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RO Clinical Boards > Gyn Onc > Flashcards

Gyn Onc Flashcards

1
Q

Type of vaginal tumors most suitable for interstititial boost

A

Apical tumor, well-defined, mobile, >0.5 cm thick

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2
Q

Type of vaginal tumors most suitable for IMRT boost

A

Large tumors, lesions involving bladder or rectum (due to fistula risk)

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3
Q

Type of vaginal tumors most suitable for cylinder

A

Superficial vaginal (<0.5 cm thick)

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4
Q

Dose for vaginal boosts

A

65-70 Gy

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5
Q

Pap smear recommendation start at age

A

21

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6
Q

How often to get Paps

A

q2y until age 29

then q3y

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7
Q

Clear cell carcinoma of cervix is associated with

A

in utero DES

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8
Q

Path of cervical cancer which is SCC

A

80-90%

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9
Q

What % of tumors associated with HPV

A

90%

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10
Q

What strains of HPV most associated with cervical ca

A

16, 18

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11
Q

Mechanism of E6

A

Degradation of p53 –> immortalization

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12
Q

Mechanism of E7

A

Inactives Rb (tumor suppressor gene)

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13
Q

Where in cervix do SCC start

A

squamocolumnar junction (transformation zone)

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14
Q

What proportion of HGSIL transforms to SCC

A

30%

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15
Q

Stage I cervix

A

strictly confined to cervix

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16
Q

Stage IA cervix

A

identified microscopically with stromal invasion <5mm and no wider than 7 mm

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17
Q

Stage IB cervix

A

Clinically apparent lesions confined to cervix or preclinical lesions >IA

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18
Q

Stage II cervix

A

extends beyond the cervix but not onto pelvic wall, involves vagina but not down to lower third

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19
Q

Stage IIA cervix

A

No parametrial invasion

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20
Q

Stage IIB cervix

A

Parametrial involvement

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21
Q

Stage III cervix

A

extend to pelvic wall
tumor involving lower third of vagina
hydronephrosis/non-functional kidney

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22
Q

Stage IV cervix

A

spread beyond true pelvis or clinically involved bladder/rectum

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23
Q

Treatment of stage IA SCC

A

Simple hysterectomy

Brachytherapy

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24
Q

What is 5 year OS of Stage IA SCC cervix

A

> 98%

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25
Q

For more advanced tumors (IA2, IB1, IIA1) what treatment is recommended

A 
radical hysterectomy (removal of parametria)
\+ PLND or RT
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26
Q

What is the Sedlis criteria

A

Determines who should get postop RT after radical hysterectomy

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27
Q

What are the Sedlis criteria?

A

LVSI
Degree of stromal invasion (deep 1/3)
Tumor >4 cm

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28
Q

GOG92 study design

A

Radical hysterectomy + PLND for IB tumors and then randomized to:

  • -Adjuvant pelvic RT (46-50 Gy)
  • -Observation
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29
Q

GOG92 findings

A

Locoregional and PFS improved with adjuvant RT, OS trended

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30
Q

Which histology benefitted most from adjuvant RT

A

adenocarcinoma

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31
Q

GOG109 design (Peters)

A

Early stage high risk patients who received radical hysterectomy –>

  1. chemoRT
  2. RT alone
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32
Q

What dose of RT on 109

A

49.3

PA field included if nodes

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33
Q

Chemotherapy used on study

A

Cisplatin (70 mg/m2)

5-FU - 1000 mg/m2 - 4 day continuous infusion

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34
Q

How many cycles of chemo used on GOG109

A

4 (2 concurrent, 2 adjuvant)

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35
Q

Peters criteria

A

3Ps

  • -positive lymph nodes
  • -positive margin
  • -parametrial invasion
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36
Q

For locally advanced disease what is preferred strategy

A

concurrent chemoRT with weeekly cisplatin

EBRT+brachy boost

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37
Q

What has cisplatin been shown to improve in terms of outcomes

A

OS, PFS

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38
Q

What did GOG 123 conclude

A

chemoRT prior to hysterectomy (vs. RT) associated with improved OS and more pCR

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39
Q

What was the research question for RTOG 90-01 (Eifel)

