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Oral Boards > GYN > Flashcards

GYN Flashcards

1
Q

Exams allowed for FIGO staging

A

EUA, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, IVP, CXR, skeletal x-ray

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2
Q

Cervical cancer: workup

A

H&P with pap and cold conization, sexual history, pelvic exam (rectovaginal, inguinal nodes, abdomen)

Labs: CBC, CMP, CA-125, possibly BHCG

If very young, consider oophoropexy to preserve hormonal function

Imaging: CT A/P, MRI, PET

Special: consider EUA, cystoscopy, sigmoidoscopy

Surgery: radical hysterectomy with nodal dissection. Ex lap with palpation of liver and cytology. Sample omentum

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3
Q

Treatment options for IB1 cervical cancer

A

Surgery (without BSO) is preferred to preserve ovarian function and prevent secondary malignancy. If RT is used, treat to 45 Gy whole pelvis then HDR.

Can do radical trachelectomy if size <2 cm

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4
Q

Cervical cancer: classic fields

A

Whole pelvis: L4/L5 to bottom of obturator foramen, 2 cm on pelvic brim, ant in front of pubic symphysis, post covers whole sacrum with extra 1 cm to cover uterosacral ligaments

If node positive, include PA up to T11/T12. In RTOG 0724, if common iliac nodes are positive then PA nodes are treated up to L1/L2. If PA nodes are positive, treated up to T11/T12. (Some might include PA nodes for multiple pelvic nodes or in Stage IIIB or IVA)

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5
Q

Cervical cancer: 5yr OS by stage

A

IA 100%

IB1 90%

IB2 70%

IIA/B 70%

III 50%

IVA 30%

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6
Q

Point-based Tandem and Ovoid narrative

A

I would take the patient to the OR place them in the dorsal lithotomy position and administer general anesthesia. I’d perform and EUA to assess response. After prepping the patient with betadine, a gold seed would be placed at the anterior cervix. A foley catheter would then be inserted to drain the bladder and the foley bulb inflated with 7cc half saline half contrast. I would inject 200 mL of saline into the bladder and clamp the foley. The uterus would be sounded to assess distance to the fundus and flexion, and the appropriate tandem inserted with the largest ovoids that could be accommodated. Packing would be placed anteriorly and posteriorly to the device with gauze soaked with contrast and clindamycin ointment to pack away from the bladder and rectum. I would then take AP and lateral orthogonal films to ensure adequate positioning and packing.

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7
Q

Cervical cancer: dose for EBRT and brachy

A

45 Gy/25 fx to whole pelvis

HDR 80-90 Gy to Point A (5x6 Gy = EQD2 of 84)

Treat 1-2 times per week. Rx to point A. Boost gross nodes to 54-60 Gy. Boost parametrium by HDR or EBRT if involved.

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8
Q

GYN cancer: concurrent chemo

A

cisplatin 40 weekly, 5-6 cycles

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9
Q

Evaluating tandem and ovoid placement

A

Laterals: ovoids bisected by seeds and tandem, tandem halfway between bladder and sacrum, adequate packing, no packing above ovoids

AP: flange between ovoids, ovoids 0.5-1cm from tandem

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10
Q

Ir192: general activity, half life, energy

A

Starts at ~10 Ci.

Half life 74 days

300kEV

change out source every 3 months

1% decay/day

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11
Q

3D Tandem and Ovoid Narrative

A

I would take the patient to the OR and place her in the dorsal lithotomy position and administer general anesthesia. I’d perform an EUA to assess response. I would prep with betadine. A foley catheter would then be inserted to drain the bladder and the foley bulb inflated with 10cc 1:9 gadolinium/saline (1cc gadolinium+9 cc saline). (Optional: inject saline into bladder and clamp foley). The uterus would be sounded to assess distance to the fundus and flexion, and the appropriate tandem inserted with the largest ovoids that could be accommodated. Packing would be placed anteriorly and posteriorly to the device with gauze soaked with saline and clindamycin ointment to pack away from the bladder and rectum. (Optional: small amount of gadolinum at cervix before placing packing). I would then transfer the patient to radiology for MRI (may need to insert catheters with water into the applicator for visualization)

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12
Q

3D Tandem and Ovoid: volumes and dose

A

HRCTV: (80-90 Gy EQD2, 5.5-6 Gy x 5) Include whole cervix, GTV at time of brachy, and “presumed tumor extension”

IRCTV: (60 Gy EQD2) Initial tumor volume prior to all therapy. Needs to have at least 10 mm margin on GTV except 5 mm anterior and posterior.

