting the focus to locally advanced cervical cancer: Improving patient outcomes through multidisciplinary teamwork

MDT specialists discuss the current standard of care for patients with locally advanced cervical cancer in light of recent data, and highlight the role of the MDT in improving outcomes for patients through improved collaboration and optimization of the patient journey.

 Overview & Learning Objectives

Patient with locally advanced
cervical cancer
Clinical oncologist and Radiation oncologist
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Current treatment of LACC Dr McCormack, Prof. Chargari

Watch two experts from the MDT discuss current treatment approaches for patients with LACC, using a patient case to illustrate best practice with the standard of care; ongoing clinical trials are also highlighted.

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Gynaecologic oncologist and Nurse practitioner
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Optimizing the patient journey in LACC Prof. Monk, Ms Smith

Watch two experts from the MDT discuss risk factors for a poor prognosis in LACC and how patients can be supported using a collaborative approach.

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Gynaecologic oncologist, Clinical oncologist and Radiation oncologist
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Sharing data to improve outcomes in LACC Prof. Monk, Dr McCormack, Prof. Chargari

Watch three experts from the MDT discuss the role of multidisciplinary teams in supporting patients with LACC and the importance of sharing knowledge on the latest developments and ongoing clinical trials.

Watch Video
Clinical oncologist and Radiation oncologist

Watch two experts from the MDT discuss current treatment approaches for patients with LACC, using a patient case to illustrate best practice with the standard of care; ongoing clinical trials are also highlighted.
Expert Spotlight
Dr Mary McCormack
University College Hospital, London, UK
Prof. Cyrus Chargari
Gustave Roussy, Villejuif, France

Dr Mary McCormack and Prof. Cyrus Chargari discuss current treatment approaches for patients with LACC and how clinicians can improve outcomes through best use of standard of care treatments.

Listen on the Go

 Learn more Back to MDT Hub Time: 11:57
 
Gynaecologic oncologist and Nurse practitioner

Watch two experts from the MDT discuss risk factors for a poor prognosis in LACC and how patients can be supported using a collaborative approach.
Expert Spotlight
Prof. Bradley Monk
University of Arizona College of Medicine, Phoenix, AZ, USA
Ms Kathleen Smith
Fox Chase Cancer Center, Philadelphia,
PA, USA

Prof. Bradley Monk and Ms Kathleen Smith discuss the prognostic risk factors for patients with LACC and how best to support patients throughout their treatment journey for optimal outcomes.

Listen on the Go

 Learn more Back to MDT Hub Time: 09:17
 
Gynaecologic oncologist, Clinical oncologist and Radiation oncologist

Watch three experts from the MDT discuss the role of multidisciplinary teams in supporting patients with LACC and the importance of sharing knowledge on the latest developments and ongoing clinical trials.
Expert Spotlight
Prof. Bradley Monk
University of Arizona College of Medicine, Phoenix, AZ, USA
Dr Mary McCormack
University College Hospital, London, UK
Prof. Cyrus Chargari
Gustave Roussy, Villejuif, France

Prof. Bradley Monk, Dr Mary McCormack and Prof. Cyrus Chargari discuss the role of the MDT in implementing change to best practice care and the importance of keeping up to date with the latest clinical trial data.

Listen on the Go

 Learn more Back to MDT Hub Time: 11:01
 
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Learning Objectives & Overview
Overview

In this activity, specialists involved in managing patients with locally advanced cervical cancer share their multidisciplinary perspectives on the best use of current standard of care approaches (chemotherapy, external beam radiotherapy and brachytherapy) and consider whether ongoing immunotherapy trials may provide additional therapeutic options in the locally advanced setting.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of oncology and radiation oncology specialists globally, including gynaecologic oncologists and oncology nurse specialists involved in the management of cervical cancer.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity.  The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Prof. Bradley Monk discloses: Consultant fees from Agenus Inc., Akeso Biopharma Inc., Aravive Inc., AstraZeneca, Clovis Oncology, Eisai Co. Ltd., Elevar, EMD Serono, Genmab/Seagen, GOG Foundation, Gradalis Inc., ImmunoGen Inc., Karyopharm Therapeutics, Iovance Biotherapeutics, Merck, Mersana Therapeutics, Novocure, Myriad Genetics, Pfizer, Puma Biotechnology, Regeneron Pharmaceuticals, Inc., Roche/Genentech Inc., Sorrento Therapeutics, TESARO/GlaxoSmithKline, US Oncology Research and VBL. Speaker’s bureau fees from AstraZeneca, Clovis Oncology, Eisai Co. Ltd., Merck, Roche/Genentech Inc. and TESARO/GlaxoSmithKline. Grants/Research Support from US Oncology Research.