A

extended field RT (para-aortic) vs.

pelvic RT with cis-5FU

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40
Q

What patients included

A

IIB to IVA or bulky stage IB-IIA

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41
Q

What was their recommendation for min dose to Point A

A

80-85 Gy

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42
Q

What is point A

A

2 cm above the cervical os and 2 cm apart from os on the line perpendicular to uterine axis

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43
Q

What is point B

A

3 cm lateral to point A

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44
Q

Superior extent of cervical field

A

L4-L5 or bifurcation of iliacs

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45
Q

Inferior extent of cervical field

A

obturator foramen or 3 cm below inferior vaginal extent

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46
Q

Inferior extent

A

Usually include full sacrum

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47
Q

Anterior extent

A

1 cm anterior to symphysis

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48
Q

For AP fields, how far laterally should you go

A

2 cm lateral to pelvic brim

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49
Q

Ir 192 half life

A

74 days

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50
Q

For cervical brachy, what sequence used for tumor GTV

A

T2 bright

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51
Q

For cervical brachy, what is the high risk CTV

A

GTV (pre-post CRT)
Full cervix
grey zones in MRI (presumed extracervical extent)

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52
Q

For cervical brachy what is the intermediate risk CTV

A

high risk CTV + 5-15 mm

based on macroscopic disease at diagnosis

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53
Q

What dose should be delivered to HR CTV

A

85-90 Gy

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54
Q

What dose should be delivered to IR CTV

A

60 Gy

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55
Q

Dose to subclinical disease

A

50 Gy

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56
Q

Bladder D2cc

A

<80-90

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57
Q

Rectum D2cc

A

<65-75

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58
Q

Sigmoid D2cc

A

<70

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59
Q

Most common gyn malignancy

A

endometrial

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60
Q

Incidence of endometrial ca

A

55,000 cases and rising, possibly due to tamoxifen

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61
Q

What are the four subgroups of endometrial ca

A
  1. POL-E
  2. MSI unstable
  3. Copy number high
  4. Copy number low
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62
Q

Which group has the best prognosis

A

POLE

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63
Q

What group has poorer prognosis

A

copy number high

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64
Q

What are the possibilities for sentinel nodes in endometrial cancer

A

obturator
external iliac
PA

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65
Q

What is a typical endometrial stripe on ultrasound for post menopausal woman

A

<4mm

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66
Q

Where is injected for sentinel node assessment

A

cervix

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67
Q

which locations in cervix

A

3PM

9PM

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68
Q

Stage IA endometrial

A

limited to endometrium or invades inner 1/2 of myometrium

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69
Q

Stage IB endometrial

A

Invades outer 1/2 of myometrium

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70
Q

Stage II endometrial

A

involves cervical stromal tissue

71
Q

Stage IIIA endometrial

A

involves serosa or adnexa

72
Q

Stage IIIB endometrial

A

involves vagina or parametria

73
Q

Stage IIIC1 endometrial

A

Pelvic LN

74
Q

Stage IIIC2 endometrial

A

Para-aortic lymph nodes with or without pelvic

75
Q

Stage IVA endometrial

A

Involves bladder or rectum

76
Q

Stage IVB endometrial

A

Distant mets including inguinal nodes

77
Q

Research question of LAP2 study

A

RCT of laparoscopy vs laparatomy

78
Q

Conclusion of LAP2

A

Identical OS and RR with both modalities

79
Q

MRC ASTEC study question

A

Does pelvic LND improve OS?

80
Q

MRC ASTEC randomization

A
  1. TAH/BSO/palpation

2. TAH/BSO/dissection of iliac/obturator

81
Q

MRC ASTEC conclusion

A

No SS difference in OS (80% in both arms)

Lymphedema worse in LND arm

82
Q

What is the surgery for endometrial cancer

A

Total Hysterectomy / BSO

83
Q

What is the benefit of RT after surgery for stage I disease

A

Significantly improves local control and DFS but no OS improvement

84
Q

GOG 99 research design

A

TAH/BSO then randomized to:

