Gyn Onc Flashcards
1
Q
Type of vaginal tumors most suitable for interstititial boost
A
Apical tumor, well-defined, mobile, >0.5 cm thick
2
Q
Type of vaginal tumors most suitable for IMRT boost
A
Large tumors, lesions involving bladder or rectum (due to fistula risk)
3
Q
Type of vaginal tumors most suitable for cylinder
A
Superficial vaginal (<0.5 cm thick)
4
Q
Dose for vaginal boosts
A
65-70 Gy
5
Q
Pap smear recommendation start at age
A
21
6
Q
How often to get Paps
A
q2y until age 29
then q3y
7
Q
Clear cell carcinoma of cervix is associated with
A
in utero DES
8
Q
Path of cervical cancer which is SCC
A
80-90%
9
Q
What % of tumors associated with HPV
A
90%
10
Q
What strains of HPV most associated with cervical ca
A
16, 18
11
Q
Mechanism of E6
A
Degradation of p53 –> immortalization
12
Q
Mechanism of E7
A
Inactives Rb (tumor suppressor gene)
13
Q
Where in cervix do SCC start
A
squamocolumnar junction (transformation zone)
14
Q
What proportion of HGSIL transforms to SCC
A
30%
15
Q
Stage I cervix
A
strictly confined to cervix
16
Q
Stage IA cervix
A
identified microscopically with stromal invasion <5mm and no wider than 7 mm
17
Q
Stage IB cervix
A
Clinically apparent lesions confined to cervix or preclinical lesions >IA
18
Q
Stage II cervix
A
extends beyond the cervix but not onto pelvic wall, involves vagina but not down to lower third
19
Q
Stage IIA cervix
A
No parametrial invasion
20
Q
Stage IIB cervix
A
Parametrial involvement
21
Q
Stage III cervix
A
extend to pelvic wall
tumor involving lower third of vagina
hydronephrosis/non-functional kidney
22
Q
Stage IV cervix
A
spread beyond true pelvis or clinically involved bladder/rectum
23
Q
Treatment of stage IA SCC
A
Simple hysterectomy
Brachytherapy
24
Q
What is 5 year OS of Stage IA SCC cervix
A
> 98%
25
For more advanced tumors (IA2, IB1, IIA1) what treatment is recommended
```
radical hysterectomy (removal of parametria)
+ PLND or RT
```
26
What is the Sedlis criteria
Determines who should get postop RT after radical hysterectomy
27
What are the Sedlis criteria?
LVSI
Degree of stromal invasion (deep 1/3)
Tumor >4 cm
28
GOG92 study design
Radical hysterectomy + PLND for IB tumors and then randomized to:
- -Adjuvant pelvic RT (46-50 Gy)
- -Observation
29
GOG92 findings
Locoregional and PFS improved with adjuvant RT, OS trended
30
Which histology benefitted most from adjuvant RT
adenocarcinoma
31
GOG109 design (Peters)
Early stage high risk patients who received radical hysterectomy -->
1. chemoRT
2. RT alone
32
What dose of RT on 109
49.3
| PA field included if nodes
33
Chemotherapy used on study
Cisplatin (70 mg/m2)
| 5-FU - 1000 mg/m2 - 4 day continuous infusion
34
How many cycles of chemo used on GOG109
4 (2 concurrent, 2 adjuvant)
35
Peters criteria
3Ps
- -positive lymph nodes
- -positive margin
- -parametrial invasion
36
For locally advanced disease what is preferred strategy
concurrent chemoRT with weeekly cisplatin
| EBRT+brachy boost
37
What has cisplatin been shown to improve in terms of outcomes
OS, PFS
38
What did GOG 123 conclude
chemoRT prior to hysterectomy (vs. RT) associated with improved OS and more pCR
39
What was the research question for RTOG 90-01 (Eifel)
extended field RT (para-aortic) vs.
