Uterine Cervix (under construction) Flashcards
Uterine Cervix
The body
of the uterus is enclosed between layers of the round ligament and is freely
mobile.
TRUE or FALSE?
False.
It’s the round ligament.
Uterine Cervix
I. The uterus is partially covered by peritoneum in its fundal and posterior portions
I. Its anterior and superior surfaces are related to the bladder and the broad ligaments, respectively.
III. It is attached to the surrounding structures in the pelvis
by two pairs of ligaments—the broad and the cardinal ligaments.
Which is/are TRUE?
I II III I & II I & III II & III I, II, & III
I only.
II. anterior and lateral (not superior)
III. broad and round (not cardinal)
Uterine Cervix
What is formed by double layer of peritoneum extending from the lateral margin of the uterus to the lateral wall of the pelvis that contains the fallopian tubes?
It encloses the parametrium as it reaches the uterus.
Inferiorly, the it follows the plane of the pelvic floor and ends medially in the upper portion of the vagina
broad ligament
Uterine Cervix
What is the band of smooth muscle and connective tissue that contains small vessels and nerves, extends forward horizontally from its
attachment in the anterolateral portion of the uterus to the lateral pelvic wall.
The cord ascending from the lateral wall of the true pelvis crosses the pelvic brim
and extends laterally to reach the abdominoinguinal ring, through which it leaves
the abdomen to traverse the inguinal canal and terminates in the superficial fascia.
round ligament
Uterine Cervix
What are these thickened connective tissue and fascia arising at the upper lateral margins of the cervix and inserting into the fascial covering of the pelvic
diaphragm?
cardinal ligaments
transverse cervical ligaments
(Mackenrodt),
Uterine Cervix
I. The major lymphatic drainage of the cervix runs in the cardinal ligament superior to the ureter, and in the uterosacral ligaments to the rectal area.
II. No lymphatic vessels run in the vesicouterine
space, rather those from the upper vagina fuse with those from the bladder and
extend laterally into the parametrium.
III. The pelvic lymphatics drain into the common iliac and the para-aortic lymph nodes.
IV. Lymphatics from the
fundus pass laterally across the broad ligament continuous with those of the
ovary, ascending along the ovarian vessels into the paraaortics.
Which is/are TRUE?
I only I, II, & III I & III II, III, & IV all
All
Uterine Cervix
What are the three frame proteins/viral genes of HPV that alter cellular proliferation?
E5, 6, & 7.
Uterine Cervix
What protein/viral gene of HPV is responsible for inactivating p53 which results in chromosomal instability, inhibition of apoptosis, and activation of telomerase?
E6
Uterine Cervix
What part of the cervix is the most common origin of squamous cell carcinomas?
SCJ (transformation zone) of the endocervical canal.
Uterine Cervix
Where is the most common site of distant metastases?
Lung
Uterine Cervix
What is the recommended routine schedule for PAP smear screening?
ACOG
begin at age 21 continue every 3 years until age 30 (when they can continue as is or have it done every 5 years with Pap+HPV testing).
stop at age 65 as long as routine screening was normal within past 10 years.
continue for 20 years for women treated for CIN2 or 3.
stop after hysterectomy for benign lesions with no history of HGSIL.
Uterine Cervix
Upon initial PAP smear, the results show atypia or mild dysplasia (class II).
What is the next step?
repeat after 2 weeks to allow representative cellular exfoliation to occur.
Uterine Cervix
Upon initial PAP smear, the results show ASCUS and HPV testing is negative.
What is the next step?
Follow-up in 1-year
Uterine Cervix
Upon initial PAP smear, the results show ASCUS and HPV testing is negative.
Follow-up in 1-year was done with similar results.
What are the next steps?
colposcopy
with biopsy (if ASCUS+ HPV+ or Ais or SIL+)
If the
biopsy results are negative, the procedure should be repeated in 6 months, and if
they are positive, a conization should be performed.
Uterine Cervix
Treatment/procedure of choice for clinically inapparent lesions but an invasive disease still suspected.
conization
+ curettage of the remaining endocervical canal
Uterine Cervix
What diagnostic procedure is often substituted for a pelvic EUA?
