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GYN Flashcards

1
Q

Vulvar cancer: 5yr OS for stage I-IV

A

5yr OS

Stage I 80%

stage II 60%

stage III 40%

stage IV 20%;;

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2
Q

Cervix T3b, FIGO IIIB

A

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

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3
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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4
Q

Uterine sarcoma T2b, FIGO IIB

A

involves other pelvic tissues

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5
Q

Vagina T2, FIGO II

A

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

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6
Q

Cervical cancer: workup

A

H&P, sexual history, pelvic exam (rectovaginal, bimanual, inguinal nodes, abdomen), PAP +/- colposcopy

Labs: CBC, CMP, CA-125, BHCG

Consider oophoropexy if young

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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7
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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8
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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9
Q

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

A

FIGO IIIC2

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10
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)

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11
Q

Cervix: what FIGO stage is regional node involvement?

A

FIGO IIIB

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12
Q

Endometrium T4, FIGO IVA

A

invades bladder or bowel mucosa

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13
Q

Vagina T4, IVA

A

invading bladder or rectum or extending beyond true pelvis

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14
Q

Uterine sarcoma T4, FIGO IVA

A

invades bladder or rectum

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15
Q

Endometrium T2, FIGO II

A

cervical stromal invasion

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16
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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17
Q

Cervical cancer: indications for post-op chemoradiation

A

Peters criteria:

positive nodes

positive margins

parametrial involvement

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18
Q

Vulvar cancer: indications for treating primary site

A

Heaps’ criteria:

positive margin

close margin of <8mm

LVSI

increasing depth (some use >5 mm)

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19
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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20
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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21
Q

Endometrial cancer: postop HDR criteria

A

Grade 1-2 with >50% invasion

Grade 3 with <50% invasion

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22
Q

Vulvar cancer: workup

A

H&P, sexual history, GYN exam (vulva, speculum, bimanual, rectovaginal, inguinal nodes), 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

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23
Q

Vagina T1, FIGO I

A

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

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24
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)

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25
Cervix T2a1, FIGO IIA1
\<4cm and involves upper vagina
26
Vagina T3, FIGO III
extending to pelvic sidewall, lower third of vagina, hydronephrosis or nonfunctional kidney
27
Cervix T3a, FIGO IIIA
invades lower third of vagina
28
Vulva T3, FIGO IVA
involves upper 2/3 urethra, upper 2/3 vagina, bladder, rectum, or is fixed to pelvic bone
29
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
30
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
31
Endometrial cancer: stage III-IVA 5yr OS on PORTEC 3
5yr OS 75%
32
Endometrium: what FIGO stage is pelvic node involvement?
FIGO IIIC1
33
Cervical cancer: classic fields
Sup: L4/5 Inf: obturator foramen Post: 1cm behind sacrum Ant: anterior to symphysis Lat: 2cm beyond pelvic brim RTOG 0724: L1/2 if positive common iliacs T11/12 if positive paraaortics
34
Vulva T1a, FIGO IA
\<2cm size and \<1mm depth of invasion
35
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
36
Endometrium T3b, FIGO IIIB
involves vagina or parametrium
37
Vaginal cancer: local control for stage I-III
LC: stage I 90% stage II 80% stage III 70%
38
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
39
Vulvar cancer: definition of depth of invasion
epithelial-stromal junction dermal papilla to the deepest point of invasion
40
Vulva N3, FIGO IVA
fixed or ulcerated nodes
41
Vulva T2, FIGO II
involves distal 1/3 urethra, distal 1/3 vagina, or anus
42
Endometrium T1b, FIGO IB
invades more than half of the myometrium
43
Exams allowed for FIGO staging
EUA, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, IVP, CXR, skeletal x-ray
44
Cervical cancer: borders of parametrium
superior: bowel lateral: pelvic wall anterior: 1 cm into bladder posterior: uterosacral ligaments (know location) inferior: UG diaphragm
45
Inoperable endometrial cancer: 15yr DSS for stage I and II
15-yr DSS Stage I 90% Stage II 45%
46
Vulva T1b, FIGO IB
\>2cm in size OR \>1mm depth of invasion
47
Cervix T1a, FIGO IA1
depth of invasion \< 3mm and horizontal spread \< 7mm
48
Vulva N2c, FIGO IIIC
extranodal extension
49
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
50
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
51
Endometrium T1a, FIGO IA
invades less than half of the myometrium
52
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. 5 Gy x 5 fx= BED 80 4. 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.
53
Ir192: general activity, half life, energy
Starts at ~10 Ci. Half life 74 days 300kEV change out source every 3 months 1% decay/day
54
Cervix T2b, FIGO IIB
parametrial invasion
55
Vulva N2a/b, FIGO IIIB
3+ nodes all \< 5mm 2+ nodes \> 5mm
56
Uterine sarcoma T3b, FIGO IIIB
invades more than one abdominal site
57
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.
58
Vulva N1, FIGO IIIA
1-2 regional nodes with one up to 5mm
59
Cervix T1b1, FIGO IB1
clinically visible lesion \<4cm
60
Cervix T4, FIGO IVA
invades mucosa of bladder or rectum and/or extends beyond the true pelvis
61
GYN cancer: concurrent chemo
cisplatin 40 weekly, 5-6 cycles
62
Uterine sarcoma T3a, FIGO IIIA
invades one abdominal site
63
Vaginal dose tolerance (upper, middle, lower)
upper 120Gy mid 90Gy lower 60Gy
64
Vagina N1, FIGO III
pelvic or inguinal nodes
65
Cervix T1b2, FIGO IB2
clinically visible lesion \>4cm
66
Vulvar cancer: sim
simulate supine with frog leg position in vac-lock, wire vulva, anus, scars, vaginal marker, possibly bolus vulva
67
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)
68
Cervix T2a2, FIGO IIA2
\>4cm and involves upper vagina
69
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.
70
Endometrium T3a, FIGO IIIA
involves ovaries or uterine serosa
71
Vulvar cancer: cCR and pCR on GOG 205
cCR 65% pCR 50%
72
Uterine sarcoma T2a, FIGO IIA
involves adnexa
73
Cervix T1a2, FIGO IA2
depth of invasion 3-5mm, horizontal spread \<7mm
74
3D Tandem and Ovoid dosimetry
D90 of 80-90 Gy EQD2 D90 of 100% on DVH Bladder D2cc\<90 Gy (\<5.5Gy/fx) Rectum/sigmoid D2cc\<75Gy (\<3.8Gy/fx) Small bowel D2cc\<60 Gy Rectovaginal point\<65 Gy
75
Uterine leiomyosarcoma and endometrial stromal sarcoma T1a/b, FIGO IA/B
T1a, FIGO IA \<5cm T1b, FIGO IB \> 5cm
76
Operable endometrial cancer: OS for stage I-IV
stage I 90% stage II 70% stage III 50% stage IV 15%
77
Inoperable endometrial cancer: dose constraints
D2cc rectum and sigmoid EQD2 \<70Gy D2cc bladder EQD2 \<90Gy
78
Uterine sarcoma N1, FIGO IIIC
regional nodal involvement
79
Inoperable Endometrial cancer: workup
H&P, sexual history, GYN exam (speculum, bimanual, rectovaginal) Labs: CBC, CMP, CA-125, bHCG Endometrial bx Consider oophoropexy to preserve hormonal function Imaging: CT A/P, CXR, MRI

OB2 (10 decks)

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