Gyne

Question 1

Brachytherapy procedure cervix

Answer 1

Brachytherapy procedure
1. General anesthetic with intraoperative antibiotics (1g Ancef)
2. Patient in dorsal lithotomy position
3. Examination under anesthesia
4. Prep patient with topical antiseptic and drape patient
5. Insert foley catheter insert contrast
6. Sound cervical length
7. Perform cervical dilatation up to 16 French (6mm)
8. Insert tandem
9. Place ovoids over tandem, insert interstitial needs if applicable
10. Pack vagina with gauze
11. Drain bladder, clamp foley, and insert 50cc of fluid
12. Perform MRI
13. Contour and develop treatment plan
14. Attach afterloader and treat
15. Remove vaginal packing and applicator
16. Apply pressure to the cervix as necessary to reduce bleeding
17. Awake patient

Question 2

Cervix: what are indications for PORT, post-op CRT? And dose/ chemo and expected benefit.

Answer 2

1) 2/3 of: greater than 1/3 stromal invasion, LVI, size >4cm
2) CRT: positive margin, positive parametria, positive node!

Dose PORT: 45Gy/25#: increases LC (by 8% to 80%)
OR CRT: 45Gy/25# with cisplatin 40mg/m2: increases OS absolute by 9%, PFS absolute by 17% (to 80%, OS also 80%)

Question 3

What are the nodal volumes and who gets treatment for them and at what dose?

Answer 3

1) Small pelvis: 55/25 EBRT with EQD2 60Gy desired after brachy: for anyone <4cm in size, node negative, no uterine invasion. This includes internal/external iliac, presacral, obturator nodes.

2) Large pelvis 55/25: intermediate risk (neither above or below criteria)
- Nodes in small pelvis and common iliac region including the aortic bifurcation.
- If distal vaginal involvement then also include inguinal nodes.

3) Large pelvis + PA nodes (PA boost to 57.5/25 becuase less brachy contribution): include up to L2 or 3cm higher than positive PA node (by PET):
- For anyone with positive common iliac node or above
- For anyone with ≥3 pathologic nodes

Question 4

Guardasil 9 strains

Answer 4

6, 11, 16, 18, 31, 33, 45, 52, and 58

Question 5

Endometrial what are the borders for CTV (same as for post-op Cervix!!!!)

Answer 5

CTVP: vaginal/parametria:
anteriorly to bladder wall
posteriorly to uterosacral ligament/mesorectal fascia
superiorly to 2cm above vaginal cuff
inferiorly to include 3cm of vagina
Laterally: to pelvic sidewall

CTVn: internal/external iliac to bifurcation, obturator, presacral

PTV: 7mm

ITV: on full bladder, empty bladder data sets.

NOTE: this is also same dose for post-op cervix: 45/25!!!!

Question 6

In gyne cancers, when do we add chemo?

Answer 6

• Cervix add chemo if positive node, margin, parametria
• Uterus add chemo if Stage III, (serosa/bussy), serous, p53
• Vulva: to primary ONLY for definitive (XRT alone if positive or close margin), and nodes if ≥3 positive or ECE!

Question 7

Vulva:
1) indications for PORT primary
2) indications for PORT LN

Answer 7

1) margins <8mm, DOI >5mm, LVI, size >4cm
2) 1 micromet on SLNB (omit LND) OR ≥2 pathologic nodes or ECE. If 3 positive or ECE add chemo.

Question 8

Simulation for vulvar cancer. Bryce: what are two things you do on set up to ensure proper dose to primary?

Answer 8

Supine, with contrast, leg rest, arms on chest, full bladder and empty rectum, wire scar, mark anal verge / introitus, assess for self-bolus (consider TLD) - legs together.

Question 9

Vulva: doses for exam

Answer 9

1) 45/25 for adjuvant simple primary and elective nodes contralateral side (NOTE: VOLUME INCLUDES ENTIRE VULVA INCLUDING MONS AND PERINEAL BODY)
2) 54/30 if close margin or node positive
3) 63/35 for definitive

Question 10

What is the dose rate for
1) LDR
2) HDR

Answer 10

1) LDR = <2Gy/hr
2) HDR = >12Gy/hr

Question 11

Cervix: define HR-CTV, IR-CTV, LR-CTV and dose objectives:

Answer 11

HR CTV: macroscopic disease at time of BT and entire cervix including grayzone. (Goal 90Gy EQD2, must receive at least 85 Gy). (macroscopic tumor cells)

IR CTV: (significant microscopic disease): HR CTV + 1cm expansion (should receive 60Gy EQD2 or 50% of prescription dose…)

LR: potential microscopic spread: upper half vagina, parametria (ant to bladder wall, post to uterosacral ligament/mesorectum, lat to pelvic sidewall, sup to broad ligament, inf to urogenital ligament)

Question 12

Clinical objectives brachy for cervix

Answer 12

GTV: D98>95Gy
HRCTV: D98 > 90Gy
IRCTV: D98 > 60Gy
Point A: EQD2 > 65 Gy (think: this is limit bc bowel right beside)

OARS:
- Bladder D2cc < 80Gy
- Rectum D2cc < 65Gy
- Sigmoid D2cc < 70Gy
- Bowel D2cc < 70Gy

Question 13

What 4 factors determine if can do SLNB for vulvar cancer?

Answer 13

1) <4cm, Stage I/II FIGO, >1mm DOI, clinically node negative