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GYN Flashcards

1
Q

What is a type I hysterectomy?

A
  • Simple hysterectomy
  • Peritoneal washings prior to resection
  • Removal of
    • Fascia of cervix
    • Lower uterine segment
    • Full uterus
    • Ovaries removed for staging and to stop estrogen production
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2
Q

Type II hysterectomy

A
  • Modified radical hysterectomy
  • Removal of
    • Uterus
    • Lower uterine segment and cervix
    • Upper 1/3 (1-2 cm) of the vagina
    • Unroofing ureters to resect parametrial tissue and paracervical tissue
    • Lymphadenectomy
    • Uterine vessels ligated medial to ureters
    • Uretosacral ligament ligated midway between uterus and sacrum
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3
Q

Type III hysterectomy

A
  • Radical hysterectomy
    • All Type II parts
    • Ureters mobilized as well as bladder and rectum
    • Resected parametrial tissue to pelvic side wall
    • Resection of 1/3 to 1/2 of vagina
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4
Q

Which cancers get Type I hysterectomy

A

Most endometrial

Some 1A1 cervix

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5
Q

What cancer get Type II hysterectomy

A

Cervical cancer IA2

Endometrial cancer with cervical involvement

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6
Q

Which cancers need type III hysterectomies

A

Most cervical cancers IB+

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7
Q

Which histologies need omental biopsy

A

Serous endometrial

Clear cell

Carcinosarcoma

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8
Q

What are the procedures for cervical sampling?

A
  • Conization
  • LEEP (Loop Electrosurgical Excision Procedure)
  • Trachelectomy
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9
Q

What is conization

A

En bloc removal of ectocervix and endocervix canal

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10
Q

What is a trachelectomy

A

All cancer removed with margin

Internal os remains and stitches closed

Can carry pregnancy with c-section for delivery

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11
Q

How can fertility be spared for women getting gyn RT

A

Ovarian transposition

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12
Q

What is the target ovarian dose for maximal fertility sparing

A

8 Gy

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13
Q

How many strains of HPV does current vaccine protect against

A

9

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14
Q

What is the current recomendation for HPV vaccination

A
  • Both boys and girls
  • Age 11-14: 2 shots, 6-12 months apart
  • Age 15-26: 3 shots q1-2m
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15
Q

What aged women should get cervical cancer screening

A

21-65

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16
Q

What is screening guideline for women 21-29

A

Pap q3 years

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17
Q

What is screening rec for woman age >30

A

Pap and HPV testing q5 years

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18
Q

How to manage ASCUS

A
  • Most resolve spontaneously
  • Get HPV test
    • If + do colposcopy
    • If - get repeat Pap and HPV test in 12 months
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19
Q

What is acute toxicities of gyn RT

A

Epilation

Hyperpigmentation

Urethritis/Cystitis

Erratic bowel function

Tenesmus

Light bleeding

Pruritis

Vag discharge

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20
Q

Late toxicity of gyn RT

A

Vaginal stenosis, thinning, dryness

Fistulas

Bowel obstruction

Bladder injury

Pelvic fractures

Sterilization (2-3 Gy)

Ovarian failure (8-10 Gy)

Lymphedema after inguinal nodal surgery/RT

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21
Q

History for cervix cancer

A

Sexual history

HIV/STDs

Smoking

DES exposure

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22
Q

Exam for cervix cancer

A
  • Abdominopelvic exam
  • PE to assess inguinal nodes
  • Gyn exam
    • Speculum to assess tumor size, vaginal involvement, PM and sidewall involvement
    • Bimanual to assess rectal involvement / fixed
    • Pap smear
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23
Q

Labwork for cervix cancer

A

Pap smear

CBC

CMP

HIV

UA

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24
Q

How to obtain tissue for diagnosis

A

EUA with biopsy

Perform cystoscopy and proctoscopy if concern for inavsion

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25
Q

What imaging to obtain for cervix cancer

A
  • Stage I: CXR
  • Stage II+
    • PET or CT CAP
    • Pelvic MRI
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26
Q

How to approach woman with symptomatic bleeding with cervix cancer

A

Pack the vagina

Transfuse Hgb > 10

Embolize if possible

Palliative RT (6 Gy in 2 fx) and incorporate into definitive dose

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27
Q

What is the general goal for cervix cancer treatment

A

Avoid tri-modality therapy

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28
Q

Which patients tend to be cured with surgery alone

A

Less than FIGO IB2

Surgery preferred for younger woman

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29
Q

In FIGO 2018 staging, what tests can be included for stging

A

All clinical and imaging modalities, including MRI to assess for parametrial invasion

Can include exploratory surgery

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30
Q

What is FIGO cervical stage: I

A

confined to cervix

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31
Q

What is FIGO cervical stage: IA

A

Microscopic tumor < 5 mm

  • IA1: <3 mm DOI
  • IA2: 3-5 mm DOI
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32
Q

What is FIGO cervical stage: IB

A
  • Visible cervical tumor
  • IB1: <2cm
  • IB2: 2-4 cm
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33
Q

What is FIGO cervical stage: II

A

Beyond cervix but not lower 1/3 of vagina or to pelvic side wall

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34
Q

What is FIGO cervical stage: IIA

A
  • IIA1: <4 cm out of cervix
  • IIA2: >4 cm beyong cervix, in upper 2/3 of vagina
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35
Q

