GYN Flashcards
What is the MOST common site of insufficiency fracture after EBRT?
A. Lumbar vertebrae
B. Sacrum
C. Pubis
D. Acetabulum
B. Sacrum
Bony fractures appear to be more common after external beam irradiation, compared to the general population. These findings, knowns as “insufficiency fractures”, can be asymptomatic. In a recent study, the most common fracture sites were sacroiliac joint (39.7%), body of the sacrum (33.9%), pubis (13%), lumbar vertebra (7%), iliac bone (2.8%), acetabulum (2.1%), and femoral head/neck (1.5%). The median time to fracture was 7.1 to 19 months after radiation therapy.
In the subset analysis of PORTEC-3 trial, patients with which histology MOST benefited from the addition of chemotherapy to RT?
A. Endometrioid
B. Carcinosarcoma
C. Clear cell
D. Serous
D. Serous
Chemotherapy is the mainstay of adjuvant treatment for advanced serous carcinomas. PORTEC-3 was a phase III study of radiotherapy alone vs. chemoradiation for advanced, resected endometrial cancers. When comparing serous cancers with all other histologies in a post-hoc exploratory subgroup analysis, women with serous cancers had significantly lower overall survival and failure-free survival than did those with other histologies, irrespective of treatment received. After adjusting for stratification factors, significant improvements in overall survival and failure-free survival were observed for serous cancers treated with chemoradiotherapy versus radiotherapy alone: 5-year overall survival was 71·4% (95% CI 60·1–84·7) with chemoradiotherapy versus 52·8% (40·6–68·6) with radiotherapy alone (HR 0·48 [95% CI 0·24–0·96]; p=0·037), and 5-year failure-free survival was 59·7% (95% CI 45·1–71·6) with chemotherapy versus 47·9% (33·9–60·6) with radiotherapy alone (HR 0·42 [95% CI 0·22–0·80]; p=0·008).
If postoperative concurrent chemoradiation is given for endometrial cancer, what is the MOST common dose of cisplatin?
A. 20 mg/m2
B. 30 mg/m2
C. 40 mg/m2
D. 50 mg/m2
D. 50 mg/m2
The role of concurrent chemoradiation after hysterectomy for stage III-IV endometrial cancer remains under investigation. In the PORTEC-3 study, in the chemoradiotherapy group, women received two cycles of cisplatin 50 mg/m2 administered intravenously in the first and fourth week of external-beam radiotherapy, followed by four cycles of carboplatin AUC5 and paclitaxel 175 mg/m2 administered intravenously at 21-day intervals. This schedule has initially been evaluated in phase II RTOG studies.
Following lymphadenectomy for endometrial cancer, a focus of tumor cells measuring 0.3 mm is detected by immunohistochemistry in a paraaortic node. What is the AJCC stage?
A. N0(i+)
B. N1mi
C. N1a
D. N2mi
D. N2mi
N2mi - Regional lymph node metastasis (greater than 0.2 mm but not greater than 2.0 mm in diameter) to para-aortic lymph nodes, with or without positive pelvic lymph nodes. This was updated in the latest, 8th edition of AJCC staging manual. FIGO staging rules for endometrial cancer have not yet been revised to match AJCC.
As demonstrated in the PORTEC-1 study, what is the absolute improvement in local control at 5 years with the addition of RT to stage I intermediate risk endometrial cancer patients?
A. 0%
B. 10%
C. 20%
D. 30%
B. 10%
The 5-year actuarial locoregional recurrence rates were 4% in the radiotherapy group and 14% in the control group (p<0.001). There was no difference in OS.
What was the approximate rate of vaginal stenosis in the EMBRACE study after cervical cancer chemoRT resulting in rectovaginal reference point dose of 85 Gy?
A. 10%
B. 15%
C. 25%
D. 35%
D. 35%
A large study of 630 cervical cancers, treated with modern definitive brachytherapy (“the EMBRACE”) found that the ICRU rectovaginal point dose significantly correlated with vaginal stenosis. With a median follow up of 24 months, the probability to develop symptomatic vaginal stenosis was 16% with a rectovaginal point of 55 Gy and 34% with 85 Gy. Other methods to evaluate vaginal dose constraints in cervical brachytherapy are under study.
In cervical cancer, what is associated with open abdominal hysterectomies compared to minimally invasive approaches?