  1. adjuvant pelvic RT (EBRT)
  2. observation
85
Q

When does cervical cancer treatment need to be complete

A

by 8 weeks

86
Q

What was finding of GOG 99

A

EBRT improves incidence of local failure but did not improve OS or DM

87
Q

What was the rate of local failure w/wo EBRT per GOG 99

A

With EBRT: 3%

Without EBRT: 12%

88
Q

Where were most of the recurrences on GOG 99

A

vaginal vault (70%)

89
Q

PORTEC-1 research question

A

Patients received TAH/BSO with palpation and biopsy of suspicious nodes then randomized to:

  1. pelvic EBRT
  2. Observation
90
Q

What patients were included in PORTEC 1

A

stage I
grade 1-2
excluded IC or grade 3

91
Q

Findings of PORTEC 1

A

Pelvic RT decreased LRR but no difference in DM or OS

92
Q

PORTEC 1 LRR at 15 years w/wo RT

A

EBRT: 6%

No RT: 16%

93
Q

What grade 1 patients should get vaginal brachy

A

Probably none, maybe >50% MMI

94
Q

What grade 2 patients should get vaginal brachy

A

> 50% MMI, maybe <50% if other risk factors

95
Q

What grade 3 patients should get vaginal brachy

A

no MMI

96
Q

PORTEC 2 research question

A

Is vaginal brachy enough for intermediate risk localized patients?

97
Q

Which patients included on PORTEC 2

A

Stage I-IIA high intermediate risk patients

98
Q

What are risk factors

A

grade 3
older age (>60)
MMI > 50%
?LVSI

99
Q

How many risk factors to be high intermediate

A

2/3

100
Q

What were the randomizations in PORTEC 2

A
  1. EBRT (46/23)

2. Vaginal brachy

101
Q

What was the vaginal brachy dose/approach

A

HDR, 21 Gy / 3 fx

102
Q

What part of vagina was treated with brachy

A

proximal 1/2

103
Q

What were the vaginal recurrence rates by arm

A

Similar: 1.6 and 1.8%

104
Q

What were the pelvic recurrence rates by arm

A

VB: 6%
VB: 1%

105
Q

What toxicity higher with VB?

A

vaginal atrophy?

106
Q

PORTEC 3 question

A

Adjuvant RT vs. CRT for women with high risk disease

107
Q

What patients included in PORTEC 3

A
  • -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
Q

What chemo was used

A

Two cycles of cis given concurrently (50 mg/m2)

Four cycles adjuvant carbo-taxol

109
Q

What radiation was used on PORTEC 3

A

48.6 Gy

110
Q

What endpoints were improved with CRT

A

OS, FFS, DMFS

111
Q

What was the OS at 5 years

A

CRT: 81%
RT: 76%

112
Q

When should vaginal brachy be done?

A

6-10 weeks postop

PORTEC up to 8 weeks

113
Q

Typical post hysterectomy length of vagina

A

8 cm

114
Q

What area is treated with vaginal brachy

A

Usually upper 2/3

115
Q

Vaginal brachytherapy dose (mono)

A

7 x 3 to 5 mm depth

4 Gy x 6 to surface

116
Q

Post-EBRT vaginal brachy dose

A

6 Gy x 3 to surface

117
Q

CTV areas to cover with EBRT

A 
common iliac
external iliac
internal iliac
upper 3 cm of vagina
paravaginal soft tissues
118
Q

Where is most common place for vulvar cancer?

A

labia major/minora

119
Q

Drainage of well-lateralized vulvar cancer

A

ipsi superficial inguinal –> deep inguinal –> external iliac

120
Q

Drainage of midline vulvar cancer

A

bilateral inguinal –> pelvic LN

121
Q

Stage IA vulvar

A

<2 cm confined to vulva, stromal invasion < 1 mm

122
Q

Stage IB vulvar

A

> 2 cm or > 1mm stromal invasion

123
Q

Stage II vulvar

A

extension to adjacent perineal structures (lower urethra, lower vagina, anus)

124
Q

Stage IIIA vulvar

A

one inguinofemoral node > 5mm

125
Q

Stage IIIB vulvar

A

2+ nodes > 5 mm

126
Q

Stage IIIC vulvar

A

any nodes with ECE

127
Q

IVA vulvar

A

Invasion into upper urethra, vagina, bladder, rectum, fixed to pelvic bones, femoral nodes

