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Gyn Onc > Cervix > Flashcards

Cervix Flashcards

1
Q

Type II vs Type III hysterectomy

A

Type II:

  1. Ligate uterine artery medial to the ureter
  2. Take the parametria halfway to the sidewall
  3. Take half the uterosacral ligaments
  4. Take 1-2cm of vagina

Type III:

  1. Ligate uterine artery at its origin
  2. Take parametria at the sidewall
  3. Take uterosacral ligaments at the sacrum
  4. Take 2-3cm of vagina
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2
Q

HPV types

A

16 and 18: 70% of cervical cancers
31, 33, 45, 52, and 58: 20% of cancers

6 and 11: 90% of warts

*These 9 make up Gardasil 9.

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3
Q

HPV vaccine

A

Who: Recommended at age 11-12.
Can be given 9-26.
Decision to give after age 26 must be individualized.
Approved in the US unto age 45.

Dose:
Age < 15: 0 and 6-12 months
Age > 15: 0, 2, and 6 months

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4
Q

Rate of ovarian mets?

A

SCC: 0.5%
Adenoca: 1.7%

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5
Q

MRI vs CT for cervical cancer staging?

A 
Bipat et al, 2003
Systematic review
MRI more sensitive than CT for LAD and parametrial involvement.
- 74% sensitivity for parametria
- 60% sensitivity for LAD
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6
Q

PET scan for cervical cancer?

A 
Havrilesky et al, 2005
Systematic review for cervical and ovarian 
Sensitivity and Specificity:
- Pelvic LN 79 / 99%
- PALN 84 / 95%
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7
Q

Stage IA1, negative LVSI

Treatment options?

A

1) Fertility-sparing: CKC
- Roman 1997: risk of residual invasion 3% with negative margins, upto 33% with positive margins AND positive ECC
- risk of LN mets < 1%

  • Wright et al 2010: SEER study, 1400 patients who had cone or hysterectomy, no difference in 5yr survival
    2) Non-fertility sparing: Simple hyst
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8
Q

Stage IA1 with LVSI, or

Stage IA2

A

1) Fertility-sparing:
- CKC with pelvic LND
- radical trachelectomy with pelvic LND

2) Non-fertility sparing:
- radical hysterectomy with pelvic LND
- RT

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9
Q

Stage IB1 (less than 2cm)

A

1) Fertility-sparing:
- radical trachelectomy with pelvic LND
* if other criteria are met

2) Non-fertility sparing:
- radical hysterectomy with pelvic LND
- chemoRT

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10
Q 
Stage IB2 (2-4cm), or
IIA1 (upper 2/3 of vagina, less than 4cm)
A
  • radical hysterectomy with pelvic LND

- chemoRT

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11
Q

Stage IB3 (>4cm), or above

A

chemoRT

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12
Q

Are surgery and RT equivalent?

A

Landoni 1997:
Stage IB1, IB2, IIA
randomized to RH or RT
RH patients got postop RT if +margins / parametria, LN, or 3mm margin

  • No difference in PFS, thus equivalent oncologic outcomes
  • Criticisms:
    Many RH patients got RT
    Less dose to point A
    83% of RH patients got RT
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13
Q

Complications of rad hysterectomy?

A 
Bladder atony
Lymphocyst
Ureterovaginal fistula
Thrombophlebitis
PE
SBO
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14
Q

Complications of radiation?

A 
Sigmoiditis
RV fistula
VV fistula
Rectal stricture
Ureteral stricture
SBO
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15
Q

Prognostic pathologic factors for recurrence in cervical cancer?

A

GOG 49:
Size
LVSI
DOI

These increase the risk of recurrence from 2 to 31%

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16
Q

Criteria for radical trachelectomy?

A 
Age < 40
No infertility issues known
size < 2cm (new IB1)
PET negative for LN disease
Upper endocervix negative
Squamous, adeno, or adenosquamous
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17
Q

Preoperative counseling for radical trachelectomy?

A
  • That patient may need hysterectomy (for example, if unable to get margin or there is upper cervical extension)
  • That patient may need RT based on final pathology
18
Q

Data to support trachelectomy?

1) Oncologic outcomes?
2) Pregnancy outcomes?

A

1) Multiple observational studies suggest equal oncologic outcomes. MSKCC case-control study by Diaz.

2) Boss 2005, systematic review of 16 studies and 355 patients. 153 tried to get pregnant. Of these:
- 70% pregnancy rate
- 49% term deliveries

19
Q

Pathologic risk factors for +pelvic LN?

A

GOG 49:

a. Depth of stromal invasion (superficial 4% vs deep 26%)
b. Gross primary tumor (occult 9% vs gross 21%)
c. LVSI (8% vs 25%)
d. Grade (G1 10%, G2 14%, G3 22%)
e. Parametrial extension (Negative 13% vs Positive 43%)

20
Q

Why do you perform open surgery for cervical cancer?

A

LACC trial

  1. randomized, noninferiority trial; stage IA1(LVSI+), IA2, IB1
  2. 92% = IB1
  3. 16% robotic
  4. 3 yr DFS: 91% vs 97%
  5. 3 yr OS: 94% vs 99%, HR for death = 6,

Conclusion: MIS rad hyst had lower DFS and OS vs open rad host

In addition, retrospective data has shown that the mortality rate was stable prior to the adoption of MIS for cervical cancer

21
Q

Would you perform adjuvant hysterectomy after RT?

A 
GOG 71, Keys et al 2003
Randomized trial
Bulky IB tumors
RT+intracavitary vs RT+RH
No difference in PFS or OS.
Authors concluded that adjuvant RH had no benefit except maybe in very large tumors.

