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Rad Onc Oral Boards > GYN > Flashcards

GYN Flashcards

1
Q

Cervical Screening

A

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
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2
Q

Cervical HPV

A

16, 18
95% related

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3
Q

Cervical LN Risk

A

IB: 15% P 10% PA
II: 30% P 20% PA
III: 45% P 30% PA

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4
Q

Cervical H/P script

A

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.

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5
Q

Cervical Workup

A

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

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6
Q

Cervical Staging

A

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

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7
Q

TAH

A

uterus, cervix, and small rim of vagina cuff

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8
Q

Mod radical hyst

A

uterus/cervix/1-2 cm of vagina, some of parametrium

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9
Q

Radical hysterectomy

A

uterus/cervix/upper 1/3-1/2 of vagina, dissection of parametrium to sidewall, PA/pelvic LND

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10
Q

Rad trachelectomy –

A

removes cervix, parametria + LN sampling

  • Preserves fertility.
  • Only for tumor < 2 cm, no LVI (not meeting Sedlis!)
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11
Q

Cervix 1A1 no LVI treatment

A

(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)

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12
Q

Cervix IA2

A

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)

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13
Q

Cervix IB1-2 and IIA1

A

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)

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14
Q

Cervix IB3, IIA2+

A

Cervix IB3, IIA2+ ie >4 cm or advanced

CRT ->brachy boost

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15
Q

Cervix Post op Whole Pelvis RT indications

A

Sedlis 2 of 3 factors:
LVSI
> 4cm
>1/3 stromal invasion

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16
Q

Cervix Post op Chemo RT

A

(Peters)
Positive margins (<3 mm)
Positive nodes
Parametrial inv (surprise FIGO IIB)

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17
Q

Cervix interstitial indications

A
  • 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
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18
Q

Cervix finish treatment within

A

8 weeks

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19
Q

cervix chemo

A

Cisplatin: 40 mg/m^2 weekly

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20
Q

Cervix Simulation

A

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)
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21
Q

Cervix pelvic targets

A

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

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22
Q

3DCRT fields (postop or definitive): All to 45 Gy (50.4Gy if EBRT alone)

Cervix

A

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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23
Q

Cervix Nodal Boost

A
  • 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)
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24
Q

Cervix post op dose

A

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

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25
Q

Cervix Treatment flow

A

CRT - > exam/MRI at 4 weeks -> Brachy twice weekly after EBRT separated by 72 hours, finish all in 8 weeks

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26
Q

cervix Brachy script

A

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
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27
Q

Cervix Brachy Volumes

A
  • 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

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28
Q

Cervix HDR goals

A

Target

D90 > 100% Rx (>80-85Gy EQD2)

Point A >65Gy (for CT/MR guided/optimized brachy)

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29
Q

Cervix OAR constraints

A
  • 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
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30
Q

Cervix not meeting normals

A
  1. Check packing
  2. Replan
  3. Change fractionation (use more fractions, lower dose per fraction)
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31
Q

Cervix Side effects

A

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%)

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32
Q

Cervix 5 year OS

A

IA - 90%

IB - 80%

II - 60%

III - 30%

IV - 10%

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33
Q

Cervix Follow-up

A

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

34
Q

Endometrial risk of pelvic LN and PA

A

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%

35
Q

Endometrial risk factors

A

-risk factors: tam, unopposed estrogen, fam hx (HNPCC, Lynch Syndrome)

36
Q

Endometrial Workup

A

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

37
Q

Endometrial Pathologic staging procedure

A

Pathologic staging:

  1. Laparoscopic inspection: peritoneal cavity/pelvis, adnexa, omentum bx (G3/HR histology)
  2. Pelvic washings for cytology
  3. 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

38
Q

Endometrial what do you want to see on Pathology report

A
  • Histology
  • Grade
  • Myometrial invasion
  • LVSI
  • Cervical involvement
  • Margins
  • # LN dissected and involved (pelvic vs PA)
  • Cytology of washings
39
Q