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13
Q

3D Tandem and Ovoid dosimetry

A

D90 of 80-90 Gy EQD2

D90 of 100% on DVH

2cc bladder<90 Gy (<5.5Gy/fx)

2cc rectum/sigmoid<75 Gy (<3.8Gy/fx)

2 cc small bowel<60 Gy

rectovaginal point<65 Gy

check refresher course for new GEC-ESTRO constraints

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14
Q

Cervical cancer: indications for post-op radiation

A

Sedlis criteria (need at least two):

LVSI

size >4 cm

≥2/3 stromal invasion

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15
Q

Cervical cancer: borders of parametrium

A

superior: bowel
lateral: pelvic wall
anterior: 1 cm into bladder
posterior: uterosacral ligaments (know location)
inferior: UG diaphragm

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16
Q

Cervical cancer: indications for post-op chemoradiation

A

Peters criteria:

positive nodes

positive margins

parametrial involvement

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17
Q

Cervical cancer intertitial brachytherapy narrative

A

Bring patient to OR and place under general anesthesia in dorsal lithotomy position.

Place Syed template, and load needles according to anatomy and tumor on axial imaging, based on the HRCTV you want to create.

Admit patient with epidural.

Perform CT simulation

Dose using 3D planning

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18
Q

Cervical cancer: indications for parametrial boost and dose utilized

A

Indication: parametrial involvement when treating definitive cervix

5.4-9 Gy boost after 45 Gy to pelvis

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19
Q

Vaginal cancer: fields and dose

A

45 Gy EBRT whole pelvis (for lower vagina consider adding inguinals) followed by boost

Boost:

Interstitial technique

Deliver twice daily or once daily

  1. 5 Gy x 5 fx= BED 80
  2. 5 Gy x 5 fx= 71.5 BED

Deliver boost to CTV with 1 cm margin.

Goal of D90%>100% and EQD2 BED 70-85 Gy (use lower BED if near organ or lower 1/3vagina)

Tumors <0.5 cm can have cylinder boost

Posterior lesions ideally still treated with brachy but total dose reduced for rectum. Keep rectum/sigmoid <70-75 Gy.

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20
Q

Vaginal dose tolerance (upper, middle, lower)

A

upper 120Gy

mid 90Gy

lower 60Gy

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21
Q

Vaginal cancer: local control for stage I-III

A

LC:

stage I 90%

stage II 80%

stage III 70%

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22
Q

Inoperable Endometrial cancer: workup

A

H&P. Postmenopausal vaginal bleeding. GYN exam

Labs: CBC, CMP, CA-125

Endometrial bx

If very young, consider oophoropexy to preserve hormonal function

Imaging: CT A/P, CXR, MRI with T2W, contrast enhanced

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23
Q

Inoperable endometrial cancer: staging

A

Stage IA <8 cm uterine cavity sound

Stage IB >8 cm

Stage II involves corpus and cervix

Stage III parametrium, vagina, adnexa

Stage IV

A local structures

B metastatic

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24
Q

Inoperable endometrial cancer: brachytherapy narrative

A

I would take the patient to the OR place them in the dorsal lithotomy position and administer general anesthesia and prep the patient with betadine. A foley catheter would then be inserted to drain the bladder and the foley bulb inflated with 7cc half saline half contrast. I would inject 200 mL of saline into the bladder and clamp the foley. The uterus would be sounded to assess distance to the fundus and flexion, and I would insert a double tandem applicator. Packing would be placed anteriorly and posteriorly to the device with gauze soaked with contrast and clindamycin ointment to pack away from the bladder and rectum.

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25
Q

Inoperable endometrial cancer: doses and fields

A

ABR guidelines 2015

GTV = tumor and endometrium

CTV = uterus, cervix, upper 1-2cm of vagina

prescribe to CTV

HDR alone:

(stage I, grade 1-2, minimal myometrial invasion on MRI)

8.5 Gy x 4 = 34 Gy (EQD2 52.4 Gy)

GTV EQD2 80-90 Gy

CTV EQD2 48-62.5 Gy

EBRT + HDR:

EBRT 45Gy

HDR 8.5 Gy x 2 (EQD2 70.5 Gy) or 5 Gy x 5 (EQD2 75 Gy).

