GYN Flashcards
Cervical Screening
Age <21: no screening regardless of 1st coitus age
- Age 21-29: cytology q.3 yrs w/o HPV co-test
- Age 30-65: co-test q.5 yrs (cytology+HPV) or cytology q.3yrs.
- Age 65+: No further testing if 3 prior negative cytologies or 2 negative prior co-tests
Cervical HPV
16, 18
95% related
Cervical LN Risk
IB: 15% P 10% PA
II: 30% P 20% PA
III: 45% P 30% PA
Cervical H/P script
I would start with a complete history and physical focusing on the presenting symptoms as well as the GYN history including any **prior abnormal Pap smears**, abnormal vaginal bleeding or discharge, and pelvic pain. I would also ask about Sexual, Social and Family History.
I would then perform a full physical exam including LN palpation for inguinal and **supraclavicular nodes**. I would perform an abdominla exam followed by pelvic exam consisting of speculum, bimanual, and rectovaginal exam (to evaluate the **cervical os, cervical mass, vaginal vault size, vaginal extension, parametrium, pelvic side wall extension, adexa, and uterus**) and PAP Smear.
Cervical Workup
Labs: CBC with diff, CMP, LFTs, HIV, pregnancy test
Imaging (IB2+)
- PET/CT or CT
- MRI – smudgy border = parametrial invasion
- cystoscopy and sigmoidoscopy if suspicion for bladder/bowel
Biopsy:
- EUA with gyn onc
- Colposcopy w biopsy. If no gross lesion noted, conization.
**If stage > IIIB: RENAL STENT prior to definitive chemoRT (creat > 3 → no cis!)
Fertility Evaluation (egg harvesting) and oophoropexy
Cervical Staging
IA1: <3mm depth
IA2: 3-5mm
IB1 – macro < 2 cm (and >5 mm depth)
IB2 – macro 2-4 cm
IB3 – macro > 4cm (bulky!)
IIA1: upper 2/3 vagina < 4cm: (small size therefore group with IB1 for tx)
IIA2: upper 2/3 vagina > 4cm
IIB - parametria
IIIA – lower 1/3 vagina
IIIB – pelvic SW, hydro, kidney dysfunction
IIIC1 – pelvic nodes
IIIC2 – PA nodes
IVA/T4: bladder, rectum, or beyond true pelvis
IVB/M1: distant organs
TAH
uterus, cervix, and small rim of vagina cuff
Mod radical hyst
uterus/cervix/1-2 cm of vagina, some of parametrium
Radical hysterectomy
uterus/cervix/upper 1/3-1/2 of vagina, dissection of parametrium to sidewall, PA/pelvic LND
Rad trachelectomy –
removes cervix, parametria + LN sampling
- Preserves fertility.
- Only for tumor < 2 cm, no LVI (not meeting Sedlis!)