What is FIGO cervical stage: IB3

A

>4 cm (bulky, visible, confined to cervix)

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36
Q

What is FIGO cervical stage: IIB

A

Parametrial involvement

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37
Q

What is FIGO cervical stage: III

A

More advanced, lower vagina, pelvic side wall, N+

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38
Q

What is FIGO cervical stage: IIIA

A

Lower 1/3 vaginal involvement

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39
Q

What is FIGO cervical stage: IIIB

A

Pelvic side wall involvement

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40
Q

What is FIGO cervical stage: IIIC

A

N+

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41
Q

Risk of pelvic LN for IB

A

15%

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42
Q

Risk of pelvic LN for cervical stage II

A

25%

Reminder stage II is outside cervix but not to pelvic side wall or lower 1/3 of vagina

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43
Q

Risk of pelvic LN for stage III

A

50%

Reminder: stage III is lower 1/3 vagina, pelvic side wall or N+

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44
Q

Rule of thumb for risk of PA nodal involvement for cervix cancer

A

pelvic nodal risk / 2

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45
Q

Stages of cervix cancer

A

IA- microscopic, confined to cervix

IB- macroscopic, confined to cervix

II - outside of cervix but not to lower 1/3 of vagina

IIIA - lower 1/3 vagina

IIIB - pelvic sidewall

IIIC - nodes

IV - bladder, rectum etc.

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46
Q

How to obtain cervical tissue for diagnosis

A
  • Gross lesion –> punch bx and endocervix curettage
  • No lesion –> colposcopy and directed bx
  • If both above are negative –> conization
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47
Q

What is the treatment approach for stage IA cervical cancer?

A
  • Treatment approach is SURGERY alone
  • Type of surgery depends on stage IA1 or IA2
    • Reminder
      • IA1 = <3 mm DOI
      • IA2 = 3-5 mm DOI
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48
Q

Management options for IA1 cervix

A
  • In general surgery is best
    • Type I hysterectomy WITHOUT PLND
    • Other options include:
      • Conization
      • LEEP
      • Cyrosurgery
      • Radical trachelectomy
    • Brachy alone (7.5 Gy x 5)
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49
Q

If for IA1 cervix woman has simple hysterectomy and found to have risk factors, next step

A

Consider Type II and PLND

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50
Q

Management options for IA2 cervical cancer

A
  • Type II (modified radical) hysterectomy and BSO
    • Adjuvant therapy based on Sedlis/Peters criteria
    • Typically 50.4 Gy in 28 daily 1.8 Gy fractions
  • RT alone
    • 45 Gy pelvic EBRT + cervical BT (Point A dose = 80 Gy)
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51
Q

If a young woman is getting RT alone for cervix cancer, how to prevent ovarian failure?

A

Oophoropexy

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52
Q

What is 5 year OS for stage IA1 and IA2 cervix cancer

A

IA1: 95%

IA2: 85%

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53
Q

What are the criteria for women who are candidates for radical trachelectomy

A
  • Size < 2cm
  • No LN
  • No LVSI
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54
Q

Following surgery for cervical cancer, what dictates adjuvant therapy options?

A
  • Intermediate risk per Sedlis criteria –> RT alone (50.4 Gy)
    • Size > 4 cm
    • LVSI
    • Depth of cervix invasion
  • High risk per Peters criteria –> Pelvic RT to 50.4 Gy with weekly cisplatin (40 mg/m2)
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55
Q

What stages of cervical cancer can we consider for surgery or RT

A

Early stages only

IA, IB1, IB2 and select IIA1

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56
Q

What stages of cervix cancer can get less than radical hysterectomy

A

IA1 - simple hys

IA2 - modified radical

Everything else should get radical hys

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57
Q

Treatment options for stage IB1, IB2, IIA1

A
  • In general, these patients can be managed with either surgery or RT alone, with adjuvant therapies as dictated by risk factors
  • Surgery
    • Type III hysterectomy +/- PLND +/- PA dissection
    • Adjuvant therapy per risk factors
      • Adjuvant EBRT +/- vaginal brachy per Sedlis
      • Adjuvant CRT per Peters
  • Radiation alone
    • 45 Gy pelvic EBRT + Brachy (point A dose of 80 Gy)
  • Fertility sparing option (if <2 cm)
    • Radical trachelectomy + PLND
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58
Q

What should be considered for IB2 patients?

A

In trials, nearly 90% needed adjuvant RT so probably makes sense to consider definitive RT

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59
Q

What side effects are higher with surgery –> adjuvant therapy for GYN malignancies?

A

Urinary

SBO

Sexual toxicity

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60
Q

For definitive cervix RT, early stage, what is the RT doses

A

EBRT of 45 Gy

Brachy therapy to Point A dose of 80 Gy

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61
Q

What defines intermediate risk Cervical Cancer?

A
  • Sedlis criteria
  • Eligibility criteria
    • >4 cm
    • LVSI
    • Deeper than 1/3 invasion
  • Need 2 of these criteria to warrant adjuvant therapy
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62
Q

What is the adjuvant treatment for intermediate risk cervical cancer

A

EBRT to 50.4 Gy to full pelvis

Improves PFS, LR, NOT OS

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63
Q

What modality to deliver post op RT for cervix cancer

A

IMRT, decreases GI/GU tox

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64
Q

What defines high risk post-op patients after hysterectomy for cervical cancer?