128
Q

IVB vulvar

A

distant mets

PELVIC nodes

129
Q

VIN how many become invasive cancer

A

5%

130
Q

Does vulvectomy improve survival

A

yes, 5 year improved 25-75%

131
Q

What is the ideal margin for vulvar cancer

A

aim for 1.5 cm

true 8 mm margin is ideal

132
Q

Indication for PORT

A
  1. positive margin or close margin
  2. LVI
  3. depth of invasion > 5 mm
133
Q

What dose for resected disease

A

54 Gy to primary

45-50.4 to nodes

134
Q

What dose for +margin or ECE

A

60-65 Gy

135
Q

If unresectable, what is the dose of RT for preoperative

A

57.6 Gy

136
Q

What chemo should be given with it

A

cisplatin

137
Q

What was the rate of pCR after neoadjuvant CRT

A

64%

138
Q

What to cover if cN0

A

vulva

bilateral inguinofemoral nodes

139
Q

What to include if distal vagina

A

obturator and internal/external iliac

140
Q

What about proximal vagina

A

add presacral

141
Q

What histology is most common for vaginal cancer

A

SCC

142
Q

Stage I vaginal

A

confined to vagina

143
Q

Stage II vaginal

A

invades to paravaginal tissue

144
Q

Stage III vaginal

A

extends to pelvic wall or involved regional nodes (inguinopelvic)

145
Q

Stage IVA vaginal

A

Invades mucosa of bladder or rectum

146
Q

Stage IVB

A

distant mets

147
Q

BRCA1 is associated with what risk of ovarian ca

A

40-60%

148
Q

BRCA2 is associated with what risk of ovarian ca

A

10-20%

149
Q

Are women with BRCA1 recommended to undergo BSO

A

yes, 72% reduction ovarian ca, breast ca and all cause mortality

150
Q

What is the dose rate of HDR

A

> 12 Gy/hr

151
Q

How long between HDR fractions

A

24h

152
Q

What form of RT does Ir-192 produce

A

beta decay

gamma rays

153
Q

Interstitial applicator needed if depth of disease is greater than

A

5 mm

154
Q

Duodenum constraint

A

D15cc < 55 Gy

D2cc < 60 Gy

155
Q

GOG 120 study cervix - design

A

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
Q

Chemo regimens studied on GOG 120

A
  1. Cisplatin 40 mg/m2 weekly
  2. Cisplatin + 5FU + Hydroxyurea
  3. Hydroxyurea alone
157
Q

Results of GOG 120

A

Improvement in PFS and OS from cisplatin containing regimens

158
Q

Standard of care chemo for concurrent cervical CRT

A

cisplatin 40 mg/m2 weekly

159
Q

High risk features identified on PORTEC I

A

Age > 60
Over 1/2 MMI
Grade 3

160
Q

Conclusion of PORTEC I

A

Significant reduced LR recurrence if 2 high risk features were present
23% vs. 5%

161
Q

PORTEC II inclusion criteria

A

Age >60, G1-2 and >50% MMI
Age >60, G3 and <50% MMI
Stage IIA any age except G3 + >50% MMI

162
Q

Strongest factor predictive of local recurrence for vulvar ca

A

margin < 8mm

163
Q

For vulvar patients with IA disease risk of inguinal nodes

A

<8% [No SLN assessment needed]

164
Q

What is the strongest predictor of OS for vulvar cancer

A

N+ status

165
Q

From Peters trial, what was the OS with and without chemo

A

CRT - 81%

RT - 71%

166
Q

What chemo used on Peters trial

A

Cis/5-FU q3w

167
Q

What is the length of vagina usually treated with brachy

A

3-5 cm

168
Q

IIIC1 cervix

A

pelvic nodes

169
Q

IIIC2 cervix

A

PA nodes

170
Q

T4 vulva

A

there is none

171
Q

most common location for vaginal cancer

A

upper posterior vagina

172
Q

Risk of pelvic nodal involvement for cervical ca

A

stage x 15

173
Q

Risk of PA nodal involvement for cervical ca

A

half of pelvic risk

174
Q

rad hysterectomy removes how much vagina

A

1/2

RO Clinical Boards (13 decks)

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