Cervix 1A1 no LVI treatment
(only group not needing nodal management)
1) Cold knife cone, if negative margins, then simple hysterectomy (if fertility not desired)
2) Fertility sparing: CKC (want margins ≥3mm, no LVI) if positive margins repeat cone or trachelectomy
3) Inoperable: definitive brachy (7.5 x5)
Cervix IA2
1) Mod rad hyst + pelvic LND/SNB > risk stratified RT/CRT (Sedlis/Peters)
2) Fertility sparing: Rad trach + PLND/SNB, or CKC with neg margins and PLND/SNB
3) Definitive RT (pelvic RT+brachy, 75Gy)
Cervix IB1-2 and IIA1
1) Rad hyst + PLND + PA sampling > risk stratified RT/CRT (Sedlis/Peters)
2) Last fertility sparing option for IB1, up to 2cm, no LVI, path node neg: rad trachelectomy+ PLND/SND
3) Definitive RT (80+Gy)
Cervix IB3, IIA2+
Cervix IB3, IIA2+ ie >4 cm or advanced
CRT ->brachy boost
Cervix Post op Whole Pelvis RT indications
Sedlis 2 of 3 factors:
LVSI
> 4cm
>1/3 stromal invasion
Cervix Post op Chemo RT
(Peters)
Positive margins (<3 mm)
Positive nodes
Parametrial inv (surprise FIGO IIB)
Cervix interstitial indications
- tumor >4cm after EBRT (poor responder)
- residual tumor extends to lateral parametria or sidewall (redundant with above)
- extensive or distal vaginal involvement
- narrow distorted vagina that would not accommodate applicator
Cervix finish treatment within
8 weeks
cervix chemo
Cisplatin: 40 mg/m^2 weekly
Cervix Simulation
SIM:
- 3DCRT (4-field box) positioned prone on belly board
- IMRT: extended field, or SIB to nodes, supine
- CT sim, IV and small bowel contrast
- anal marker
- gyn marker: vaginal if post-op, if intact fiducial to mark extent of vaginal disease
- full bladder, empty rectum (IMRT – full and empty bladder scan – to generate uterus and cervix ITV)
Cervix pelvic targets
Targets (definitive or postop):
- gross disease (cervix and entire uterus if definitive), vagina, parametria/uterosacrals, and pelvic LN
- always: Pelvic LN: obturator, internal/external iliac, presacral
- Cover common iliacs if pelvic LN + (to bifurcation of aorta)
- Extended field to level of renal vessels (or higher, ~5cm above highest LN) if common iliacs or PA involved
- Inguinal nodes if IIIA (distal vagina involved)
IMRT? indicated for SIB to gross nodes, extended field, or postop (TIME-C trial for postop cervix and endometrial, IMRT reduced pt reported acute GI and GU toxicity). Otherwise, prob safest to say 3DCRT.
*parametria positive – 45, then boost parametria to 54
3DCRT fields (postop or definitive): All to 45 Gy (50.4Gy if EBRT alone)
Cervix
AP/PA:
sup: L4/L5 at int/ext iliac nodes (bifurcation of common iliacs)
- if pelvic nodes +, tx common iliac nodes (L3/4 – bifurcation of aorta)
inf: 3 cm below inf vaginal inv or inferior obturator (whichever is lower)
lat: 2 cm on pelvic brim (don’t block SI joints or femoral head)
Lat field:
- anterior: 1 cm anterior to pubic symphysis
- posterior: entire sacrum (don’t split!)
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Cervix Nodal Boost
- Nodes <2cm à 60 Gy (SIB in 25 fractions to 54-56 Gy/2.16-2.24Gyfx à sequential boost in 2 Gy fx to 60Gy) – wait to do sequential dose until after brachy
- Nodes >2cm à 63Gy or higher depending on OARs (usually limited by bowel dose); as above, do SIB to 54-56Gy in 25 fx then sequential bode post to 63Gy
- Don’t forget brachy throw-off (important for obturator nodes, get about 1 Gy/fx)
Cervix post op dose
Post-op
- Treating for Sedlis criteria, negative margins and negative LN: 45 Gy to pelvis
- Treating for Positive margins: 45 Gy to pelvis, parametrial boost as above to 54 Gy, vaginal cylinder boost 4Gy x 3 to surface (EQD2 62.4-67Gy) – goal 60-66Gy to areas of concern for positive margins