Endometrial staging

A
  • 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
40
Q

Endometrial Stage IA G1-2

A

Observation

41
Q

Endometrial Stage IA G3 / IB, G1-2

A

VBT

42
Q

Endometrial IB G3

A

Pelvic RT

43
Q

Endo Stage II

A

Pelvic RT + VBT

44
Q

Endo Stage III-IV

A

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

45
Q
A
46
Q

Endometriod Stage III CRT chemo

A

chisplatin 50 mg/m2 D1/29

47
Q

Endometrial Serous or Clear Cell management by stage

A

IA non-invasive(polyp): if neg washings: VBT, + washings: chemo and VBT

IA-IV: Chemo +/- EBRT +- VBT

48
Q

Endometrial sim

A

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
49
Q

Endometrial RT volumes / fields

A

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+

50
Q

Endo VBT dose

A

Brachy VBT alone: 6G x 5 to surface or 7 x 3 to 0.5mm

EBRT boost: 5-6Gy x 3 to surface

51
Q

Uterine Sarcoma IB-IV

A

chemo +/- RT

52
Q

VBT technique

A

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
53
Q

Endometrial constraints

A

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.

54
Q

Endometrial OS

A

IA – 90%

IB – 80%

II – 70%

III – 60%

55
Q

Endometrial Followup

A

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
56
Q

Endometrial inoperable treatment

A

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

57
Q

Uterine sarcoma treatment

  • leiomyo
  • endo stromal
  • high grade undiff
A

Surgery (LND not indicated!)

  • ESS: adj hormone therapy (megesterol, NOT TAM)
  • leiomyo or undiff: adj chemotherapy (docetaxel/gem)
58
Q
  • Pt had simple hysterectomy & found to have IA2 cervical or higher disease. What do you do?
A
  • 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
59
Q

Vulvar drainage pattern

A

Nodal drainage:

  • inguinal (1st)
  • external iliac and pelvis (2nd) – clitoris may drain directly to iliac)
60
Q

Radical Vulvectomy

A

Removal of vulva to deep fascia of thigh with removal of periostem of the pubis and 2cm margin. +/- uni or bilat groin LND

61
Q

Vulvar H/P

A

History: young and HPV+, or old and lichen sclerosis

Physical: proximity to central structures (urethra, clitoris, anus, vagina), synchronous lesion, pap smear, inguinal node

62
Q

Vulvar subsites

A

SUBSITES:

  1. Labia majora
  2. Labia minora
  3. Clitoris
  4. Urethral meatus
  5. Introitus
  6. Bartholin’s gland

*Skene’s is periurethral

63
Q

Vuvlar staging

A

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
64
Q

Vuvlar IA

A

IA: WLE with 1 cm margin (no LND)

65
Q

Vulvar IB/II

A

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%

66
Q

Vulvar Stage III-IV

A

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%)

67
Q

vulvar Sim

A

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
68
Q

Vulvar IMRT volumes

A

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

69
Q

Vulvar dose

A

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)

70
Q

vulvar constraints

A
  • 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
71
Q

Vulvar OS

A

5 yr OS:

I – 95%

II – 80%

III – 60%
IV – 45% for pelvic LN+, 20% hematogenous mets

Predominal failure pattern is LOCAL

72
Q

Vuvlar side effects

A

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

73
Q

Vaginal VAIN

A

treat with WLE, laser or 5-FU topical, progresses to invasive if left alone

74
Q

Vaginal workup

A

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

75
Q
A
76
Q

Vaginal Staging

A
  • I – vagina
  • II: paravaginal
  • III: pelvic sidewall, N+
  • IVA: bladder, rectum
  • IVB: mets
77
Q

Vaginal Stage I

A

: Surgery (vaginectomy and nodal dissection) or definitive RT alone (EBRT + brachy)

78
Q

Vaginal Stage II

A

II: Surgery, if can; chemoradiation or RT alone (if small)

79
Q

Vaginal Stage II+

A

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

80
Q

Vaginal CA 5 y DFS

A

5 yr DFS

I/II- 80%

III/IVA - 60%

Local failure very similar to cervix

81
Q

Vaginal Radiation technique

A

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

82
Q

challenging T/O issues

Perforation:

Anteverted Uterus

High bowel dose

high bladder dose

A

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

Rad Onc Oral Boards (11 decks)

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