GYN Flashcards
Exams allowed for FIGO staging
EUA, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, IVP, CXR, skeletal x-ray
Cervical cancer: workup
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
Treatment options for IB1 cervical cancer
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
Cervical cancer: classic fields
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)
Cervical cancer: 5yr OS by stage
IA 100%
IB1 90%
IB2 70%
IIA/B 70%
III 50%
IVA 30%
Point-based Tandem and Ovoid narrative
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.
Cervical cancer: dose for EBRT and brachy
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.
GYN cancer: concurrent chemo
cisplatin 40 weekly, 5-6 cycles
Evaluating tandem and ovoid placement
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
Ir192: general activity, half life, energy
Starts at ~10 Ci.
Half life 74 days
300kEV
change out source every 3 months
1% decay/day
3D Tandem and Ovoid Narrative
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)
3D Tandem and Ovoid: volumes and dose
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.
3D Tandem and Ovoid dosimetry
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
Cervical cancer: indications for post-op radiation
Sedlis criteria (need at least two):
LVSI
size >4 cm
≥2/3 stromal invasion
Cervical cancer: borders of parametrium
superior: bowel
lateral: pelvic wall
anterior: 1 cm into bladder
posterior: uterosacral ligaments (know location)
inferior: UG diaphragm
Cervical cancer: indications for post-op chemoradiation
Peters criteria:
positive nodes
positive margins
parametrial involvement
Cervical cancer intertitial brachytherapy narrative
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
Cervical cancer: indications for parametrial boost and dose utilized
Indication: parametrial involvement when treating definitive cervix
5.4-9 Gy boost after 45 Gy to pelvis
Vaginal cancer: fields and dose
45 Gy EBRT whole pelvis (for lower vagina consider adding inguinals) followed by boost
Boost:
Interstitial technique
Deliver twice daily or once daily
- 5 Gy x 5 fx= BED 80
- 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.
Vaginal dose tolerance (upper, middle, lower)
upper 120Gy
mid 90Gy
lower 60Gy
Vaginal cancer: local control for stage I-III
LC:
stage I 90%
stage II 80%
stage III 70%
Inoperable Endometrial cancer: workup
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
Inoperable endometrial cancer: staging
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
Inoperable endometrial cancer: brachytherapy narrative
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.
Inoperable endometrial cancer: doses and fields
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
Inoperable endometrial cancer: dose constraints
D2cc rectum and sigmoid EQD2 <70Gy
D2cc bladder EQD2 <90Gy
Inoperable endometrial cancer: 15yr DSS for stage I and II
15-yr DSS
Stage I 90%
Stage II 45%
Endometrial cancer: postop workup
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
Endometrial cancer: postop observation criteria
Grade 1-2 with <50% invasion and no other high risk factors
Operable endometrial cancer: OS for stage I-IV
stage I 90%
stage II 70%
stage III 50%
stage IV 15%
Endometrial cancer: indications for postop WPRT
grade 3
IB
cervical stromal invasion
grade 1-2 with >50% invasion if other risk present such as age >60 or LVSI
Endometrial cancer: postop WPRT classic fields and 3D contours
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.
Endometrial cancer: postop HDR criteria
Grade 1-2 with >50% invasion
Grade 3 with <50% invasion
Endometrial cancer: postop HDR dose
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
Endometrial cancer: stage III-IVA treatment paradigm and chemo doses
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)
Endometrial cancer: stage III-IVA 5yr OS on PORTEC 3
5yr OS 75%
Vulvar cancer: indications for treating primary site
Heaps’ criteria:
positive margin
close margin of <8mm
LVSI
increasing depth (some use >5 mm)
Vulvar cancer: definition of depth of invasion
epithelial-stromal junction dermal papilla to the deepest point of invasion
Vulvar cancer: indications for treating nodes
After SLN, give RT for 1 SLN+.
