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.
