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GYN > Vaginal, Vulvar, Misc. > Flashcards

Vaginal, Vulvar, Misc. Flashcards

1
Q

Which site of recurrence post definitive CRT for vaginal cancer has the worst prognosis?

A
  • Groin
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2
Q

What is the most important prognostic factor for a pt w/ new vulvar cancer?

A

LN status

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3
Q

Which pathologic features of vulvar cancer s/p surgery confer the highest risk of LR and should receive RT to the primary site?

A

Pathological factors and their associated LR Rates
- Margins < 8 mm (strongest factor)
– < 8 mm → 48%
– ≥ 8 mm → 0%
- +LVSI → LR 39%
- DOI > 9.1 mm → 15%.

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4
Q

What is the pt population, randomization, and primary end-point of GOG 37 for vulvar cancer?

A

Pts:
- Invasive SqCC
- s/p vulvectomy and b/l inguinal lymphadenectomy
- Inguinal LN+

Randomization:
- 🏆 RT 45-50 Gy to b/l inguinal and pelvic nodes (but not vulva/primary)
- PLND

Primary end-point
- OS

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5
Q

What are the results of GOG 37 for vulvar cancer?

A

RT vs. PLND
- 2-yr OS 68% vs. 54% (p=0.03)
– On subanalysis, effect only in ECE and ≥2 nodes
- 6-yr OS 51% vs. 41% (NS)
– benefit only in palpable N+, ECE, ulcerated, or ≥2 nodes, or >20% nodal positivity
- 6-yr groin recurrence 5% vs. 24% (p=0.02)
- Lymphedema 16 vs. 22% (NS)

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6
Q

What is the primary RO interpretation of GOG 37 for vulvar cancer?

A
  • Adjuvant RT improves OS in palpable N+, ECE, ulcerated, and ≥2 nodes, vs. PLND after radical vulvectomy and inguinal LND
  • Trial was closed early as 2-yr results showed an improvement in LR and OS w/ RT
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7
Q

What is the rate of groin recurrence in vulvar cancer pts following WLE and SLNBx showing micro vs. macrometastases who subsequently receive RT w/o inguinal LND?

A

GROINSS V-II study
- Micro vs. macro: 2% vs. 22%

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8
Q

What is the rate of lymphedema in vulvar cancer pts s/p WLE and SLNBx f/b ± RT ± inguinal LND?

A
  • GROINSS V-II: LE at 6 / 12 mos
    – SLNBx alone: 5.1% / 4.1%
    – SLNBx + RT: 16.4% / 10.7%
    – Inguinal LND ± RT: 32% / 22.9%(p < 0.001).
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9
Q

What are the field borders for a vulvar cancer pt being tx w/ 3D CRT, including to the inguinal LNs?

A
  • Wide AP field to tx pelvic and inguinal LNs
    – Sup: L5/51 or L4/L5 for positive or suspicious pelvic LNs
    – inf: flash vulva
    – Lat: greater trochanter
  • Narrow PA field to tx pelvic LNs and spare femoral heads
    – Sup and inf as above
    – Lats: 2 cm beyond pelvic inlet
  • e- can be used to supplement inguinal dosing
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10
Q

What RT doses are recommended for vulvar cancer s/p resection w/ -margins, close margins (<8mm), +margins, or gross disease?

A
  • RT Dosing:
    – -Margins: 45-50
    – Close (<8mm): 56 Gy for close
    – +Margins: 63 Gy
    – Gross disease: 65-70 Gy
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11
Q

What is the T staging for vulvar cancer?

A
  • Tx: Cannot be assessed
  • T0: No evidence of tumor
  • T1a (IA): confined to the vulva or perineum, ≤ 2 cm in size, ≤ 1.0 mm DOI
  • T1b (IB): confined to the vulva or perineum, > 2 cm in size, > 1.0 mm DOI
  • T2 (II): Any size with extension to adjacent perineal structures
    – lower/distal 1/3 urethra
    – lower/distal 1/3 vagina
    – Anal involvement
  • T3 (IIIA): Tumor of any size with extension to any of the following:
    – upper/proximal 2/3 of urethra
    – upper/proximal 2/3 vagina
    – bladder mucosa
    – rectal mucosa
    – Fixed to pelvic bones (IVA)
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12
Q

What is the N staging for Vulvar cancer?

A
  • NX: Regional lymph nodes cannot be assessed
  • N0
  • N1a (IIIA): 1-2 LNs, each < 5 mm
  • N1b (IIIB): 1 LN >= 5 mm
  • N2a (IIIB)
    – 3+ LNs < 5 mm
    – 2+ LNs > 5 mm
  • N2c (IIIC): ECE
  • N3 (IVA): Fixed or ulcerated regional LN(s)
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13
Q

What is the risk of LN involvement for a pt w/ FIGO IA vulvar cancer?

A
  • < 8%
  • No SLN assessment required
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14
Q

What is the risk of pathologic LN+ for a vulvar cancer pt w/ clinically LN-?

A

~30%

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15
Q

What are the most common indications for post-op RT to the pelvic and inguinal LNs for vulvar cancer?

A
  • Per GOG 37 unplanned post-hoc analysis:
    – Clinically palpable or matted LNs
    – ≥ 2 pathologic LN+
    — In practice, even 1 LN+ is tx w/ RT given the poor prognosis of inguinal LN recurrence
    – LN+ ratio ≥ 20%
    – ECE
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16
Q

What is the pattern of LN drainage for the vagina?