Parametrial Boost – 54 Gy, if involved, with IMRT
-3D borders – AP/PA – lower sup border to bottom of SI joint, 4-4.5 cm wide midline block – all other borders stay the same
Cervix Treatment flow
CRT - > exam/MRI at 4 weeks -> Brachy twice weekly after EBRT separated by 72 hours, finish all in 8 weeks
cervix Brachy script
Applicator selection: T&O – safe to say
- in OR, anesthesia à dorsal lithotomy position
- EUA: primary, parametria, rectovaginal septum, mucosal involvement; select T&O size
- place fiducials to mark any vaginal disease and at cervix to evaluate applicator placement – at cervix, inferior extent of vaginal involvement
- place foley in bladder
- sound uterus (to determine tandem length)
- serially dilate cervical os under US guidance
- place tandem and ovoids (want snug fit – largest possible ovoids)
- set flange at end of uterine cavity
- pack: start posterior, then anterior
- insert dummy wire into tandem
- image: CT scan or film – to ensure placement
- fuse to diagnostic MRI for contouring guidance
*each fraction separated by at least 72 hrs*
Film evaluation:
Anterior
- Tandem bisects ovoids
- Tandem not rotated
- Flange close to marker seeds
- Ovoids high in fornices <1 cm from marker seeds, with ~1 cm spacing between them
Lateral
- Tandem bisects ovoids, not rotated
- Tandem midway between sacrum & bladder, at least 3 cm from sacral promontory
- Packing is ant & post to ovoids, but not sup to ovoids
- Foley balloon pulled down
Cervix Brachy Volumes
- contour on T2 based sequences, fuse diagnostic MR to planning CT
- HRCTV= entire cervix, GTV w/ parametrial/vaginal/uterine extension at time of brachy
- IRCTV=HRCTV+ 0.5-1.5cm (excluding OARs) + also includes initial extent of disease; should get 60% of Rx
Dose: HDR 1;5.5 Gy x 5, Ir-192, dose rate 12 Gy/hr (~equal to 35-40 LDR). 80-85 Gy EQD2 total
Points (images at end of sheet):
A: 2cm superior to cervical OS and 2cm lateral (uterine vessels cross ureter)
B: 3cm lateral to point A (parametrium/ obturator); receives 33% point A dose
C: 4cm lateral to point A (sidewall), 20% dose
Bladder – posterior surface of foley balloon on lat and center on AP film
Rectal – 5mm behind posterior vag wall between ovoids
Vaginal point – AP film lateral edge of ovoid, Lat – mid-ovoid
Cervix HDR goals
Target
D90 > 100% Rx (>80-85Gy EQD2)
Point A >65Gy (for CT/MR guided/optimized brachy)
Cervix OAR constraints
- Small Bowel: D2cc <55-60Gy EQD2
- Rectum: D2cc <65Gy EQD2
- Sigmoid: D2cc <70Gy EQD2
- Bladder: D2cc <80Gy EQD2
- Cumulative:
- Vagina:
- -upper < 120 Gy
- -mid < 80 Gy
- -lower < 60 Gy
- Fem head < 45
Cervix not meeting normals
- Check packing
- Replan
- Change fractionation (use more fractions, lower dose per fraction)
Cervix Side effects
Vaginal stenosis with 50-60 Gy
Side effects
Acute: cystitis, diarrhea, vaginal discharge, dysuria, decreased counts
Late: Vaginal stenosis, stricture, fibrosis, ureteral stricuture, cystits, SBO, proctitis, thinning mucosa, ovarian failure, painful intercourse, femoral neck fx (5%)
Tandem specific:
Uterine perf (<3%), vaginal laceration (1%)
Cervix 5 year OS
IA - 90%
IB - 80%
II - 60%
III - 30%
IV - 10%
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Cervix Follow-up
H&P with pap every 3 months x 1 year, 6 months x 2 years, annually; PET at 3 months then CT annually
-Use vaginal dilator
Endometrial risk of pelvic LN and PA
IF Pel - PA 2%
if Pel + PA 40%
Risk of Pelvic LN+
MMI
G1 0, 5, 10
G2 5, 10, 15
G3 10 15 35
Inner 1/3
0%
5%
10%
Mid 1/3
5%
10%
15%
Deep 1/3
10%
