Cervix

Question 0

Where is point B?

Answer 0

3 cm lateral and in the same plane as point A, it correlates to the obturator nodes

Question 1

Where is point A?

Answer 1

Point A: 2 cm from the central uterus and 2 cm superior to the external os, corresponds to paracervical tissue, the point of crossage between ureter and uterine artery

Question 2

What are typical doses forLDR and HDR?

Answer 2

LDR: 0.4-2 Gy/ hr in 1-2 insertions
HDR: 12 Gy/ hr in 3-6 insertion

Question 3

What are the pros and cons of HDR?

Answer 3

Cons: Late complications because high fraction does not allow for recovery from sublethal injury.

Pros: convenience, safety of personnel

Question 4

What are Brachytherapy doses LDR for cervical cancer?hdr?

Answer 4

LDR: 40–60 cGy /hour delivered in 72 to 96 hours
HDR: 5-6 Gy x 5 total to point A all outpt

Question 5

What is the inferior,superior and lateral borders for cervical cancer?

Answer 5

Inferior: mid pelvis or 3–4 cm below most distal disease
Superior: L4 – L5. If small disease L5 – S1
Lateral: 1–2 cm lateral to the pelvic lymph nodes or at least 1 cm lateral to the margins of bony pelvis. Ant: 1cm in front if symphysis and post include sacrum and uterosacral ligament (s3)

Question 6

For locally advanced cervical cancer what is the total dose to point A? Point B?

Answer 6

Point A: 75-90 Gy
Point B: 45–65 Gydepending on extent of parametrial or sidewall disease

Starts w initial 40-45Gy EBRT x 4-5 weeks and then brachytherapy

Question 7

For cervical cancer what is the dosing for stage 1BI?

Answer 7

Total dose to point A: 75 gray

Question 8

And treating cervical cancer for Palliative bony minutes or PA nodes what is the dosing?

Answer 8

20 gray in five fractions or 30 gray in 10 fractions

Question 9

For vulvar disease what is the dose for microscopic disease?

Answer 9

45–50 Gy

Question 10

For vulvar disease what is the dose for positive margins, extracapsular nodal involvement, macroscopic residual disease?

Answer 10

60 Gy

Question 11

For vaginal hemorrhage how do you treat it with Radiation?

Answer 11

Monsels, pack, several days of accelerated external beam radiation =1.8 Gy b.i.d.

Question 12

For extended field Radiation what is the border?

Answer 12

T 12 –L1 superior border
Inferior: no gap btw pelvic field
Lateral: 9-10 cm wide

Question 13

What’s the total max dose for EBRT and Brachytherapy to small intestines? Bladder? Rectum?

Answer 13

Small bowel 60 gray, some say 50 or even 40.
Rectum 70 Gray
bladder 80 gray,

Question 14

What is data for adding chemo to RT?

Answer 14

1999 5 RCT showed chemotherapy to Radiation improved OS and changed landscape( Whitney, rose, Morris). Across the five studies cisplatin based chemo reduce the risk of death by 30 to 50%

Question 15

GOG 85 :patients and stage 2b -4a, 386 patients. Arm A patients received radiation for cisplatin and 5-FU arm B patients to receive radiation or a hydroxy urea: results?

Answer 15

Was no radiation alone arm. They did find that there was a survival benefit patients received the cisplatin 5-FU(67 vs 57%)

Question 16

Rtog 9001 stages 2B-4A got RT + cis/5FU vs RT alone

Answer 16

75% versus 63% or alive at 3 years with the chemo arm

Question 17

Gog 120: stages IIB-IV A
3 arms
Arm a: radiation plus cisplatin. Arm B Radiation plus cisplatin 5fu/hydroxyurea
Arm C Radiation plus hydroxyurea

Answer 17

Cisplatin-based therapy conferred a survival advantage arm a and B.
65 vs 47%
This led to cisplatin based chemoradiation

Question 18

What about adding cisplatin to Radiation for early-stage high-risk cervical cancers?

Answer 18

GOG 109 swig 8797were early-stage patient had high-risk features after radical surgery (positive lymph nodes positive parametria positive margins) 243 patients randomized to receive postoperative radiation cisplatin 5-FU versus radiation alone this protocol again conferred a survival benefit patients to receive the cisplatin 5-FU containing arm

Question 19

Cisplatin to bulky stage IB?

Answer 19

GOG 123 patients with stage one so-called barrel shaped tumors were randomized to upfront radiation for cisplatin versus RT radiation alone and again there was a survival benefits as seen in these patients that received cisplatin with the radiation at three years. 87 vs 77%

Question 20

In patients that have renal disease and you substitute carboplatinum for cisplatin for cervical cancer during chemo radiation?

Answer 20

Yes for patients I cannot tolerate cisplatin, carboplatinum we can AUC 2 qweek can be used