Prof. Cyrus Chargari discloses: Advisory board fees from GlaxoSmithKline and Merck Sharp & Dohme (both relationships terminated). Grants/research support fees from Roche.

Dr Mary McCormack discloses: Advisory board fees from AstraZeneca, Eisai Co Ltd., GlaxoSmithKline, Merck Sharp & Dohme and Roche.

Ms Kathleen Smith discloses No relevant financial disclosures in relation to this educational activity.

Content reviewer

Mitchel S. Hoffman, MD has no financial interests/relationships or affiliations in relation to this activity

Touch Medical Director

Kathy Day has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu 

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu)

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 31 March 2022. Date credits expire: 31 March 2023.

If you have any questions regarding credit please contact cpdsupport@usf.edu

 

Learning Objectives

After watching this activity, participants should be better able to:

  • Recall the heterogeneity of patients and prognostic risk factors in locally advanced cervical cancer (LACC) and how they affect clinical decision-making
  • Describe the use of current treatment strategies for LACC and best practices for effective management
  • Recognize the importance of the multidisciplinary team in optimizing outcomes in LACC and as early adopters of emerging treatment options
Faculty & Disclosures
Prof. Bradley Monk

University of Arizona College of Medicine, Phoenix, AZ, USA

Prof. Bradley Monk is Professor of Obstetrics and Gynecology at the University of Arizona College of Medicine, Phoenix, AZ, USA. read more

Prof. Monk’s research interests include the prevention and treatment of gynaecological cancers. He was the first to report the activity of anti-vascular growth factor (VEGF) therapy in ovarian cancer, which led to the global approval of anti-VEGF therapy and PARP inhibitors in recurrent ovarian and cervical cancers in 2014. 

Prof. Monk is on the board of directors for the GOG Foundation, Inc., and is the Cervical Cancer Chair for the Gynecologic Cancer InterGroup (GCIG). He is Past President of the Western Association of Gynecologic Oncologists (WAGO) and a current co-director for the GOG Research Consortium (GOG Partners). Prof. Monk is a fellow of the American College of Surgeons (ACS), the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP), as well as being an active member of the Society of Gynecologic Oncology (SGO) and American Society of Clinical Oncology (ASCO).

Prof. Bradley Monk discloses: Consultant fees from Agenus Inc., Akeso Biopharma Inc., Aravive Inc., AstraZeneca, Clovis Oncology, Eisai Co. Ltd., Elevar, EMD Serono, Genmab/Seagen, GOG Foundation, Gradalis Inc., ImmunoGen Inc., Karyopharm Therapeutics, Iovance Biotherapeutics, Merck, Mersana Therapeutics, Novocure, Myriad Genetics, Pfizer, Puma Biotechnology, Regeneron Pharmaceuticals, Inc., Roche/Genentech Inc., Sorrento Therapeutics, TESARO/GlaxoSmithKline, US Oncology Research and VBL. Speaker’s bureau fees from AstraZeneca, Clovis Oncology, Eisai Co. Ltd., Merck, Roche/Genentech Inc. and TESARO/GlaxoSmithKline. Grants/Research Support from US Oncology Research.
Prof. Cyrus Chargari

Gustave Roussy, Villejuif, France

Prof. Cyrus Chargari is Professor of Radiation Oncology and Head of Brachytherapy at Gustave Roussy, Villejuif, France. read more

Prof. Chargari’s clinical activity is mainly dedicated to gynaecological cancers (cervical cancer, uterine/endometrial cancer, vulvo-vaginal cancer) and interstitial brachytherapy, including head and neck and paediatric brachytherapy. His translational research activity includes the development of early-phase clinical trials in the field of immune modulation and novel radiosensitizers (nanoparticles, immune checkpoint inhibitors). 

Prof. Chargari is General Secretary of the French Society for Radiation Oncology, a member of the European Society for Radiotherapy and Oncology (GEC-ESTRO) and a member of the European Society of Gynaecological Oncology (ESGO). He is an author/co-author of more than 370 publications on cancer treatment, including international guidelines for the treatment of gynaecological tumours.

Prof. Cyrus Chargari discloses: Advisory board fees from GlaxoSmithKline and Merck Sharp & Dohme (both relationships terminated). Grants/research support fees from Roche.
Dr Mary McCormack

University College Hospital, London, UK

Dr Mary McCormack is Consultant Clinical Oncologist at University College Hospital, London, UK. read more

Dr McCormack is a specialist in the non-surgical management of gynaecological cancers (radiation/chemotherapy and biologic therapy). She is active in clinical research, contributing to both national and international clinical trial efforts. Her clinical interests include radiotherapy and gynaecological oncology. She is particularly interested in cervical cancer treatment, radiation-induced bowel injury, fertility and cancer therapy, and targeted agents in breast and gynaecological cancers. She is a major contributor to national and international clinical trials.

