GYN Flashcards
FIGO stage IA staging for cervix
Stage IA is microscopic disease, IA1: DOI<3mm, IA2: DOI>3mm but < 5mm
FIGO Stage II uterine
Invades cervical stroma but not extend beyond uterus.
Early dermatitis during vulvar RT is likely due to:
yeast infection, treat with diflucan
uterine high risk hisotlogy Stage IA
adj cht + VBT
IB G2
VBT but consider obs or consider EBRT depending on risk factors
T1a and T1b for vulvar cancer
T1a: confined to vulva/perineum <=2cm with stromal invasion <=1mm, T1b: >2cm OR any size with stromal invasion > 1mm
4 genomic classifications of endometrial cancer
POLE, MSI unstable, copy number low, copy number high (worst prognosis)
Management of cervix IB1
same as IA2 and IA1 with LVSI, radical hysterectomy instead of modified radical hysterectomy.
IB G3
EBRT
Management of vulvar cancer that is unresectable AND LND not feasible
CCRT + primary + inguinal/pelvic LN
How to treat a vaginal cuff recurrence of uterine
45 in 25 + VBT
IA, G3
VBT
FIGO Stage IIIA,IIIB,IIIC uterine
IIIA, serosa and/or adnexa, IIIB: Bagina or parametrial involvement, IIIC1: pelvic LN, IIIC2: PA LN involvement
d2cc bladder, rectum, sigmoid, bowel
80, 65, 70, 65 (90, 75, 75, 75)
VBT dose for monotherapy
6 Gy x 5 fractions to 5 mm depth
What dose to Primary, elective, and gross residual LN for postop vulvar
50 Gy to postop bed, if close or positive margin or ECE to 60 Gy, gross residual LN go to 66 Gy, 50 Gy to elective nodes
uterine high risk hisotlogy Stage IB-IV
adj cht +/-EBRT +/- VBT
Management of T1b vulvar
Modified radical vulvectomy, R0: observe, R1: re-resection v. CCRT, SLNB: if positive finish LND
What are the patients that could get postop RT without chemo (vulvar)
SLNB alone with 1 LN with < 2mm. Anyone with more LN gets LND and then anyone with 2+ LN gets adj CCRT.
When is a radical hysterectomy preferred over total hysterectomy in uterine cancer
with gross cervical involvement.( proximal third of vagina also taken)
Imaging needed for vulvar workup
CXR, MRI, PET CT
Management of IA1 cervix without LVSI
CKC with 3mm margin, R0: observe, R1: repeat CKC or simple trachelectomy. IF fertility not an issue, extrafaxscial hysterectomy.
Stage IVA and IVB uterine
IVA: invasion of bladder and/or bowel mucosa, IVB: DM
What imaging is needed for uterine
Transvaginal US, MRI pelvis, CXR, CTCAP
What chemo is given with RT for vulvar
Cisplatin 40mg/m2 weekly
Management of T1a vulvar
WLE, R0: observe vs risk-directed adj RT, R1: Re-resection
What are indications for adj rt to vulva after surgery for vulvar cancer
Positive margin, close margin <8mm, LVSI, DOI>5mm, Size > 4cm
bladder ebrt constraint for 45 Gy gyn
V45<35%
Management for medically inoperable uterine
EBRT 45/25 then BT 5x5 with Rotte Y applicator, GTV to 90 Gy, HR-CTV to 65 Gy(entire uterus, serosal surface, cervix and upper 1-2 cm vagina.
Small bowel dmax
55 Gy
What are the postop indications for RT for cervix
You have to have 2 of these: outer two-third cervical stromal invasion, size>4cm, LVSI
Staging IB-IVB for cervix
IB1: >5mm DOI and size < 2 cm, IB2: >2 but <4 cm, IB3: >=4cm, IIA: involvement of upper 2/3 of vagina, IIA1: size<4cm, IIA2: >=rcm, IIB: parametria involvement, IIIA: lower third of vagina, IIIB: pelvic side wall involvement and/or hydronephrosis, IIIC1: pelvic LN involvement, IIIC2: PA LN, IVA: into bladder or rectum, IVB: distant mets.