A. Lower rates of DFS and OS
B. Lower rates of DFS, but no OS difference
C. Higher rates of DFS, but no OS difference
D. Higher rates of DFS and OS
D. Higher rates of DFS and OS
The LACC randomized trial demonstrated that minimally invasive radical hysterectomy (laparoscopic or robot-assisted) was associated with lower disease-free survival and overall survival when compared to open radical hysterectomy in early stage cervical cancer patients.
According to the original GEC ESTRO working group recommendations from 2006 for cervical cancer brachytherapy, what parameter MUST be reported for the high-risk CTV?
A. V90
B. D90
C. V95
D. D95
B. D90
The GEC ESTRO working group guidelines recommended reporting the D90 for HR-CTV and IR-CTV as well as the D100 for GTV.
For cervical brachytherapy, what is the risk of fistulae development when the total rectal D2cc EQD2 of ≥75 Gy?
A. <1%
B. 2-5%
C. 6-10%
D. >10%
D. >10%
A large DVH analysis has shown that rectal D2cc doses ≤ 75 Gy was associated with a 2.7% rate of fistula development vs 12.5% when D2cc is >75 Gy.
What muscle muscle originates from the sacrum and inserts on the greater trochanter.
A. Iliacus
B. Internal obturator
C. Psoas
D. Piriformis
D. Piriformis
What genetic syndrome predisposes to a higher risk of endometrial cancer?
A. Hereditary nonpolyposis colorectal cancer
B. Ataxia-telangectasia
C. Fanconi’s Anemia
D. Li-Fraumeni
A. Hereditary nonpolyposis colorectal cancer
Lynch Syndrome (hereditary nonpolyposis colorectal cancer) results from mismatch repair deficiency (MLH1, MSH2, MSH6, PMS2) and has an increased risk of colon, gastric, small bowel, urothelial and endometrial cancers. Other syndromes with increased risk include Cowden syndrome, PTEN mutation, and Peutz-Jeghers, STK11.
What is a benefit of IMRT over 3D-CRT after hysterectomy for gynecologic cancers?
A. OS
B. Local control
C. Less acute GI side effects
D. Improved patient throughput
C. Less acute GI side effects
In RTOG 1203, patients with cervical and endometrial cancer who received pelvic radiation postoperatively were stratified by dose (45 or 50.4 Gy), use of chemotherapy (none or 5 cycles of weekly cisplatin at 40 mg/m2), and disease site, and then randomly assigned to standard 4-field radiation or IMRT. The primary endpoint was a change in acute gastrointestinal (GI) toxicity from baseline to 5 weeks measured by the bowel domain of Expanded Prostate Cancer Index Composite (EPIC). 20.4% of women on the standard RT arm took 4 or more antidiarrheal medications daily, as compared to 7.8% of women on the IMRT arm (P =0.04). At the 3-year update (abstract form), improvements in late GU toxicity are demonstrated while sustained difference GI toxicity is not apparent.
What is the preferred postoperative treatment for IBG2 endometrioid adenocarcinoma of the endometrium with positive LVI?
A. Pelvic EBRT
B. Concurrent chemoRT
C. Chemotherapy alone
D. Re-resection of residual vaginal tissue
A. Pelvic EBRT
GOG 249 enrolled 610 patients randomly assigned to the typical pelvic irradiation vs. the combination of chemotherapy and vaginal brachytherapy. Most patients had the G1-2 endometrioid histology with additional risk features. Standard EBRT resulted in lower nodal relapse rate, better acute toxicities, and lower patient-reported fatigue levels while maintaining the same OS and RFS as the experimental treatment.
Which brachytherapy apparatus is the LEAST suitable in newly diagnosed, medically inoperable endometrial cancer?
A. Tandem and ring
B. Multichannel vaginal cylinder
C. Heyman packing
D. Tandem and ovoids
B. Multichannel vaginal cylinder
Curative-intent brachytherapy is the treatment of choice for uterine neoplasms that cannot be safely removed via hysterectomy. An appropriate apparatus must allow introduction of the radioactive sources into the endometrial cavity. Among implant types listed, only vaginal cylinders do not meet this goal.
What is an expected adverse reaction to cervical brachytherapy?
A. Bacteremia
B. Insufficiency fracture
C. Lymphedema
D. Hyperpigmentation
A. Bacteremia
Brachytherapy for intact cervical cancer is an example of an invasive medical procedure. As such, it is associated with a risk of infection including sepsis. Other syndromes listed may result from pelvic EBRT but are unlikely to be caused by brachytherapy.