MRI
Uterine Cervix
What is the appearance of a cervical cancer/mass on T2W images?
intermediate to high signal
intensity, usually of greater intensity than the fibrocervical stroma
Uterine Cervix
What is the appearance of a cervical cancer/mass on T1W images?
isointense with the normal cervix
Uterine Cervix
I. Squamous cell tumors are more likely seen on MRI than adenocarcinoma.
II. Squamous cell tumors are more likely FDG avid than adenocarcinoma.
I & II are true
only I is true
only II is true
I & II are both true
Uterine Cervix
FIGO staging.
Assume the minimum stage based only on the given minimum findings.
lateral parametrial involvement
cannot say. lateral parametria is not included in the FIGO staging
Uterine Cervix
FIGO staging.
Assume the minimum stage based only on the given minimum findings.
parametrial involvement in general
IIB (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
mid-third of the vagina
IIB (FIGO 2019)
IIIA is lower third
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
mid-third of the vagina
pelvic side wall involvement, no fixation
IIIB (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
non-functioning kidney
IIIB (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
confined to the cervix, >4 cm
bullous edema of the bladder mucosa
IB3 (for FIGO 2019)
1B2 (2009)
*bullous edema is not included in the FIGO staging
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
pelvic node+
IIIC1 (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
paraaortic node involvement
IIIC2 (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
node +
IIIC (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
lung involvement
IVB (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
biopsy proven bowel mucosal involvement
IVA (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
lateral invasion <7mm
depth <3 mm
IA1 (FIGO 2019)
*lateral spread not accounted in this staging
IA2 for FIGO2009.
IA2 for FIGO 2009 is more than 3 but less than 5 mm
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
gross disease beyond the uterus ≤2cm
IB1 (FIGO 2019)
Uterine Cervix
FIGO staging.
Identify the maximum stage based only on the given minimum findings. Assume that higher stage findings are not found.
gross disease beyond the uterus >4 cm
IIA2 (FIGO 2019)
*IIA1 is ≤4 cm
Uterine Cervix
What is the most common histologic type of cervical cancer?
SCC (90%)
Uterine Cervix
What histological subtype of SCC is a well-differentiated variant that tends to recur locally but not metastasize?
Verrucous carcinoma
Uterine Cervix
What is the most common histologic subtype of endocervical adenocarcinoma?
Endometrioid carcinoma.
Uterine Cervix
What is the histologic subtype of adenosquamous carcinoma with benign squamous component (metaplasia)?
adenoacanthoma
Uterine Cervix
What is the histologic subtype of adenocarcinoma with an ominous natural history, few reported cures, and is associated with Peutz-Jeghers syndrome?
adenoma malignum
Uterine Cervix
Give one subtype of HPV most implicated in higher node involvement and other distant metastases.
It is also associated with α-7 (high-risk)
HPV 18
Uterine Cervix
Prognostic Factors
What is the impact of histology on survival? adeno vs. scc
None.
in the era of chemoradiation, no difference
in outcome exists between squamous cell and adenocarcinoma in this large
retrospective analysis.
(based on GOG retrospective analysis)
Uterine Cervix
Prognostic Factors
What is the impact of histologic grade on survival? adeno vs. scc
None.
in the era of chemoradiation, no difference
in outcome exists between squamous cell and adenocarcinoma in this large
retrospective analysis.
(based on GOG retrospective analysis)
(Alfsen et al. Crissman et al., )
Uterine Cervix
Prognostic Factors
What parameter of treatment outcome measures is greatly affected by overall treatment time prolongation?
local tumor control
Uterine Cervix
What are the selection criteria for patients who may undergo radical trachelectomy?
<40 years stage IA1, IA2, or IB1 no nodal involvement on MRI/PET <2 cm is better. no LVSI and no upper endocervical involvement
Uterine Cervix
If high- or intermediate-risk features are present (+N or +margins) after trachelectomy, what is the next step?