What surgery is needed for vulvar cancer
modified radical vulvectomy
Vaginal cuff brachy dose
6Gy x 3 to surface
T2, T3 for vulvar cancer
T2: involvement of lower third urethra, vagina, or anus, T3: involvement of upper two thirds urethra, vagina, bladder, rectum, or fixation to bone.
What are indications of postop radiation to nodal regions for vulvar cancer
2+ lnvolved (must have at least 12 taken out), >2mm focus, ECE: 60-66Gy, Gross residual LN: 60-70 Gy
Management of cervix IA2
same as IA1 with LVSI,
radical trachelectomy + PLND or modified radical hysterectomy + PLND
N staging for vulvar cancer
N1a: 1-2 LN each < 5mm, N1b: 1 LN>=5mm, N2a: 3+ LN each <5mm, N2b: 2+ LN>=5mm
Management of cervix IA1 with LVSI
radical trachelectomy + PLND or modified radical hysterectomy + PLND
What labs are needed for uterine workup
CBC/CMP/CA-125
Screening guidelines for cervical cancer
age 21 q3yrs pap smear, age 30 pap smear/HPV cotesting q5yr or pap smear q3y, Age 65 no further screening if 3 negative pap within 10 years.
Uterine Stage IA, G1-2
Observe, consider VBT if LVSI, or age>=60
Rectal V40
<40%
Management of cervix IB2 or IIA1
radical hysterectomy + PLND
Bone marrow V40
V40<40
Upper vagina brachy max dose
120-140
Lower vagina brachy max dose
<90
bowel constriant
V45<195 cc
Brachy coverage goals
D90 HR-CTV>=85 Gy, D98 HR-CTV >=75 Gy, D98 GTV>= 95 Gy, D98 IR-CTV >=60 Gy, Point A >=65 Gy
Rectum constraint
V40<80%
What should be marked at sim in a vulvar case
vaginal introitus, anal verge, vulva/scars/suspicious LN
IB, G1
VBT, consider observation if no other risk factors
indications for ccrt in recurrent endometrial
large recurrence, high grade, LN involvement.
Postop management for uterine Stage II
EBRT + VBT
cervix postop chemoRT criteria
positive LN, positive margin, parametrial involvement
when is SLNB indicated in vulvar management
if DOI>1mm and unifocal T1-T2 disease<4cm. (more advanced needs LND)
What are indications for vaginal cuff brachy after hysterectomy for cervix cancer
Less than radical hysterectomy, close/positive margin, bulky tumor, extensive LVSI
what is your ctv for an intact cervix case
GTV and cervix and uterus and upper half of vagina (2/3 if involved), and parametrium
Bone marrow constraint
V10<90%
In whom can LND be omitted with uterine cnacer
Primary <=2cm, G1-2, <=50 MMI
Postop management for uterine Stage III
Adj CHT x 6 cycles + EBRT +/-VBT, consider CCRT then adj cht per PORTEC-3 for stage IIIC
N2c and N3 for vulvar
N2c: ECE, N3: fixed or ulcerated LN
What dose to Primary, elective, and gross LN for intact vulvar
Primary to 66 Gy, elective to 50 Gy, Gross disease to 66
Bladder constraint for vulvar
V45<35%
how far down presacral do you treat for cervix
S2/S3
Management of cervix IB3 or IIA2-IVA
concurrent chemoRT + brachy
Management of unresectable disease vulvar cancer
Perform inguinal LND, if positive CCRT to primary and bilateral inguinal/pelvic LN, if negative CCRT to primary +/- inguinal LN
What if biopsy is non-diagnostic for uterine
do Hysteroscopy with D&C
VBT dose after EBRT
6 Gy x 3 to surface
What path is needed in vulvar workup
primary excisional or incisional biopsy, FNA node, pap smear