GTV EQD2 80-90 Gy

Stage I CTV EQD2 70Gy

Stage II-III CTV EQD2 75 Gy

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26
Q

Inoperable endometrial cancer: dose constraints

A

D2cc rectum and sigmoid EQD2 <70Gy

D2cc bladder EQD2 <90Gy

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27
Q

Inoperable endometrial cancer: 15yr DSS for stage I and II

A

15-yr DSS

Stage I 90%

Stage II 45%

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28
Q

Endometrial cancer: postop workup

A

H&P. Postmenopausal vaginal bleeding. GYN exam

Labs: CBC, CMP, CA-125

Endometrial bx

Imaging: CT A/P, CXR

Surgery: TAH/BSO with nodal dissection. ex lap with palpation of liver and cytology. Sample omentum if advanced or sarcoma. Lymph node dissection controversial

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29
Q

Endometrial cancer: postop observation criteria

A

Grade 1-2 with <50% invasion and no other high risk factors

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30
Q

Operable endometrial cancer: OS for stage I-IV

A

stage I 90%

stage II 70%

stage III 50%

stage IV 15%

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31
Q

Endometrial cancer: indications for postop WPRT

A

grade 3

IB

cervical stromal invasion

grade 1-2 with >50% invasion if other risk present such as age >60 or LVSI

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32
Q

Endometrial cancer: postop WPRT classic fields and 3D contours

A

Field borders: superior L4/L5 to inferior at bottom of obturator foramen, 2 cm on pelvic brim, ant in front of pubic symphysis, post is at S2/3

Contours for 3D or IMRT: common, external and internal iliacs, presacral nodes, parametrium and postop area, vaginal cuff and upper 3 cm of vagina.

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33
Q

Endometrial cancer: postop HDR criteria

A

Grade 1-2 with >50% invasion

Grade 3 with <50% invasion

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34
Q

Endometrial cancer: postop HDR dose

A

First examine vaginal cuff for healing

6 Gy x 5 to surface (favored), 7 Gy x 3 to 0.5 cm depth

Use 11 dwell points 0.5 cm apart. Dwell pt 11, the most inferior, has weight of 1.0, and dwell position 1 superior has dwell weight of 0.5

On applicator points, don’t want less than 10% dose or >10% dose

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35
Q

Endometrial cancer: stage III-IVA treatment paradigm and chemo doses

A

surgery, adjuvant WPRT with concurrent cisplatin, outback carbo/taxol (PORTEC 3, GOG 258, RTOG 9708)

cisplatin concurrent 50 mg/m2 on days 1 and 29

adjuvant carbo (AUC 5) and paclitaxel (175) x 4 (PORTEC 3)

36
Q

Endometrial cancer: stage III-IVA 5yr OS on PORTEC 3

A

5yr OS 75%

37
Q

Vulvar cancer: indications for treating primary site

A

Heaps’ criteria:

positive margin

close margin of <8mm

LVSI

increasing depth (some use >5 mm)

38
Q

Vulvar cancer: definition of depth of invasion

A

epithelial-stromal junction dermal papilla to the deepest point of invasion

39
Q

Vulvar cancer: indications for treating nodes

A

After SLN, give RT for 1 SLN+.

After dissection, give RT for 2 nodes positive or ECE (or consider for 1 node)

40
Q

Vulvar cancer: sim

A

simulate supine with frog leg position in vac-lock, wire vulva, anus, scars, vaginal marker, possibly bolus vulva

41
Q

Vulvar cancer: workup

A

H&P, pelvic and lymph exam with pap smear, vulvar biopsy.

Labs: CBC, CMP, UA, pregnancy test

Imaging: CXR, CT scan, consider MRI and PET. Consider EUA with cystoscopy or sigmoidoscopy

surgery: radical local resection or modified radical vulvectomy with SLN bx. Use unilateral SLN for Stage I. For <2cm size and >2 cm from midline can do unilateral SLN or inguinal node dissection. Can do SLN if size <4cm and no positive nodes and no prior surgery

42
Q

Vulvar cancer: adjuvant radiation doses

A

NCCN: 45-50.4 Gy elective dose

Unresectable: 59.4 - 64.8 Gy, up to 70 Gy for large nodes

Close margin, ECE: NCCN unclear

43
Q

Vulvar cancer: 5yr OS for stage I-IV

A

5yr OS

Stage I 80%

stage II 60%

stage III 40%

stage IV 20%;;

44
Q

Vulvar cancer: cCR and pCR on GOG 205

A

cCR 65%

pCR 50%

45
Q

Vulvar cancer: neoadjuvant treatment paradigm on GOG 205

A

45 Gy to elective areas then boost gross disease to 57.6 Gy in 32 fx with 2 cm margins

concurrent cisplatin 40

surgery

(per NCCN may observe if complete response confirmed with biopsy)