Dr McCormack is the current chair of the international Cervical Cancer Research Network (CCRN) and an executive member of the Gynecologic Cancer InterGroup (GCIG). She is a current member of the International Gynecologic Cancer Society (IGCS) Education Committee and the American Society of Clinical Oncology (ASCO) International Affairs Committee (IAC).

Dr Mary McCormack discloses: Advisory board fees from AstraZeneca, Eisai Co Ltd., GlaxoSmithKline, Merck Sharp & Dohme and Roche.
Ms Kathleen Smith

Fox Chase Cancer Center, Philadelphia, PA, USA

Ms Kathleen Smith is Nurse Practitioner at the Fox Chase Cancer Center, Philadelphia, PA, USA. read more

Ms Smith started her career as a nurse in the inpatient setting, followed by 14 years in chemotherapy infusion administration. During that time, she became experienced caring for many patients with fears, anxieties, questions and the need for information regarding their cancer, chemotherapy, and how to manage the potential side effects of treatment along with their disease process.  

Ms Smith completed her Master’s degree and CRNP certification in 2011, which allowed her to pursue a special interest in women’s health and, in particular, women’s cancers. Her focus is in gynaecological cancers, and she has worked collaboratively with physicians who specialize in gynaecologic and breast cancers. She is passionate about learning and continuing education to be able to provide the highest quality of care. In 2017, Ms Smith earned her Advanced Oncology Nurse Practitioner Certification.

Ms Kathleen Smith discloses: No relevant financial disclosures in relation to this educational activity.
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This Activity Is Funded By:

An independent medical education request from AstraZeneca.
This activity is jointly provided by USF Health and touchIME.

The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

This content is intended for healthcare professionals.

Date of original release: 31 March 2022. Date credits expire: 31 March 2023.

This content is intended for healthcare professionals only. Please confirm that you are a healthcare professional.

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Question 1/5
Which of these risk factors is not associated with a poor prognosis in LACC?

LACC, locally advanced cervical cancer.
 Correct

A retrospective review of data from 127 patients with LACC identified that tumour size ≥6 cm, positive lymph nodes and adenocarcinoma are significantly associated with shorter loco-regional-recurrence-free survival or distant-metastasis-free survival rates.1

During a median follow-up of 7.2 years of 397 patients with locally advanced cervical cancer treated with definitive chemoradiation between June 2001 and February 2010, large tumour size (>5 cm), nonsquamous histology, positive lymph nodes and advanced stage (III–IV) were identified as risk factors for locoregional failure.2

Abbreviation

LACC, locally advanced cervical cancer.

References

  1. Queiroz ACM, et al. Eur J Obstet Gynecol Reprod Biol. 2019;235:6–12.
  2. Bae HS, et al. Int J Gynecol Cancer. 2016;26:737–42.
Question 2/5
Your 34-year-old patient has experienced vaginal bleeding and pain over the past 3 months. Following biopsy, MRI and PET-CT scan, she is diagnosed with stage IIIC1 LACC. Based on the latest EU/US treatment guideline recommendations and recent clinical trial data, what would be your preferred treatment approach?

ACT, adjuvant chemotherapy; cCRT, concurrent chemoradiotherapy; EBRT, external beam radiotherapy; IO, immunotherapy; LACC, locally advanced cervical cancer; MRI, magnetic resonance imaging; PET-CT, positron emission tomography-computed tomography.
 Correct

The standard of care treatment for LACC is platinum-based cCRT plus brachytherapy.1–4

There is currently no evidence for a survival benefit with ACT after standard cCRT in patients with LACC, with recent data from the OUTBACK trial showing no significant improvement in 5-year survival outcomes with ACT compared with no ACT.5

Clinical trials with several IOs are ongoing in patients with LACC; efficacy results have not yet been reported.

Abbreviations

ACT, adjuvant chemotherapy; cCRT, concurrent chemoradiotherapy; EBRT, external-beam radiotherapy; IO, immunotherapy; LACC, locally advanced cervical cancer.