A
  • Vaginal LN drainage:
    – Upper 2/3 → internal iliacs, external iliacs, and obturator (pelvic nodes)
    – Lower 1/3 → Inguinofemoral nodes.
17
Q

What is the pattern of LN drainage for the vulva?

A
  • Vulvar LN drainage
    – Superficial inguinal/femoral LNs,
    – f/b deep femoral LNs
    – f/b external and common iliac lymph nodes
  • Clitoris
    – Can bypass the superficial nodes and drain directly to the deep femoral nodes and pelvic lymph nodes (obturator and external iliac)
18
Q

What is the FIGO staging for ovarian cancer?

A
  • I:
    – IA: Tumor limited to 1 ovary, capsule intact, ovarian surface -ve; no malignant cells in ascites or peritoneal washings
    – IB: Tumor limited to 2 ovaries, capsules intact, ovarian surfaces -ve; no malignant cells in ascites or peritoneal washings
    – IC: Tumor limited to one or both ovaries with one of the following: surgical spill (IC1), capsule rupture before surgery or tumor on the ovarian surface (IC2), or malignant cells in ascites or peritoneal washings (IC3)
  • Il: Extension to
    – IIA: Uterus and/or fallopian tubes
    – IIB: Other pelvic intraperitoneal tissues
  • III: Spread to the peritoneum outside the pelvis and/or retroperitoneal LNs
    – IIIA: Retroperitoneal LN+ only
    – IIIB: Macroscopic, extrapelvic, peritoneal metastasis 2 cm or less in greatest dimension ± retroperitoneal LNs+. Includes extension to capsule of liver or spleen
    – IIIC: Macroscopic, extrapelvic, peritoneal metastasis more than 2 cm in greatest dimension ± retroperitoneal LNs+. Includes extension to capsule of liver or spleen
  • V:
    – IVA: Pleural effusion with positive cytology
    – IVB: Hepatic and/or splenic parenchymal metastasis, metastasis to extra-abdominal organs (including inguinal nodes and nodes outside the abdominal
19
Q

What is the preferred management of all stages of ovarian cancer?

A
  • Maximal surgical cytoreduction for all stages
    – Adjuvant CHT
    – Neoadjuvant CHT for pts for whom complete cytoreduction might otherwise be unlikely
  • OS improved from 17 to 37 mos w/ optimal surgical cytoreduction/debulking
  • RT is used in the palliative setting only
20
Q

What is the most common histology for fallopian tube cancers?

A
  • Serous
21
Q

What is the FIGO and TNM staging for vaginal cancer?

A
  • Figo Stage (TM classification)
    – Stage I (T1a ≤2cm, T1b > 2cm): Tumor confined to vaginal mucosa
    – Stage II (T2a ≤2cm, T2b >2cm): Submucosal infiltration into the parametrium; not extending out to the pelvic wall
    – Stage III (T3): Tumor extends to the pelvic wall, defined as muscle, fascia, neurovascular structures, or skeletal portions of the bony pelvis, lower 1/3 vaginal involvement, and or hydronephrosis as a result of obstruction. Also nodal involvement
    – Stage IVA (T4): Tumor invades mucosa of bladder or rectum or is growing out of the pelvis
    – Stage IVB (M1): Cancer has spread to distant organs
  • There is no N classification for vaginal cancer
22
Q

What are the usual duodenal constraints when treating PA nodes?

A

Verma et al., IJORBP, 2014
- D2cc < 60 Gy
– ≥ G2 tox with D2cc < 60 Gy vs. > 60 Gy→ 4.4% vs. 18.6% (p- 0.07)
- V55 < 15 cc
– ≥ G2 tox with V55 < 15cc vs. > 15cc → 7.4% vs. 48.6^% (p- 0.05)

23
Q

Why is the duodenum especially vulnerable to RT compared to other parts of the small and large bowels?

A
  • Duodenum is relatively immobile, leading to consistent exposure to RT doses
  • Most of the duodenum is retroperitoneal, lying in close proximity to the PA nodes
24
Q

What are the pt population, design, and primary end-point of GOG 205 for vulvar cancer?

A
  • Pt:
    – T3, T4, N+
  • Phase II:
    – RT 57.6 Gy/ 32 fx + weekly cisplatin → resection
  • cCR defined by biopsy, pCR defined by surgical resection
25
Q

What were the results of GOG 205 for vulvar cancer?

A
  • cCR 64%
  • pCR 50%
    – compared to 40% in GOG 101
26
Q

What are the pt population, design, and primary end-point of the UCLA HEAPS study for vulvar cancer?

A
  • Pt:
    – s/p surgical resection
  • Retrospective review
    – Path factors related to recurrence
27
Q

What were the results of the UCLA HEAPS study for vulvar cancer?

A
  • Factors a/w local recurrence in order of significance
    – Stage
    – Margin
    — Margin <8mm had LR of 48%
    — Margin <5mm had LR of 57%
    – Depth
    – Growth pattern
    – Vascular invasion
    – Keratin amount
    – Mitotic activity
  • NOT: Tumor size, Nucleoli, grade
28
Q

Which muscles form the lateral boundaries of the inguinal LN contours?

A

GYN (3 decks)

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