15%
35%
Endometrial risk factors
-risk factors: tam, unopposed estrogen, fam hx (HNPCC, Lynch Syndrome)
Endometrial Workup
Labs: CA-125 (normal < 35), CBC, CMP
Imaging:
- transvaginal U/S (> 4mm is thickened stripe)
- MRI if inoperable, cervical invasion on exam
*Grade 3 patients – do CT before surgery
Biopsy:
- endometrial biopsy
- D&C under anesthesia if initial biopsy nondiagnostic
Other: genetic counseling if young or history suggestive of HNPCC
Endometrial Pathologic staging procedure
Pathologic staging:
- Laparoscopic inspection: peritoneal cavity/pelvis, adnexa, omentum bx (G3/HR histology)
- Pelvic washings for cytology
- Extrafascial hysterectomy and BSO w/ nodal assessment
- Bilateral SNB for all
- Otherwise, use Mayo criteria (below) to determine whether to do b/l PA-PLND (want 12+ nodes – at least one from each of 5 stations bilat; PA, CI, EI, II, obturator)
Per LL – can just do SLNBx
Mayo
Do NOT need to perform nodal dissection if all apply:
- G1-2 endometrioid
- MMI <50%
- Tumor 2cm or less
OR 0% MMI
Endometrial what do you want to see on Pathology report
- Histology
- Grade
- Myometrial invasion
- LVSI
- Cervical involvement
- Margins
- # LN dissected and involved (pelvic vs PA)
- Cytology of washings
Endometrial staging
- IA: endometrium or <50% MMI
- IB:_>_50% MMI
- II – cervical stromal inv
- IIIA – serosa, adnexa
- IIIB – vagina or parametrial involvement
- IIIC1 - PLN : N1
- IIIC2 - PALN : N2
- IVA – bladder, bowel
- IVB – distant met
Endometrial Stage IA G1-2
Observation
Endometrial Stage IA G3 / IB, G1-2
VBT
Endometrial IB G3
Pelvic RT
Endo Stage II
Pelvic RT + VBT
Endo Stage III-IV
CRT or chemo +/- RT
Stage III: post-op RT w cisplatin (50 mg/m^2, Day 1 and Day 29) à carbo/tax x 4 cycles
Endometriod Stage III CRT chemo
chisplatin 50 mg/m2 D1/29
Endometrial Serous or Clear Cell management by stage
IA non-invasive(polyp): if neg washings: VBT, + washings: chemo and VBT
IA-IV: Chemo +/- EBRT +- VBT
Endometrial sim
WP 45 Gy (50.4 if using EBRT alone)
4 field vs IMRT
- IMRT: sim w bladder full and empty – vaginal ITV. Plan and daily tx w full bladder
- PO and IV contrast
- place vaginal cuff markers
- prone – 3D
Endometrial RT volumes / fields
CTV = int iliac, ext iliac, obturator, pre-sacral if cervical involvement (7mm margin on vessels excluding muscle, bone, and bowel), proximal ½-1/3 of vagina
PTV_nodes=CTV+ 7mm
PTV_vagina=ITV+ 1-1.5 cm
sup: L4/L5
- if PLN+: L3/L4 (cover commons to aorta bifurcation)
- if PALN+ - cover 5 cm above highest node or EFRT (T12/L1 or renal vessels)
inf: obturator foramen, include upper half of vagina
lat: 2cm on pelvic brim
ant: 1 cm ant to pubic symph
post: split sacrum to S3 (include entire sacrum if cervical involvement)
*LL – cover pre-sacrals if N+
Endo VBT dose
Brachy VBT alone: 6G x 5 to surface or 7 x 3 to 0.5mm
EBRT boost: 5-6Gy x 3 to surface
Uterine Sarcoma IB-IV
chemo +/- RT
VBT technique
VC HDR brachy:
- 4-8 weeks post-op
Technique (single channel cylinder)
- Examine – confirm cuff healed, estimate cylinder diameter (2-3.5 cm)
- Insert cylinder in vagina flush against vaginal vault, secure on brachy board
- Plan: divide vagina length in half, so if 8 cm treat 4 cm = 9 dwells (4 x 2 + 1)
- Do CT scan to confirm placement, review plan
- Note: VSD relative to 5 mm depth=160%
- Ir-192, 74 days half life
- largest cynlinder size to decrease vaginal surface dose
Endometrial constraints
Bladder: V45 < 40%
Rectum: V40 < 80%
BM: V10<95%; V40<37%
Bowel: V45 < 200cc
V45<25% - femoral heads
Keep rectum and bladder to <75% of full dose. Anterior surface of the rectum receives full dose.