After dissection, give RT for 2 nodes positive or ECE (or consider for 1 node)
Vulvar cancer: sim
simulate supine with frog leg position in vac-lock, wire vulva, anus, scars, vaginal marker, possibly bolus vulva
Vulvar cancer: workup
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
Vulvar cancer: adjuvant radiation doses
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
Vulvar cancer: 5yr OS for stage I-IV
5yr OS
Stage I 80%
stage II 60%
stage III 40%
stage IV 20%;;
Vulvar cancer: cCR and pCR on GOG 205
cCR 65%
pCR 50%
Vulvar cancer: neoadjuvant treatment paradigm on GOG 205
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)
Cervix T1a, FIGO IA1
depth of invasion < 3mm and horizontal spread < 7mm
Cervix T1a2, FIGO IA2
depth of invasion 3-5mm, horizontal spread <7mm
Cervix T1b1, FIGO IB1
clinically visible lesion <4cm
Cervix T1b2, FIGO IB2
clinically visible lesion >4cm
Cervix T2a1, FIGO IIA1
<4cm and involves upper vagina
Cervix T2a2, FIGO IIA2
>4cm and involves upper vagina
Cervix T2b, FIGO IIB
parametrial invasion
Cervix T3a, FIGO IIIA
invades lower third of vagina
Cervix T3b, FIGO IIIB
extends to pelvic wall or causes hydronephrosis and/or nonfunctioning kidney
Cervix T4, FIGO IVA
invades mucosa of bladder or rectum and/or extends beyond the true pelvis
Cervix: what FIGO stage is regional node involvement?
FIGO IIIB
Endometrium T1a, FIGO IA
invades less than half of the myometrium
Endometrium T1b, FIGO IB
invades more than half of the myometrium
Endometrium T2, FIGO II
cervical stromal invasion
Endometrium T3a, FIGO IIIA
involves ovaries or uterine serosa
Endometrium T3b, FIGO IIIB
involves vagina or parametrium
Endometrium T4, FIGO IVA
invades bladder or bowel mucosa
Endometrium: what FIGO stage is pelvic node involvement?
FIGO IIIC1
Endometrium: what FIGO stage is para-aortic node involvement?
FIGO IIIC2
Vulva T1a, FIGO IA
<2cm size and <1mm depth of invasion
Vulva T1b, FIGO IB
>2cm in size OR >1mm depth of invasion
Vulva T2, FIGO II
involves distal 1/3 urethra, distal 1/3 vagina, or anus
Vulva T3, FIGO IVA
involves upper 2/3 urethra, upper 2/3 vagina, bladder, rectum, or is fixed to pelvic bone
Vulva N1, FIGO IIIA
1-2 regional nodes with one up to 5mm
Vulva N2a/b, FIGO IIIB
3+ nodes all < 5mm
2+ nodes > 5mm
Vulva N2c, FIGO IIIC
extranodal extension
Vulva N3, FIGO IVA
fixed or ulcerated nodes
Vagina T1, FIGO I
tumor confined to vagina (T1a<2cm, T1b>2cm)
Vagina T2, FIGO II
tumor invading paravaginal tissue (T2a<2cm, T2b>2cm)
Vagina T3, FIGO III
extending to pelvic sidewall, lower third of vagina, hydronephrosis or nonfunctional kidney
Vagina T4, IVA
invading bladder or rectum or extending beyond true pelvis
Vagina N1, FIGO III
pelvic or inguinal nodes
Uterine sarcoma T2a, FIGO IIA
involves adnexa
Uterine sarcoma T2b, FIGO IIB
involves other pelvic tissues
Uterine sarcoma T3a, FIGO IIIA
invades one abdominal site
Uterine sarcoma T3b, FIGO IIIB
invades more than one abdominal site
Uterine sarcoma T4, FIGO IVA
invades bladder or rectum
Uterine sarcoma N1, FIGO IIIC
regional nodal involvement
Uterine leiomyosarcoma and endometrial stromal sarcoma T1a/b, FIGO IA/B
T1a, FIGO IA <5cm
T1b, FIGO IB > 5cm
Uterine adenosarcoma T1a-c, FIGO IA-C
T1a, FIGO IA endometrium
T1b, FIGO IB <50% myometrium
T1c, FIGO IC >50% myometrium