| pelvic RT with cis-5FU
40
What patients included
IIB to IVA or bulky stage IB-IIA
41
What was their recommendation for min dose to Point A
80-85 Gy
42
What is point A
2 cm above the cervical os and 2 cm apart from os on the line perpendicular to uterine axis
43
What is point B
3 cm lateral to point A
44
Superior extent of cervical field
L4-L5 or bifurcation of iliacs
45
Inferior extent of cervical field
obturator foramen or 3 cm below inferior vaginal extent
46
Inferior extent
Usually include full sacrum
47
Anterior extent
1 cm anterior to symphysis
48
For AP fields, how far laterally should you go
2 cm lateral to pelvic brim
49
Ir 192 half life
74 days
50
For cervical brachy, what sequence used for tumor GTV
T2 bright
51
For cervical brachy, what is the high risk CTV
GTV (pre-post CRT)
Full cervix
grey zones in MRI (presumed extracervical extent)
52
For cervical brachy what is the intermediate risk CTV
high risk CTV + 5-15 mm
| based on macroscopic disease at diagnosis
53
What dose should be delivered to HR CTV
85-90 Gy
54
What dose should be delivered to IR CTV
60 Gy
55
Dose to subclinical disease
50 Gy
56
Bladder D2cc
<80-90
57
Rectum D2cc
<65-75
58
Sigmoid D2cc
<70
59
Most common gyn malignancy
endometrial
60
Incidence of endometrial ca
55,000 cases and rising, possibly due to tamoxifen
61
What are the four subgroups of endometrial ca
1. POL-E
2. MSI unstable
3. Copy number high
4. Copy number low
62
Which group has the best prognosis
POLE
63
What group has poorer prognosis
copy number high
64
What are the possibilities for sentinel nodes in endometrial cancer
obturator
external iliac
PA
65
What is a typical endometrial stripe on ultrasound for post menopausal woman
<4mm
66
Where is injected for sentinel node assessment
cervix
67
which locations in cervix
3PM
| 9PM
68
Stage IA endometrial
limited to endometrium or invades inner 1/2 of myometrium
69
Stage IB endometrial
Invades outer 1/2 of myometrium
70
Stage II endometrial
involves cervical stromal tissue
71
Stage IIIA endometrial
involves serosa or adnexa
72
Stage IIIB endometrial
involves vagina or parametria
73
Stage IIIC1 endometrial
Pelvic LN
74
Stage IIIC2 endometrial
Para-aortic lymph nodes with or without pelvic
75
Stage IVA endometrial
Involves bladder or rectum
76
Stage IVB endometrial
Distant mets including inguinal nodes
77
Research question of LAP2 study
RCT of laparoscopy vs laparatomy
78
Conclusion of LAP2
Identical OS and RR with both modalities
79
MRC ASTEC study question
Does pelvic LND improve OS?
80
MRC ASTEC randomization
1. TAH/BSO/palpation
| 2. TAH/BSO/dissection of iliac/obturator
81
MRC ASTEC conclusion
No SS difference in OS (80% in both arms)
| Lymphedema worse in LND arm
82
What is the surgery for endometrial cancer
Total Hysterectomy / BSO
83
What is the benefit of RT after surgery for stage I disease
Significantly improves local control and DFS but no OS improvement
84
GOG 99 research design
TAH/BSO then randomized to:
1. adjuvant pelvic RT (EBRT)
2. observation
85
When does cervical cancer treatment need to be complete
by 8 weeks
86
What was finding of GOG 99
EBRT improves incidence of local failure but did not improve OS or DM
87
What was the rate of local failure w/wo EBRT per GOG 99
With EBRT: 3%
| Without EBRT: 12%
88
Where were most of the recurrences on GOG 99
vaginal vault (70%)
89
PORTEC-1 research question
Patients received TAH/BSO with palpation and biopsy of suspicious nodes then randomized to:
1. pelvic EBRT
2. Observation
90
What patients were included in PORTEC 1
stage I
grade 1-2
excluded IC or grade 3
91
Findings of PORTEC 1
Pelvic RT decreased LRR but no difference in DM or OS
92
PORTEC 1 LRR at 15 years w/wo RT
EBRT: 6%
| No RT: 16%
93
What grade 1 patients should get vaginal brachy
Probably none, maybe >50% MMI
94
What grade 2 patients should get vaginal brachy
>50% MMI, maybe <50% if other risk factors
95
What grade 3 patients should get vaginal brachy
no MMI
96
PORTEC 2 research question
Is vaginal brachy enough for intermediate risk localized patients?
97
Which patients included on PORTEC 2
Stage I-IIA high intermediate risk patients
98
What are risk factors
grade 3
older age (>60)
MMI > 50%
?LVSI
99
How many risk factors to be high intermediate
2/3
100
What were the randomizations in PORTEC 2
1. EBRT (46/23)
| 2. Vaginal brachy
101
What was the vaginal brachy dose/approach
HDR, 21 Gy / 3 fx
102
What part of vagina was treated with brachy
proximal 1/2
103
What were the vaginal recurrence rates by arm
Similar: 1.6 and 1.8%
104
What were the pelvic recurrence rates by arm
VB: 6%
VB: 1%
105
What toxicity higher with VB?
vaginal atrophy?
106
PORTEC 3 question
Adjuvant RT vs. CRT for women with high risk disease
107
What patients included in PORTEC 3
- -I: endometrioid grade 3 cancer with deep myometrial invasion or lymphovascular space invasion, or both;
- -stage II or III disease
- -stage I–III disease with serous or clear cell histology
108
What chemo was used
Two cycles of cis given concurrently (50 mg/m2)
| Four cycles adjuvant carbo-taxol
109
What radiation was used on PORTEC 3
48.6 Gy
110
What endpoints were improved with CRT
OS, FFS, DMFS
111
What was the OS at 5 years
CRT: 81%
RT: 76%
112
When should vaginal brachy be done?
