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Rad Onc Oral Boards Quick > 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 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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3
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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4
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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5
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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6
Q

Cervix IB3, IIA2+

A

Cervix IB3, IIA2+ ie >4 cm or advanced

CRT ->brachy boost

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7
Q

Cervix Post op Whole Pelvis RT indications

A

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

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8
Q

Cervix Post op Chemo RT

A

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

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9
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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10
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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11
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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12
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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13
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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14
Q

Cervix OAR constraints

A
  • 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
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15
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
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16
Q

Endometrial Stage IA G1-2

A

Observation

17
Q

Endometrial Stage IA G3 / IB, G1-2

A

VBT

18
Q

Endometrial IB G3

A

Pelvic RT

19
Q

Endo Stage II

A

Pelvic RT + VBT

20
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

21
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

22
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+

23
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

24
Q

Uterine Sarcoma IB-IV

A

chemo +/- RT

25
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.

26
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

27
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
28
Q

Vuvlar IA

A

IA: WLE with 1 cm margin (no LND)

29
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%

30
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%)

31
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

32
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)

33
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
34
Q

Vaginal Staging

A
  • I – vagina
  • II: paravaginal
  • III: pelvic sidewall, N+
  • IVA: bladder, rectum
  • IVB: mets
35
Q

Vaginal Stage I

A

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

36
Q

Vaginal Stage II

A

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

37
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

Rad Onc Oral Boards Quick (11 decks)

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