I would only consider in patients with residual disease after RT.

22
Q

Why do you give primary chemoRT to your bulky stage IB+ patients?

A 
GOG 123, Keys et al 1999
Randomized trial
Bulky IB2
RT+RH vs cisRT+RH
Improved outcomes with cis!
-3yr PFS 63 vs 79%
-3yr OS 74 vs 83%

*The additional information provided by GOG 71 makes it such that adjuvant hyst can be omitted.

23
Q

How did cisplatinum come to have a major role in treatment of cervical cancer?

A

1999 NCI Alert: Three randomized GOG trials showed benefit with cis over other regimens.

GOG 85: cis/5FU+RT > HU+RT
GOG 120: cisRT vs cis/5FU/HU-RT vs HU-RT. Both cis groups > HU
GOG 123: cisRT+RH > RT+RH

24
Q

What is the rate of PALN involvement?

A 
Depends on clinical stage:
I = 7%
II = 18%
III = 27%
IV = 33%
25
Q

Which patients get adjuvant radiation after surgery? Which patients get adjuvant chemoradiation?

A 
Radiation: Sedlis criteria per GOG 92
Patients with IM factors were randomized to RT vs obs. There was improvement in PFS with RT. The study was not powered to detect a difference in OS.
\+LVSI, superficial DOI, >5cm
\+LVSI, middle DOI, >2cm
\+LVSI, deep DOI, any size
-LVSI, middle/deep DOI, >4cm
cisRT: Peters criteria per GOG 109
Patients with HR factors randomized to RT vs cis/5FU-RT. There was improvement in PFS and OS. HR was 2 for both metrics. 
\+margins
\+parametria
\+LN
26
Q

Ongoing trials:

Why do you not give cisRT to IM factor patients?

Should you give more chemotherapy to HR factor patients?

A

GOG 263 is currently studying this. Randomized trial of IM factor patients after surgery, randomized to cisRT vs RT

The OUTBACK trial is studying patients that are HR and randomizing them to cisRT vs cisRT+carbo/taxol x 4

27
Q

How does chemotherapy work as a radiation sensitizer?

A
  1. Inhibits sublethal repair
  2. Synchronizes cell populations
  3. Induces proliferation in non-proliferating cells
  4. Reduces fraction of hypoxic cells
  5. Increases apoptosis
28
Q

What is GTV? CTV? PTV?

A

Gross target volume = actual tumor as determined clinically and radiographically

Clinical target volume = an area that has high likelihood of harboring malignancy

Planned target volume = added margin to account for motion and daily set up error

29
Q

What radiation doses are given to GTV and CTV in cervical cancer?

A 
GTV = 80-90Gy
CTV = 45-54Gy
30
Q

How does radiation work?

A

Ionizing radiation induces cell DNA damage, which results in cell death.

31
Q

How does oxygenation impact radiation?

A

Oxygen fixation hypothesis: oxygen is known to chemically modify radiation-included DNA damage making it irreparable.

32
Q

What phase of the cell cycle is most radiosensitive? Most radioresistant?

A

Sensitive: M phase
Resistant: S phase

33
Q

What is a Linac?

A

Linear accelerator. The principles behind this involve accelerating electrons across a variable electric field.

The gantry is the portion which emits radiation.

Multileaf collimators control the shape of the of the radiation beam before it reaches the patient.

34
Q

3D conformational treatment and IMRT

A

IMRT is an improvement over 3D.

3D: uses fewer fields. At each gantry angle, the radiation is either hitting the target or not.

IMRT: with IM, can use same angles but create more complex dose distribution. It is of particular use when normal tissues and target tissues are in close proximity, or in varying proximity across a field and gantry angles.

35
Q

What is IGRT?

A

Image-guided radiation therapy.

Historically treatment setups were verified with radiographs, and treatment fields by x-rays superimposed on the patient.

Modern linacs have on-board imaging that allows fields to be recorded electronically at every treatment step. By comparing computer generated radiographs and actual patient images, discrepancies in field shape and patient set up can be corrected before treatment is delivered.

  • Allows for treatment shape to change throughout course of treatment (ie, as tumors shrinks)
  • CT scanners have been added to linacs
36
Q

Inverse-square law?

A

The dose delivered to the target is inversely proportional to the square of the distance to the target.

*So if you double the distance, the dose is reduced by a factor of 4.

37
Q

Point A

A

2cm lateral to the central canal of the uterus and 2cm from the lateral fornix in the axis of the uterus.

Where the uterine artery crosses the ureter.
Correlates to the paracervical triangle.

38
Q

Point B

A

3cm lateral to Point A.

Correlates to the obturator nodes.

39
Q

Total dose to Point A and B?

A

85Gy to Point A
60Gy to Point B

when combining EBRT and brachytherapy.

40
Q

How do you pick ovoid sizes?

A

Use largest size possible, and position as far laterally and cephalad as possible, in order to given the highest tumor dose at depth for a given mucosal dose.

41
Q

T&O: What is the ideal positioning?

A

Tandem in the axis of the pelvis, equidistant from the sacral promontory, pubis and lateral pelvic walls.

Tandem should bisect the ovoids in AP films, and bisect their heights in lateral films.

42
Q

What is the usual vaginal surface dose?
Bladder dose?
Rectal dose?

A

Vaginal: <140 Gy (average 120-140)
Bladder: should be <75-80 (average 68)
Rectum: should be <70-75 (average 70)

Gyn Onc (5 decks)

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