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 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
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 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!)
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 HDR goals
Target
D90 > 100% Rx (>80-85Gy EQD2)
Point A >65Gy (for CT/MR guided/optimized brachy)
Cervix OAR constraints
- Small Bowel: D2cc <65Gy EQD2
- Rectum: D2cc <65Gy EQD2
- Sigmoid: D2cc <65Gy EQD2
- Bladder: D2cc <80Gy EQD2
- Cumulative:
- Vagina:
- -upper < 120 Gy
- -mid < 80 Gy
- -lower < 60 Gy
- Fem head < 45
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
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 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
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 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
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 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
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