References

  1. NCCN Clinical Practice Guidelines in Oncology: Cervical Cancer. V1.2022. 2021. Available at: www.nccn.org/professionals/
    physician_gls/pdf/cervical.pdf (accessed 12 February 2022).
  2. Chino J, et al. Pract Radiat Oncol. 2020;10:220–34. 
  3. Marth C, et al. Ann Oncol. 2017:28(Suppl. 4):iv72–83.
  4. Concin N, et al. Int J Gynecol Cancer. 2021;31:12–39.
  5. Mileshkin LR, et al. J Clin Oncol. 2021;39(Suppl. 18).LBA3.
Question 3/5
Which of the following patients would be eligible for inclusion in the phase III clinical trials (CALLA and KEYNOTE-A18/ENGOT-cx11) evaluating durvalumab or pembrolizumab in combination with cCRT?

cCRT, concurrent chemoradiotherapy; LACC, locally advanced cervical cancer.
 Correct

CALLA (NCT03830866) is a phase III, global RCT assessing durvalumab in combination with cCRT in patients with FIGO 2009 stages IB2–IIB (N ≥1) or IIIA–IVA LACC.

KEYNOTE-A18/ENGOT-cx11(NCT04221945) is a phase III, global RCT assessing pembrolizumab in combination with cCRT in patients with FIGO 2014 stages IB2–IIB (N ≥1) or III–IVA LACC.

Both trials exclude patients with evidence of metastatic disease above the L1 cephalad body, in the inguinal region.

Abbreviations

cCRT, concurrent chemoradiotherapy; FIGO, International Federation of Gynecology and Obstetrics; LACC, locally advanced cervical cancer; N, positive lymph node; RCT, randomized controlled trial.

References

All clinical trials can be accessed at ClinicalTrials.gov using their study identifier.

Question 4/5
Your 40-year-old patient was recently diagnosed with stage IIB LACC and is yet to begin treatment. Which of the following strategies, using standard treatment options, would you consider adopting to optimize outcomes?

LACC, locally advanced cervical cancer; RT, radiotherapy.
 Correct

Prolonged total treatment times (>56 days) are associated with worse outcomes for patients with cervical cancer. A report from one centre in the US found that preventable treatment delays were attributed to inefficient scheduling, lack of education and unnecessarily staggered RT treatment.1

The NCCN guidelines state that the entire RT course, including EBRT and brachytherapy, should be completed within 56 days, with delays or splits in the RT treatment avoided wherever possible.2 

The ASTRO clinical practice guidelines state that physicians should aim to limit the total treatment time to within 56 days.3

Abbreviations

ASTRO, American Society for Radiation Oncology; EBRT, external beam radiotherapy; NCCN, National Comprehensive Cancer Network; RT, radiotherapy.

References

  1. Vitzthum L, et al. BMJ Open Qual. 2019;8:e000516.
  2. NCCN Clinical Practice Guidelines in Oncology: Cervical Cancer. V1.2022. 2021. Available at: www.nccn.org/professionals/physician_gls/pdf/cervical.pdf (accessed 14 February 2022). 
  3. Chino J, et al. Pract Radiat Oncol. 2020;10:220–34.
Question 5/5
Your patient with stage IIIA, node-positive LACC with periaortic involvement is discussed by the multidisciplinary tumour board. Which of the following treatment regimens would be preferred as a potential add-on to standard of care treatment, based on ongoing clinical research in high-risk patients with LACC?

CTLA-4, cytotoxic T-lymphocyte protein 4; LACC, locally advanced cervical cancer; LAG-3, lymphocyte activation gene 3 protein; PD-1, programmed cell death protein 1; PD-L1, programmed death ligand 1; TIGIT, T-cell immunoreceptor with Ig and ITIM domains.
 Correct

In the LACC setting, where patients have a particularly poor prognosis, anti-PD-1 and anti-PD-L1 therapies are being investigated in combination with cCRT. Durvalumab (anti-PD-1) in combination with cCRT is being evaluated in the phase III CALLA trial (NCT03830866). Pembrolizumab (anti-PD-1) in combination with cCRT is being evaluated in the phase III  KEYNOTE-A18/ENGOT-cx11 trial (NCT04221945).

In the metastatic cervical cancer setting, relatlimab (anti-LAG-3) is being evaluated in the phase I/II CheckMate358 trial (NCT02488759), zalifrelimab (anti-CTLA-4) is being evaluated in the phase II RaPiDs trial (NCT03894215), and tiragolumab (anti-TIGIT) is being evaluated in the phase II SKYSCRAPER-04 trial (NCT04300647).   

Abbreviations

cCRT, concurrent chemoradiotherapy; CTLA-4, cytotoxic T-lymphocyte protein 4; LACC, locally advanced cervical cancer; LAG-3, lymphocyte activation gene 3 protein; PD-1, programmed cell death protein 1; PD-L1, programmed cell death 1 ligand 1; TIGIT, T-cell immunoreceptor with Ig and ITIM domains.

References

All clinical trials can be accessed at ClinicalTrials.gov using their study identifier.

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