6-10 weeks postop
| PORTEC up to 8 weeks
113
Typical post hysterectomy length of vagina
8 cm
114
What area is treated with vaginal brachy
Usually upper 2/3
115
Vaginal brachytherapy dose (mono)
7 x 3 to 5 mm depth
| 4 Gy x 6 to surface
116
Post-EBRT vaginal brachy dose
6 Gy x 3 to surface
117
CTV areas to cover with EBRT
```
common iliac
external iliac
internal iliac
upper 3 cm of vagina
paravaginal soft tissues
```
118
Where is most common place for vulvar cancer?
labia major/minora
119
Drainage of well-lateralized vulvar cancer
ipsi superficial inguinal --> deep inguinal --> external iliac
120
Drainage of midline vulvar cancer
bilateral inguinal --> pelvic LN
121
Stage IA vulvar
<2 cm confined to vulva, stromal invasion < 1 mm
122
Stage IB vulvar
>2 cm or > 1mm stromal invasion
123
Stage II vulvar
extension to adjacent perineal structures (lower urethra, lower vagina, anus)
124
Stage IIIA vulvar
one inguinofemoral node > 5mm
125
Stage IIIB vulvar
2+ nodes > 5 mm
126
Stage IIIC vulvar
any nodes with ECE
127
IVA vulvar
Invasion into upper urethra, vagina, bladder, rectum, fixed to pelvic bones, femoral nodes
128
IVB vulvar
distant mets
| PELVIC nodes
129
VIN how many become invasive cancer
5%
130
Does vulvectomy improve survival
yes, 5 year improved 25-75%
131
What is the ideal margin for vulvar cancer
aim for 1.5 cm
| true 8 mm margin is ideal
132
Indication for PORT
1. positive margin or close margin
2. LVI
3. depth of invasion > 5 mm
133
What dose for resected disease
54 Gy to primary
| 45-50.4 to nodes
134
What dose for +margin or ECE
60-65 Gy
135
If unresectable, what is the dose of RT for preoperative
57.6 Gy
136
What chemo should be given with it
cisplatin
137
What was the rate of pCR after neoadjuvant CRT
64%
138
What to cover if cN0
vulva
| bilateral inguinofemoral nodes
139
What to include if distal vagina
obturator and internal/external iliac
140
What about proximal vagina
add presacral
141
What histology is most common for vaginal cancer
SCC
142
Stage I vaginal
confined to vagina
143
Stage II vaginal
invades to paravaginal tissue
144
Stage III vaginal
extends to pelvic wall or involved regional nodes (inguinopelvic)
145
Stage IVA vaginal
Invades mucosa of bladder or rectum
146
Stage IVB
distant mets
147
BRCA1 is associated with what risk of ovarian ca
40-60%
148
BRCA2 is associated with what risk of ovarian ca
10-20%
149
Are women with BRCA1 recommended to undergo BSO
yes, 72% reduction ovarian ca, breast ca and all cause mortality
150
What is the dose rate of HDR
>12 Gy/hr
151
How long between HDR fractions
24h
152
What form of RT does Ir-192 produce
beta decay
| gamma rays
153
Interstitial applicator needed if depth of disease is greater than
5 mm
154
Duodenum constraint
D15cc < 55 Gy
| D2cc < 60 Gy
155
GOG 120 study cervix - design
IIB to IVA cervical cancer patients
All received EBRT + brachy (total point A dose of 81 Gy)
Randomization was to different concurrent chemo regimens
156
Chemo regimens studied on GOG 120
1. Cisplatin 40 mg/m2 weekly
2. Cisplatin + 5FU + Hydroxyurea
3. Hydroxyurea alone
157
Results of GOG 120
Improvement in PFS and OS from cisplatin containing regimens
158
Standard of care chemo for concurrent cervical CRT
cisplatin 40 mg/m2 weekly
159
High risk features identified on PORTEC I
Age > 60
Over 1/2 MMI
Grade 3
160
Conclusion of PORTEC I
Significant reduced LR recurrence if 2 high risk features were present
23% vs. 5%
161
PORTEC II inclusion criteria
Age >60, G1-2 and >50% MMI
Age >60, G3 and <50% MMI
Stage IIA any age except G3 + >50% MMI
162
Strongest factor predictive of local recurrence for vulvar ca
margin < 8mm
163
For vulvar patients with IA disease risk of inguinal nodes
<8% [No SLN assessment needed]
164
What is the strongest predictor of OS for vulvar cancer
N+ status
165
From Peters trial, what was the OS with and without chemo
CRT - 81%
| RT - 71%
166
What chemo used on Peters trial
Cis/5-FU q3w
167
What is the length of vagina usually treated with brachy
3-5 cm
168
IIIC1 cervix
pelvic nodes
169
IIIC2 cervix
PA nodes
170
T4 vulva
there is none
171
most common location for vaginal cancer
upper posterior vagina
172
Risk of pelvic nodal involvement for cervical ca
stage x 15
173
Risk of PA nodal involvement for cervical ca
half of pelvic risk
174
rad hysterectomy removes how much vagina
1/2