A
  • Peters Criteria
    • Positive margin
    • Positive Lymph nodes
    • Parametrial extension
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65
Q

What is the adjuvant treatment for high risk cervix cancer post op

A
  • CRT
    • IMRT to 50.4 Gy in daily 1.8 Gy fractions
    • Weekly cisplatin 40 mg/m2
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66
Q

What is the advantage of adjuvant CRT for high risk cervical ca

A

OS benefit: 10%

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67
Q

Treatment options for stage IB3 and IIA2 cervix cancer

A
  • Reminder
    • IB3: >4 cm (bulky) in cervix
    • IIA2: >4 cm beyond cervix in upper 2/3 vag
  • These patients should get definitive CRT
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68
Q

Definitive CRT regimen for locally advanced cervix cancer

A
  • Weekly cisplatin 40 mg/m2
  • EBRT to 45 Gy (using 3DCRT, 4 field)
  • Cervix brachytherapy to Point A dose of 85 Gy
    • ​7 Gy x 4 (BID, spaced one week apart)
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69
Q

Schedule for interventions if getting EBRT then brachy

A
  • Finish 25 fx of EBRT
  1. Next day get HDR brachy inserted
  2. First treatment that evening
  3. Admit to hospital
  4. Next treatment following morning
  5. Removal and discharge
  • Return and repeat 1-5 one week later
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70
Q

5 year OS for IB3 or IIA2 cervix cancer

A

70%

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71
Q

Treatment of stage IIB cervical cancer

A
  • Parametrial involvement
  • CRT
    • 45 Gy to pelvis with weekly cis 40 mg/m2
    • Parametrial boost 540 cGy
    • Brachytherapy to point A dose of 85 Gy
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72
Q

Treatment of stage IIIA cervical cancer

A
  • Reminder: lower 1/3 of the vagina
  • Definitive CRT
    • EBRT to 45 Gy with weekly cisplatin
    • Parametrial boost?
    • Brachytherapy to Point A dose of 85 (consider using vaginal cylinder or implant for vaginal disease)
    • Cover inguinal nodes
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73
Q

Treatment of stage IIIB cervix

A
  • Pelvic sidewall involvement or hydronephrosis
  • Definitive CRT
  • Stent for hydronephrosis
  • Boost pelvis with 540 cGy
  • HDR brachy 7 Gy x 4
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74
Q

Treatment of stage IIIC cervical cancer

A
  • IIIC1 - pelvic nodes
  • IIIC2 - PA nodes
  • Definitive CRT
    • Consider boosting affected nodes to 225 x 25 = 5625 cGy
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75
Q

Treatment of Stage IVA cervical cancer

A

Definitive CRT

5 year OS of 10%

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76
Q

Cervix ca patients who don’t need parametrial boost

A
  • Earlier stage (IA-IIA) without parametrial involvement
  • Significant pelvic nodes getting boosted
  • Bulky parametrial disease likely to get interstitial implant
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77
Q

Where is Point A

A

2 cm superior and lateral to Os

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78
Q

Point A doses

A

80 Gy for cervix confined disease or IIA

85 Gy for anything more advanced

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79
Q

General follow-up for GYN malignancies after treatment

A
  • H&P q3-6 months x2 years, q6 months through 5 years, annual after
  • PET 3-6 months post
  • Cervix and vaginal cytology screening
  • Dilator usage
  • Risk reduction education
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80
Q

Simulation for intact cervix (endometrial or cervix)

A
  • Supine in alpha cradle (if IMRT)
  • Consider prone if doing 3DCRT
  • IV and small bowel contrast
  • Vaginal barium or marker
  • Full bladder scan
  • Fuse PET and/or MRI for disease delineation
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81
Q

3D superior border of intact pelvic field

A

Typically L5-S1

Consider L4-L5 if common iliacs are involved

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82
Q

For 3D pelvic field inferior extent

A

3 cm below tumor or bottom of obturator foramen

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83
Q

3D pelvic field, lateral extent

A

1.5-2 cm lateral to pelvic brim

Ensure good margin on obturator nodes

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84
Q

3D pelvic field, anterior extent

A

1 cm anterior to the pubic symphysis

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85
Q

3D pelvic field - posterior extent

A

Behind sacrum

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86
Q

Should femoral heads be blocked with 3D pelvic field

A

No

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87
Q

If doing a parametrial boost what is the dose

A

5.4 Gy in 3 fractions of 1.8 Gy

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88
Q

What is the total dose to parametrial or pelvic sidewall

A

60 Gy

45 Gy whole pelvis

5.4 Gy parametrial boost

20% of HDR boost

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89
Q

What is Point B

A

surrogate for pelvic sidewall

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90
Q

Describe parametrial block

A

Sup/inferior block extending from inferior edge of the field to roughly isocenter blocking the cervix/uterus (about 9-12 cm)