Endometrial OS
IA – 90%
IB – 80%
II – 70%
III – 60%
Endometrial Followup
H&P with vaginal canal exam
- Imaging as clinically indicated (except routine CT chest for sarcoma)
- CA-125 if initially elevated
- pap smears not rec’d on NCCN
Endometrial inoperable treatment
IA, G1-2: brachy alone (EQD2 80-90, 7.5 x 5)
IA, G3, IB-II: WP (45) + brachy (5 x 5) – prescribed to serosa (so cavity is hotter) – include cervix in volume, along with upper 2/3 of vagina
III-IV: ChemoRT (WP) + interstitial brachy
Brachy device: Y-applicator
-target: uterus, cervix, top 1-4 cm of vagina
Consider progestin-based hormone therapy if ER/PR positive and not candidate for RT
Uterine sarcoma treatment
- leiomyo
- endo stromal
- high grade undiff
Surgery (LND not indicated!)
- ESS: adj hormone therapy (megesterol, NOT TAM)
- leiomyo or undiff: adj chemotherapy (docetaxel/gem)
- Pt had simple hysterectomy & found to have IA2 cervical or higher disease. What do you do?
- Re-stage w/ labs, PET, & CT/MRI
- Options
- Take back to OR for radical parametrectomy & pelvic LND
- Postop RT for deep stromal invasion, >4 cm, or LVSI
- Postop chemoRT for +margin, +LN, +parametria
- Or, post-op RT or chemoRT with same indications as above
- Take back to OR for radical parametrectomy & pelvic LND
Vulvar drainage pattern
Nodal drainage:
- inguinal (1st)
- external iliac and pelvis (2nd) – clitoris may drain directly to iliac)
Radical Vulvectomy
Removal of vulva to deep fascia of thigh with removal of periostem of the pubis and 2cm margin. +/- uni or bilat groin LND
Vulvar H/P
History: young and HPV+, or old and lichen sclerosis
Physical: proximity to central structures (urethra, clitoris, anus, vagina), synchronous lesion, pap smear, inguinal node
Vulvar subsites
SUBSITES:
- Labia majora
- Labia minora
- Clitoris
- Urethral meatus
- Introitus
- Bartholin’s gland
*Skene’s is periurethral
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Vuvlar staging
Pathologically staged:
- I: confined to vulva:
- IA: ≤2cm and ≤1mm inv
- IB: >2cm or >1mm inv (>1mm = 10+% risk of LN involvement)
- II: invades lower urethra, vagina, or anus
- IIIA: upper urethra, vagina or rectum
- IIIB: Node + >5mm
- IIIC: ECE
- IVA: fixed to bone or ulcerated nodes
- IVB: mets, inc pelvic LN
Vuvlar IA
IA: WLE with 1 cm margin (no LND)
Vulvar IB/II
IB/II: WLE + inguinal LND
Lateral lesion, cN0, pN0, <2cm: unilateral LND
Central lesion (< 1 cm of midline), cN+, pN+: bilateral LND
RT to primary, LNs as indicated (see below):
*if positive SLN -> recommend dissection*
RT to primary: (based on Heaps surgical review)
1) >5 mm depth of invasion
2) close (<8 mm fixed, 1 cm gross) or positive margin
3) LVSI
*note: if close/pos margin is only indication, re-resect
RT to LNs: any positive nodes
ChemoRT: any positive nodes
***SLNB – GOG 173 (Levenback JCO 2012) showed 92% sensitivity. If tumor < 4 cm, false neg rate <2%
Vulvar Stage III-IV
1) Preop ChemoRT (cisplatin 40mg/m^2 weekly, RT to 57.6) -> surgical excision of residual disease -> if not resectable continue chemoRT to definitive dose
2) Def chemoRT (unresectable): weekly cisplatin (40 mg/m^2) + RT to 64.8
3) Radical vulvectomy – may require pelvic exenteration
**for positive pelvic nodes, treat with curative intent (even though M1; survival ~45%)
vulvar Sim
CT simulation:
- supine, frog leg, vac-lok
- wire the tumor, scar, palpable nodes, and place a BB at the vaginal introitus.
