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OB2 > GYN > Flashcards

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
Q

Cervix T2a1, FIGO IIA1

A

<4cm and involves upper vagina

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26
Q

Vagina T3, FIGO III

A

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

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27
Q

Cervix T3a, FIGO IIIA

A

invades lower third of vagina

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28
Q

Vulva T3, FIGO IVA

A

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

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29
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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30
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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31
Q

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

A

5yr OS 75%

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32
Q

Endometrium: what FIGO stage is pelvic node involvement?

A

FIGO IIIC1

33
Q

Cervical cancer: classic fields

A

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
Q

Vulva T1a, FIGO IA

A

<2cm size and <1mm depth of invasion

35
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

36
Q

Endometrium T3b, FIGO IIIB

A

involves vagina or parametrium

37
Q

Vaginal cancer: local control for stage I-III

A

LC:

stage I 90%

stage II 80%

stage III 70%

38
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

39
Q

Vulvar cancer: definition of depth of invasion

A

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

40
Q

Vulva N3, FIGO IVA

A

fixed or ulcerated nodes

41
Q

Vulva T2, FIGO II

A

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

42
Q

Endometrium T1b, FIGO IB

A

invades more than half of the myometrium

43
Q

Exams allowed for FIGO staging

A

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

44
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

45
Q

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

A

15-yr DSS

Stage I 90%

Stage II 45%

46
Q

Vulva T1b, FIGO IB

A

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

47
Q

Cervix T1a, FIGO IA1

A

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

48
Q

Vulva N2c, FIGO IIIC

A

extranodal extension

49
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

50
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

51
Q

Endometrium T1a, FIGO IA

A

invades less than half of the myometrium

52
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.

53
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

54
Q

Cervix T2b, FIGO IIB

A

parametrial invasion

55
Q

Vulva N2a/b, FIGO IIIB

A

3+ nodes all < 5mm

2+ nodes > 5mm

56
Q

Uterine sarcoma T3b, FIGO IIIB

A

invades more than one abdominal site

57
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.

58
Q

Vulva N1, FIGO IIIA

A

1-2 regional nodes with one up to 5mm

59
Q

Cervix T1b1, FIGO IB1

A

clinically visible lesion <4cm

60
Q

Cervix T4, FIGO IVA

A

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

61
Q

GYN cancer: concurrent chemo

A

cisplatin 40 weekly, 5-6 cycles

62
Q

Uterine sarcoma T3a, FIGO IIIA

A

invades one abdominal site

63
Q

Vaginal dose tolerance (upper, middle, lower)

A

upper 120Gy

mid 90Gy

lower 60Gy

64
Q

Vagina N1, FIGO III

A

pelvic or inguinal nodes

65
Q

Cervix T1b2, FIGO IB2

A

clinically visible lesion >4cm

66
Q

Vulvar cancer: sim

A

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

67
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)

68
Q

Cervix T2a2, FIGO IIA2

A

>4cm and involves upper vagina

69
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.

70
Q

Endometrium T3a, FIGO IIIA

A

involves ovaries or uterine serosa

71
Q

Vulvar cancer: cCR and pCR on GOG 205

A

cCR 65%

pCR 50%

72
Q

Uterine sarcoma T2a, FIGO IIA

A

involves adnexa

73
Q

Cervix T1a2, FIGO IA2

A

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

74
Q

3D Tandem and Ovoid dosimetry

A

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
Q

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

A

T1a, FIGO IA <5cm

T1b, FIGO IB > 5cm

76
Q

Operable endometrial cancer: OS for stage I-IV

A

stage I 90%

stage II 70%

stage III 50%

stage IV 15%

77
Q

Inoperable endometrial cancer: dose constraints

A

D2cc rectum and sigmoid EQD2 <70Gy

D2cc bladder EQD2 <90Gy

78
Q

Uterine sarcoma N1, FIGO IIIC

A

regional nodal involvement

79
Q

Inoperable Endometrial cancer: workup

A

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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