Block should be ~4 cm wide at midline

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91
Q

If treating common iliac nodes, how high should you treat

A

L1/L2

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92
Q

If treating PA nodes, how high should you treat

A

Renal vessels or ~T12

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93
Q

Why should IMRT be chosen for intact cervical fields

A
  • Covering PA or inguinal nodes
  • SIB for nodes or sidewall
  • Decreases GI/GU and bone marrow tox
  • Decreases pelvic fractures
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94
Q

How to contour intact cervical volumes for IMRT

A
  • Create CTV1 = GTV, cervix, uterus
    • PTV1 - 2 cm expansion with daily IGRT
  • Create CTV2 = parametria and vaginal CTV
    • PTV2 - 1 cm expansion
  • Create CTV3 = nodes which are vessels + 7mm (exlcude bowel, bone, muscle)
    • Cover obturator, Int Iliac, Ext. Iliac, Common Iliac, Pre-Sacral to S3
    • If involved - common iliac to L1
    • If involved - PA nodes to T12
    • PTV3 - 7 mm expansion
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95
Q

Determining vaginal coverage for CTV2 (intact cervix) IMRT

A
  • No vaginal involvement = cover upper half
  • Upper vaginal involvement = cover upper 2/3
  • Extensive vaginal involvement = cover full vagina
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96
Q

When should parametrial boost be given

A

Can do it SIB or sequential after the 45 Gy between the two brachy insertions

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97
Q

Contouring postop cervix IMRT

A
  • Create CTVp
    • Vaginal ITV (full and empty bladder)
    • Parametria
    • At least 3 cm of vagina
  • Create CTVn
    • 7 mm expansion of vessels off bone/bowel/muscle
    • Include obturator, internal iliac, external iliac, common iliac
    • Inguinals if lower vagina involved
  • GTV nodes (not resected)
  • PTV margins
    • 7 mm for CTVp and CTVn
    • 3 mm for nodes
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98
Q

Combined Point A dose if adjuvant

A

75 Gy

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99
Q

When contouring gyn cases, OARs should be contoured on which scan

A

full bladder

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100
Q

When is the optimal time from surgery to perform vaginal cuff brachy

A

When it is healed

Pref 4-6 weeks

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101
Q

How should a vaginal cylinder be selected?

A

Largest diameter to minimize mucosal surface dose

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102
Q

Typical vaginal brachy dose

A

For cylinders >3 cm: 700 cGy x3 prescribed to 0.5 cm depth

For cylinders <3 cm: 600 cGy x 3

like 500 x 5

103
Q

What is total length of typical vagina

104
Q

How much of vagina to treat for vaginal brachy

A

upper 4-7 cm determined by risk profile of the cancer

105
Q

How to check vaginal brachy films

A
  • Cylinder should be perpendicular to the pelvis (AP or PA film)
  • On lat film, <5 degrees
  • Consistent with prior images
106
Q

If vaginal brachy prescribed to 0.5 cm from vaginal surface, what is the dose at the surface

107
Q

What patient is best suited for tandem and ovoid

A

Deep fornices

108
Q

What patient is best suited for tandem and ring

A
  • shallow fornices
  • effaced cervix
109
Q

What patient is best suited for tandem and cylinder

A

narrow vagina or vaginal disesae

110
Q

Best candidate for tandem and needles

A
  • Asymmetric tumor
  • Lateral tumor
  • Thick upper vaginal dz
  • Bulky disease >5 cm
111
Q

Describe how to perform a Tandem and ovoid procedure

A
  • Bring patient to OR and induce general anesthesia
  • Place patient in dorsal lithotomy position
  • Perform EUA and rectal exam to note extent of disease - parametrial extension
  • Prep and drape
  • Insert foley and place 7cc of 30% constrast in the balloon
  • Place gold marker into OS
  • Grab cervix with tenaculum and dilate using serially larger dilators
  • Place smit sleeve into dilated os and suture into place
  • Place tandem through sleeve into the uterus with the flange flush against the os. Tandem should reflect angle of uterus
  • Dissasemble speculum
  • Place ring over the tandem or ovoids into the fornices to maximum depth and affix to tadem
  • Place packing rubbed in aerated lubricating gel to displace bladder and rectum and to stabilize the implant
  • MRI simulation
  • Evaluate implant placement
  • Contour –> intraop planning
  • Hook up catheters –> deliver treatment
112
Q

How to approach if the tandem perforates the uterus

A
  • Readjust back into the uterus
  • Give prophylactic antibiotics
  • Resim and treat
113
Q

Current planning approach for tandem and ovoid

A

Volume based

114
Q

Strategies if constraints cannot be met

A
  • Adjust packing
  • Fill bladder more to push away bowel
  • Re-implant
  • Add free hand needles
115
Q

How much constrast goes into Foley balloon for cervical brachy

A

7 cc of 30% constrast

116
Q

What are the GTVs for cervical brachy

A

GTVD = macroscopic tumor seen at diagnosis

GTVB1, B2 = tumor seen clinically or on MRI at brachy insertion 1, 2

117
Q

How to define brachy high risk CTV

A

Includes GTVB1 + whole cervix + presumed extra cervical extension

This is the volume receiving total Rx dose

118
Q

Goal dose to HR CTV for cervical brachy

A

D90: 90-95 Gy (combined EBRT and brachy)