- 5mm bolus (if needed – can check with TLDs) – often for IMRT you don’t
Vulvar IMRT volumes
GTV=gross disease vulva and nodes
CTV_primary= primary tumor + 2 cm
CTV_nodes=(inguinal vessels + 2-3 cm) + (external/internal iliacs + 1 cm)
PTV= CTV+1 cm
-average depth of femoral vessels ~ 6 cm
Vulvar dose
Boost the primary (+margin or gross disease) or the groins (ECE)
*Always need to treat nodes if neoadjuvant or definitive*
Dosing:
Post-op: 50.4Gy
+ margin or + ECE: 59.4
Neoadjuvant: 57.6
Gross disease (definitive): 64.8
-always treat the primary – no central blocking (50% recurrence in the Dusenberry study)
vulvar constraints
- Femoral heads
- Max < 50
- V35 < 35%
- Small bowel
- V45 < 200 cc
- Bladder
- Max 75
- Rectum Max 70
- Skin as tolerated – likely to be dose limiting
Vulvar OS
5 yr OS:
I – 95%
II – 80%
III – 60%
IV – 45% for pelvic LN+, 20% hematogenous mets
Predominal failure pattern is LOCAL
Vuvlar side effects
Side effects:
Skin and vaginal stenosis
Early skin rxns (before 35Gy) is usually yeast – give diflucan and keep treating!
sitz baths for prevention of infection during RT
Vaginal VAIN
treat with WLE, laser or 5-FU topical, progresses to invasive if left alone
Vaginal workup
Imaging:
-PET/CT
Biopsy:
- Remember to colpo w/ biopsies of cervix/vulva to r/o primary cervical or vulvar cancer
- FNA any grossly positive node
If adeno: D/C to r/o endometrial, colonscopy to rule out colon, mammo/chest CT, CA-125
Vaginal Staging
- I – vagina
- II: paravaginal
- III: pelvic sidewall, N+
- IVA: bladder, rectum
- IVB: mets
Vaginal Stage I
: Surgery (vaginectomy and nodal dissection) or definitive RT alone (EBRT + brachy)
Vaginal Stage II
II: Surgery, if can; chemoradiation or RT alone (if small)
Vaginal Stage II+
II+: Definitive CRT
- EBRT + brachy boost
- Concurrent cisplatin 40 mg weekly x 6
If after EBRT, disease is < 5 mm deep by exam and MRI, can do VC alone. Otherwise do IS (Syed).
IVA: brachy can cause fistula! Consider exenteration
Vaginal CA 5 y DFS
5 yr DFS
I/II- 80%
III/IVA - 60%
Local failure very similar to cervix
Vaginal Radiation technique
EBRT target: primary + pelvic nodes; treat inguinals if lower 1/3 vagina involved
Need beam and brachy
- beam to 45
- sup/border: L5/S1
- lateral: pelvic brim + 2 cm, parametria
- inferior: vaginal canal
*if involvinig lower 1/3 of vagina – inguinals
- brachy total to 75-80 Gy, 6 Gy x 3
- interstital vs. Syed
- use multi-channel
- again, need repeat exam and pelvic MRI
- prescribe to 5mm depth – if surface, won’t get deep enough dose
*dose forget for fiducials*
Dose:
45 Gy
Boost positive LN (III) and parametria (II) to 59.4 Gy
Boost primary w EBRT instead of Syed if involving rectovaginal septum/bladder: ~ 70 Gy
Syed: single insertion; 5 Gy x 5 fraction BID (EQD2 75-80)
One week prior to insertion, do CT/MRI sim with template in place
challenging T/O issues
Perforation:
Anteverted Uterus
High bowel dose
high bladder dose
Perforation: withdraw, oral antibiotic, re-try with US guidance
Anteverted Uterus: Fill bladder, US guidance
High bowel dose: fill bladder, reduce tandem loading length
high bladder dose: alternate full/empty bladder