46
Q

Cervix T1a, FIGO IA1

A

depth of invasion < 3mm and horizontal spread < 7mm

47
Q

Cervix T1a2, FIGO IA2

A

depth of invasion 3-5mm, horizontal spread <7mm

48
Q

Cervix T1b1, FIGO IB1

A

clinically visible lesion <4cm

49
Q

Cervix T1b2, FIGO IB2

A

clinically visible lesion >4cm

50
Q

Cervix T2a1, FIGO IIA1

A

<4cm and involves upper vagina

51
Q

Cervix T2a2, FIGO IIA2

A

>4cm and involves upper vagina

52
Q

Cervix T2b, FIGO IIB

A

parametrial invasion

53
Q

Cervix T3a, FIGO IIIA

A

invades lower third of vagina

54
Q

Cervix T3b, FIGO IIIB

A

extends to pelvic wall or causes hydronephrosis and/or nonfunctioning kidney

55
Q

Cervix T4, FIGO IVA

A

invades mucosa of bladder or rectum and/or extends beyond the true pelvis

56
Q

Cervix: what FIGO stage is regional node involvement?

A

FIGO IIIB

57
Q

Endometrium T1a, FIGO IA

A

invades less than half of the myometrium

58
Q

Endometrium T1b, FIGO IB

A

invades more than half of the myometrium

59
Q

Endometrium T2, FIGO II

A

cervical stromal invasion

60
Q

Endometrium T3a, FIGO IIIA

A

involves ovaries or uterine serosa

61
Q

Endometrium T3b, FIGO IIIB

A

involves vagina or parametrium

62
Q

Endometrium T4, FIGO IVA

A

invades bladder or bowel mucosa

63
Q

Endometrium: what FIGO stage is pelvic node involvement?

A

FIGO IIIC1

64
Q

Endometrium: what FIGO stage is para-aortic node involvement?

A

FIGO IIIC2

65
Q

Vulva T1a, FIGO IA

A

<2cm size and <1mm depth of invasion

66
Q

Vulva T1b, FIGO IB

A

>2cm in size OR >1mm depth of invasion

67
Q

Vulva T2, FIGO II

A

involves distal 1/3 urethra, distal 1/3 vagina, or anus

68
Q

Vulva T3, FIGO IVA

A

involves upper 2/3 urethra, upper 2/3 vagina, bladder, rectum, or is fixed to pelvic bone

69
Q

Vulva N1, FIGO IIIA

A

1-2 regional nodes with one up to 5mm

70
Q

Vulva N2a/b, FIGO IIIB

A

3+ nodes all < 5mm

2+ nodes > 5mm

71
Q

Vulva N2c, FIGO IIIC

A

extranodal extension

72
Q

Vulva N3, FIGO IVA

A

fixed or ulcerated nodes

73
Q

Vagina T1, FIGO I

A

tumor confined to vagina (T1a<2cm, T1b>2cm)

74
Q

Vagina T2, FIGO II

A

tumor invading paravaginal tissue (T2a<2cm, T2b>2cm)

75
Q

Vagina T3, FIGO III

A

extending to pelvic sidewall, lower third of vagina, hydronephrosis or nonfunctional kidney

76
Q

Vagina T4, IVA

A

invading bladder or rectum or extending beyond true pelvis

77
Q

Vagina N1, FIGO III

A

pelvic or inguinal nodes

78
Q

Uterine sarcoma T2a, FIGO IIA

A

involves adnexa

79
Q

Uterine sarcoma T2b, FIGO IIB

A

involves other pelvic tissues

80
Q

Uterine sarcoma T3a, FIGO IIIA

A

invades one abdominal site

81
Q

Uterine sarcoma T3b, FIGO IIIB

A

invades more than one abdominal site

82
Q

Uterine sarcoma T4, FIGO IVA

A

invades bladder or rectum

83
Q

Uterine sarcoma N1, FIGO IIIC

A

regional nodal involvement

84
Q

Uterine leiomyosarcoma and endometrial stromal sarcoma T1a/b, FIGO IA/B

A

T1a, FIGO IA <5cm

T1b, FIGO IB > 5cm

85
Q

Uterine adenosarcoma T1a-c, FIGO IA-C

A

T1a, FIGO IA endometrium

T1b, FIGO IB <50% myometrium

T1c, FIGO IC >50% myometrium

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