D98 > 75 Gy

119
Q

What is the intermediate risk CTV for cervical brachy

A
  • GTVD (initial disease)
  • High risk CTV + margin
    • 5 mm AP
    • 10 mm Sup/Inf/Lateral
120
Q

What is the goal dose for the IR CTV

121
Q

Specific process for interstitial implant

A
  • After Smit Sleeve, place obturator over tandem and advace to full length of vaginal canal
  • Template placed over obturator and sutured to perineum
  • Catheters inserted with transrectal US image guidance for maximal coverage
  • MRI simulation
122
Q

Intact cervix and BT total dose constraint to bladder

A

D2cc < 90 Gy

123
Q

Intact cervix and BT total dose constraint to rectum

A

D2cc < 70 Gy

124
Q

Intact cervix and BT total dose constraint to Sigmoid

A

D2cc < 70 Gy

125
Q

What is the V45 for bladder, rectum, sigmoid for cervix + BT?

A

All are 50%

126
Q

What dose causes ovarian sterilization

127
Q

What dose causes ovarian failure

128
Q

If you get a complex interstitial case how to reply

A

Refer to high volume brachytherapy center

129
Q

What is a typical dose for interstitial implant

130
Q

History for endometrial cancer

A
  • Post menopausal bleeding - history, severity
  • Abdominal, rectal exam
  • Gyn exam
    • Speculum
    • Bimanual
    • Rectovaginal
    • Pap smear
131
Q

Labwork for endometrial cancer

A
  • CBC
  • CMP
  • CA-19-9
  • Pap smear
  • B-hCG if pre-menopausal
132
Q

Imaging workup for endometrial cancer

A
  • TVUS
  • CXR/CT chest for high grade, serous, CC
  • IF ADVANCED DISEASE SUSPECTED
    • MRI/CT
    • Cystoscopy/Sigmoidoscopy
133
Q

Normal TVUS result

A
  • Pre-menopausal varies with cycle
  • Post-menopausal
    • <5 mm if no PMB
    • Up to 11 mm for no PMB
134
Q

Approach to get tissue diagnosis for endometrial

A
  • Start with in office EMB
  • If non-diagnostic –> D&C
135
Q

Type I histology endometrial

A
  • Majority of cases
    • Estrogen driven
    • Well diff
    • Superficial
    • Endometrioid histology
    • PTEN mutation
136
Q

Type II endometrial cancer

A

Older age

Poor differentiation

Deeper disease

Non-endometrioid histology

High stage

p53 and HER2+

137
Q

Which endometrial patients should get a SLNBx

A

Everyone except very early stage disease

Tumor < 2cm

G1-2

<50% MMI

138
Q

For endometrial ca, if pelvic LN + what is the risk of PA LN

139
Q

For endometrial if pelvis is negative, risk of PA nodes

140
Q

What anatomic location has greater risk of PA LN

141
Q

For early stage endometrial what is the risk of pelvic nodes for G3, deep MMI?

142
Q

FIGO stage I for endometrial is…

A

Confined to uterus

143
Q

FIGO stage II endometrial is…

A

involving cervix or corpus

144
Q

What is FIGO stage IA?

145
Q

Treatment options for FIGO IA endometrial

A
  • TAH/BSO
  • SLNBx
  • Adjuvant therapy
    • G1: observation
    • G2: VCBT
    • G3: VCBT
    • LVSI: VCBT
146
Q

What if stage IA patient endometrial is non operative candidate

A

Intracavitary HDR with vaginal cylinder

Dose of 7 Gy x 5 to uterus and upper 2/3 of vagina

147
Q

If higher stage (IB+) endometrial patient is non operative candidate, what is the treatment plan

A
  • EBRT to 45 Gy (pelvis)
  • Brachytherapy (6.3 Gy x 3)
148
Q

In general, what is the treatment strategy for local endometrial cancer

A

TAH/BSO followed by adjuvant RT (either vaginal brachy or EBRT pelvis)

149
Q

What is the surgical recommendation for endometrial cancer

A
  • In general:
    • Type I extrafascial TAH/BSO with Pelvic SLNBx
    • Visual inspection of the peritoneal, diaphragmatic and serosal surfaces
    • Peritoneal washings
    • Consider Type III rad hys if cervix involvement
150
Q

What to look at on path report for endometrial

A
  • Histology
  • Grade
  • MMI depth
  • LVSI
  • Cervix involvement
  • Margins
  • Peritoneal cytology
  • # LN involved/dissected
151
Q

What are the treatment options for recurrent endometrial cancer

A
  • If no prior RT: EBRT 45 Gy plus VBCT (6x3 cylinder) or 5x5 interstitial implant if tumor >5 mm thick
  • If prior EBRT or VBCT - consider surgery, maybe EBRT
152
Q

Of the endometrial histologies, which is most aggressive

A

serous - 5 year OS of 45%

153
Q

What is outcome for FIGO IA endometrial

A

Excellent LRC and OS 95%

154
Q

What is FIGO IB endometrial?

155
Q

Treatment of FIGO IB endometrial

A
  • TAH/BSO
  • Pelvic SLNBx
  • Adjuvant treatment
    • G1: Obs vs. VBCT
    • G2: VBCT
    • G3: Depends - WPRT
156
Q

What is the workup for recurrent endometrial cancer

A

H&P

Prior RT records

Bx

CTCAP or PET

157
Q

What are the high risk features for endometrial cancer

A

Age > 60

LVSI

Lower uterine segment involvement

Depth of invasion

Size >2cm

158
Q

How do higher risk features change stage I management

A

If multiple risk factors, and planning for VBT, consider WPRT

159
Q

What is FIGO stage II endometrial

A

Cervical stroma involvement

160
Q

Treatment of stage II endometrial cancer

A
  • TAH/BSO + SLNBx
  • Pelvic RT to 45 Gy
  • VCBT to 5 Gy x 3 prescribed to 5 mm depth

**If full type III hysterectomy was performed, consider just VCBT

161
Q

What is stage IIIA endometrial

A

Involves serosa or adnexa

162
Q

What is stage IIIB endometrial

A

Vaginal involvement or parametrial involvement

163
Q

What is stage IIIC endometrial

A

Positive nodes

164
Q

What is stage IIIC1 endometrial

A

Pelvic nodes

165
Q

What is stage IIIC2 endometrial

166
Q

What is stage IVA endometrial

A

Bladder or bowel

167
Q

What is stage IVB endometrial

A

Distant mets including inguinals or peritoneum

168
Q

Treatment of stage III or IV endometrial

A

Concurrent chemoRT

  • WPRT + weekly cisplatin 40 mg/m2
  • Adjuvant carbo-taxol x4
169
Q

Dose of carbo taxol for endometrial cancer

A

Carbo AUC 5

Taxol 175 mg/m2

170
Q

How to approach serous or clear cell endometrial histology

A

Doesn’t matter the stafe, approach with CRT

  • RT dependent on the specific situation
  • Chemo is weekly cis 40 mg/m2 and adjuvant carbo-taxol
171
Q

WPRT fields for endometrial - superior

A

Superior: L4/L5 or L5/S1 at common iliac bifurcation

172
Q

WPRT fields for endometrial - inferior

A

below obturator foramen including lower 1/2 to 2/3 vagina

173
Q

WPRT fields for endometrial - anterior

A

1 cm anterior pubic symphysis

174
Q

WPRT fields for endometrial - posterior

A

Typically can split sacrum but if cervix is involved –> posterior to entire sacrum since the presacrals are at risk

175
Q

Script for vaginal brachy

A
  • Use the largest vaginal cylinder possible (2.5-3.5 cm) to decrease the relative vaginal surface dose to the dose at Rx depth due to inverse square law
  • Target the upper 2/3 of vagina (approx 4 cm) unless stage IIIB, LVSI, poor histology or poorly diff in which case I would consider treating full vagina
176
Q

Dose of vaginal brachytherapy (mono)

A

If monotherapy: 7 Gy x 3 to 5 mm depth OR 6 Gy x 5 to surface

177
Q

Dose of vaginal brachytherapy (combo)

A

6 Gy x 2 to vaginal surface

178
Q

If cervix cancer pt is actively bleeding –> next step

A

Pack and control bleeding

Ideally Hgb > 11 for better outcomes

Consider QS if difficult to control

179
Q

ASCUS next step

A

Repeat Pap in 6 mos –> abnormal –> colposcopy

180
Q

LGSIL recommendations

A

Repeat Pap in 6 months –> if abnormal –> colposcopy

181
Q

Recommendation for HGSIL

A

All get colposcopy and biopsy

182
Q

Biopsy options for cervix pre-invasive disease

A

Conization

Loop electrosurgical excisional procedure (LEEP)

Laser or cryo ablation

Type I hysterectomy

183
Q

Cervix 1A1 treatment

A

microscopic <3mm deep

  • If no LVSI –> type I hysterectomy
  • If +LVSI –> type II + PLND
  • If fertility preservation and no LVSI –> cone bx with close FU
  • If fertility preservation and +LVSI –> radical trachelectomy + PLND
184
Q

Cervix IA2 treatment

A

3-5 mm depth

  • Modified radical hysterectomy (Type II) + PLND +/- PA sampling OR
  • Pelvic RT (45 Gy) + Brachy (point A dose 80 Gy)
185
Q

Cervix IB1 treatment

A

<4 cm macroscopic

  • Radical hysterectomy (Type III) + PLND + PA sampling
  • Adjuvant RT/CRT per Sedlis and Peters criteria

OR

  • Pelvic RT (45 Gy) + HDR brachy (point A dose 85 Gy) +/- weekly cisplatin 40 mg/m2
186
Q

Cervix IIA1 treatment

A

Upper 2/3 vagina, <4 cm

  • Radical hysterectomy (Type III) + PLND + PA sampling
  • Adjuvant RT/CRT per Sedlis and Peters criteria

OR

  • Pelvic RT (45 Gy) + HDR brachy (point A dose 85 Gy) + weekly cisplatin 40 mg/m2
187
Q

Cervix IB2 treatment

A

Macroscopic >4 cm

  • Definitive CRT
  • 45 Gy in 25 daily 1.8 Gy fractions
  • Dose paint nodes to 2.25 x 25 = 56.25
  • Weekly concurrent cisplatin 40 mg/m2
  • HDR brachy 7 Gy x 4 (total dose of 85 Gy)
188
Q

Cervix IIA2 treatment

A

Upper 2/3 vaginal extension - > 4cm

  • Definitive CRT
  • 45 Gy in 25 daily 1.8 Gy fractions
  • Dose paint nodes to 2.25 x 25 = 56.25
  • Weekly concurrent cisplatin 40 mg/m2
  • HDR brachy 7 Gy x 4 (total dose of 85 Gy)
189
Q

Cervix IIB treatment

A

Parametria extension

  • Definitive CRT
  • 45 Gy to pelvis with concurrent weekly cisplatin 40 mg/m2
  • Parametrial boost to 1.8 x 3 = 5.4 Gy
190
Q

Describe parametrial boost

A

Same inferior and lateral borders of field

Drop sup border to bottom of SI joint to get off bowel

Add 4-5 cm midline block over uterus/cervix

191
Q

Treatment of stage IIIA cervix cancer

A

Lower 1/3 of vagina

  • Definitive CRT
  • EBRT to 50.4 Gy including whole pelvis, whole vagina, inguinals
  • Concurrent cis 40 mg/m2
  • Boost nodes
  • HDR to 85 gy
192
Q

Treatment of stage IIIB cervical cancer

A

Pelvic side wall or hydronephrosis

  • Place stent
  • Definitive CRT with pelvic RT 45 Gy
  • Parametrial boost to 50.4 Gy
  • Weekly cisplatin 40 mg/m2
  • HDR to Point dose 85 Gy
193
Q

Goal to finish all cervical RT

194
Q

Endometrial IA G1

A

Observe

Assuming no high risk features (LVI, >60 age)

195
Q

Endometrial IA G2

A

Observe

OR

Vaginal brachy 7 Gy x 3 5 mm from vaginal surface

196
Q

Endometrial IA G3

A

VCBT (7 Gy x 3)

197
Q

Endometrial IB G1

198
Q

Endometrial IB G2

199
Q

Endometrial IB G3

A

WPRT to 50.4 Gy

200
Q

Endometrial stage II treatment

A

Surgery –> WPRT (50.4 Gy)

If medically inoperable 45 Gy WPRT followed by HDR 6x3 to uterine serosa, cervix and upper 2-3 cm of vagina

201
Q

Stage III endometrial treatment

A

Vaginal, serosal, nodes

  • WPRT to 50.4 Gy with concurrent cis weekly 40 mg/m2
    • If low vagina, consider inguinals
    • Boost nodes
  • Adjuvant carbo-taxol x 4 cycles
    • AUC 5
    • Taxol 175 mg/m2
202
Q

Stage IVA endometrial treatment

A

Bowel or bladder

  • Definitive CRT
  • 50.4 Gy EBRT
  • Boost nodes
  • Weekly cisplatin 40 mg/m2
  • hDR to Point dose 85 Gy
203
Q

How to approach serous or clear cell histology

A

Treat like stage III, integrate adjuvant chemo

204
Q

History questions to ask about vulvar cancer

A
  • Pain
  • Pruritis
  • Smoking history
  • Hx of Pagets disease or Bowen’s disease
  • Prior vulvar surgery
  • Prior leichen planus
205
Q

Exam for vulvar cancer

A

Targeted physician exam

Gyn exam, speculum

Cervix, Vagina Pap Smear

206
Q

Approach to obtaining tissue for vulvar cancer

A
  • Perform EUA and colposcopy and biopsy
  • If a small lesion (<2 cm) ok to do excisional bx with 1 cm margin
  • If larger lesion (>2 cm) do punch or incisional bx for depth of invasion
  • Bx any suspicious nodes (FNA ok)
207
Q

Imaging for vuvlar cancer

A

CXR

Pelvic MRI

PET/CT better for evaluation of nodal involvement

208
Q

Stage IA vulvar

A

<2cm and <1 mm stromal invasion

209
Q

Stage IB vulvar cancer

A

>2 cm or > 1mm stromal invasion

210
Q

How is staging done for vulvar cancer

211
Q

What clinical feature of vulvar cancer predicts LN risk

212
Q

What is treatment for IA vulvar cancer

A

WLE (if well lateralized) vs. radical vulvectomy

No need to address nodes

213
Q

What is the LN risk for IB vulvar cancer

214
Q

What is the management of stage IB vulvar cancer

A
  • If lesion is >2cm from midline
    • Radical LE or modified Radical vulvectomy with SLNBx of ipsilateral inguinal LND
  • If lesion is <2 cm from midline
    • Radical WLE vs. Radical vulvectomy, bilateral SLNBx or bilateral inguinal LND
  • Risk stratified RT
215
Q

Stage II vulvar

A

Spread to lower 1/3 of urethra, vagina, anus

216
Q

Treatment of stage II vulvar cancer

A

If possible: Radical vulvectomy + unlateral or bilateral inguinal LND

+/- postop RT

If non-operative: definitive CRT

217
Q

Stage III vulvar cancer

A

+inguinofemoral nodes

218
Q

Options for stage III vulvar cancer

A
  • If resectable: radical vulvectomy + unilateral/bilateral inguinal LND + post op RT
  • If unresectable
    • Neoadjuvant CRT with cis/5FU –> surgery
  • Definitive CRT
219
Q

What is the approach to neoadjuvant treatment for initially unresectable vulvar cancer

A
  • Chemo
    • Cis 50 mg/m2 on Day 1 & 29
    • 5-FU 1000mg/m2 on Days 1-4 (week 1/5)
  • RT
    • 180 x 28 to 50.4 then re-eval
    • If CR –> surgery or Obs
    • If PR, give boost of 10-15 Gy
220
Q

What is the approach for definitive chemoradiation for vulvar cancer

A

RT: 66-70 Gy

2 cycles of cis/5-FU

  • cis 50 mg/m2 Day 1,29
  • 5-FU 1000 mg/m2 Day 1-4 (wk 1,5)
221
Q

Stage IVA vulvar cancer

A

Spread to upper urethra, bladder, rectal mucosa or pelvic bone

Fixed or ulcerated LN

222
Q

Treatment for IVA vulvar cancer

A

Definitive CRT

223
Q

For vulvar cancer, pelvic nodes are considered

A

M1!

Always bx to confirm

224
Q

What is considered well lateralized for vulvar cancer

A

2 cm from midline

225
Q

Who is eligible for SLNBx for vulvar cancer

A

Tumor < 4 cm

cN0

No prior vulvar surgery

226
Q

If SLNBx is negative for vulva –> next step

A

Observation (only <5% chance of recurrence)

227
Q

If SLNBx is positive for vulva –> next step

A
  • If <2mm node: EBRT +/- chemo
  • If >2mm node: LND preferred
228
Q

Indications for post op RT for vulvar cancer (primary)

A
  • Primary
    • Margin < 8mm
    • LVSI
    • DOI > 5-10 mm
    • Size >4 cm
    • Diffuse pattern
229
Q

Indications for postop RT for vulvar cancer (nodes)

A

> 1 LN+ (always treat bilateral)

ENE

Clinically LN+

230
Q

If the patient meets criteria for adjuvant nodal RT for vulvar cancer, should vulva be treated?

231
Q

Which vulvar patients should get postop CRT

A

+margin

+ECE

maybe for >1 +

232
Q

What chemo should be given postop with RT for vulvar cancer

A

weekly cis 40 mg/m2

233
Q

How to sim a patient for vulvar cancer

A
  • Supine
  • Frog leg
  • Wire anus, nodes, tumor, scars
  • Vaginal contrast or marker
  • Full bladder and oral contrast
  • IV contrast
  • Fusion with PET or MRI
234
Q

CTV for vulvar cancer

A

Gross disease plus full vulva (at least 1 cm on GTV)

Add structures involved (vagina, anus etc.)

Nodal volume includes inguinals

235
Q

Definitive vulvar cancer RT doses

A
  • Vulva CTV - 50.4 Gy
  • Primary 64 Gy
  • Elective nodes: 45 Gy
  • Gross nodes
    • Most 64 Gy
    • Massive or fixed 70 Gy
236
Q

Adjuvant vulvar RT doses

A
  • 50.4 to operative bed, surgical scar, vulva
  • Tumor bed to 54-60 Gy
  • Nodes with elective or microscopic 45 Gy
  • ECE 66 Gy
  • Gross residual 70 Gy
237
Q

Outcome for stage I vulva

A

90% 5 year OS

238
Q

Outcomes for stage II vulva

239
Q

Outcomes for stage III vulva

240
Q

Outcomes for stage IV vulva

A

20% 5 year OS

241
Q

For cervical brachy, where is the dose prescribed to?

242
Q

What is the HR-CTV?

A

GTV residual at time of brachy insertion

Whole cervix

Presumed extra-cervical extension

243
Q

What is goal coverage for HR CTV

A

D90 = 90-95

244
Q

For HDR brachy cervix, what is target Rectum D2cc

A

Goal is 65 Gy

Limit is 75

245
Q

For hDR brachy cervix what is the target D2cc for bladder

A

Target - 80

Hard limit is 90

246
Q

Ways to combat proctitis

A

anusol suppository

carafate enemas

proctifoam

247
Q

ITV–> PTV for postop pelvis

A
  • Scan first with full bladder
  • Then with empty bladder
  • FULL BLADDER SCAN is planning scan
  • Contour
    • Vaginal cuff on both full and empty bladder
    • Upper 3 cm of parametrial tissue
  • Add 7 mm margin around ITV
248
Q

For vaginal cuff recurrences, what is best treatment strategu

A

Pelvic RT followed by brachy

249
Q

What brachy should be used after EBRT for pelvic recurrence

A

If <5 mm residual –> vaginal cuff brachy

If >5 mm residual –> interstitial

250
Q

What is the dose of brachy for vaginal cuff recurrence

251
Q

What are the indications for postop RT for vulvar cancer

A
  • Primary
    • Margins < 1 cm for fresh or 8mm fixed tissue
    • LVSI
    • DOI > 5-10 mm
    • Size > 4 cm
    • Diffuse involvement
  • Nodal findings
    • >1 LN
    • ENE
    • Clinically LN+
252
Q

When is postop chemo added for vulva?

A

+margin

+ECE

Consider for >1 LN

253
Q

What is SLNBx size cutoff to do RT alone

A

2mm

If greater, needs lymph node dissection

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