RT + IGBT
Uterine Cervix
Identify the landmark/nodes in a level 1 lymphadenectomy.
internal and external iliac
Uterine Cervix
Identify the landmark/nodes in a level 2 lymphadenectomy.
common iliac and presacral
Uterine Cervix
Identify the landmark/nodes in a level 3 lymphadenectomy.
aortic intramesenteric
Uterine Cervix
Identify the landmark/nodes in a level 4 lymphadenectomy.
aortic infrarenal
Uterine Cervix
Identify the structures removed/mobilized in the type of hysterectomy.
Type A
EFH (cervix and small cuff of vagina)
+
minimum resection of the paracervix medial to the ureter
minimal vaginal resection <1 cm
no removal of paracolpos
Uterine Cervix
Identify the structures removed/mobilized in the type of hysterectomy.
Type B
MRH (cervix and upper vagina + paracervical tissues + lymphadenectomy)
+
partial resection of vesicouterine and uterosacral ligaments
unroofing of ureter (dissected at the point of entry to bladder)
transection of the parametrial tissue at the ureter
removal of at least 1 cm of vagina
B1 - without removal of paracervical LN
B2 - with
Uterine Cervix
Identify the structures removed/mobilized in the type of hysterectomy.
Type C
Classic radical hysterectomy, variant in which the entire uterosacral
and vesicouterine ligaments are removed, 1.5 to 2 cm of the vagina with
paracolpos is excised, and neuronal preservation is critical.
Uterine Cervix
Identify the structures removed/mobilized in the type of hysterectomy.
Type D
Includes the complete radical hysterectomy and resects tissues to the
pelvis sidewall, including the hypogastric (internal iliac) vessels, and
exposes the sciatic nerve (type D1). Type D2 also removes the fascial and
lateral muscles, called the laterally extended endopelvic resection.
Uterine Cervix
What are absolute contraindications to pelvic exenteration?
pelvic sidewall fixation and/or disease outside the pelvis
Uterine Cervix
BONUS:
What are the traditional field borders for APPA RT of the pelvis?
superior: L4-L5 interspace
inferior: below the obturator foramen
lateral: 1.5 to 2 cm from the pelvic brim
anterior: anterior to the symphysis
posterior: entire sacrum
Uterine Cervix
IMRT
For postoperative IMRT (based on RTOG 0921)
the dose is prescribed to cover ___% of the vaginal and nodal PTV.
97%
Uterine Cervix
IMRT
For postoperative IMRT (based on RTOG 0921)
a volume of ____cc of within any PTV should not receive more than >110%.
no more than ____cc of any PTV will receive <93% of doses.
0.03 cc
Uterine Cervix
IMRT
For postoperative IMRT (based on RTOG 0921)
dose constraints:
entire bowel
30% must not receive >40 Gy
Uterine Cervix
IMRT
For postoperative IMRT (based on RTOG 0921)
dose constraints:
rectum/sigmoid
60% must receive ≤40 Gy
Uterine Cervix
IMRT
For postoperative IMRT (based on RTOG 0921)
dose constraints:
bladder
35% must receive ≤45 Gy
Uterine Cervix
IMRT
For postoperative IMRT (based on RTOG 0921)
dose constraints:
femoral head
15% must receive ≤35 Gy
Uterine Cervix
PORT dose to the whole pelvis?
45 Gy
Uterine Cervix
PORT dose to the gross residual?
54 to 65 Gy (depending on small-bowel dose limitis)
Uterine Cervix
PORT dose to the whole para-aortic if common iliac or para-aortic nodes are positive?
45 Gy
Uterine Cervix
PORT dose to the gross residual nodal disease
up to 65 Gy
Uterine Cervix
How much is the absolute benefit for chemoradiation?
(labo ba?)
12% lam mo na yan.
10-13%
Uterine Cervix
Follow up schedule (pelvic exam).
every month first 3 months after RT,
every 3 months for the remainder of the first year
every 4 months for the second year
every 6 months for years 3-5
every year thereafter
Uterine Cervix
(from inservice bank 2020)
- Which of the following statements is FALSE?
A. Among the HPV strains, the most common types characterized as causative agents for cervical cancer are HPV-16 and HPV-18.
B. Higher incidence of cervical cancer exists among women whose partners have a history of testicular carcinoma.
C. HPV (Human Papilloma Virus) which is related to cervical cancer >90% of the time is a small double stranded deoxyribonucleic acid (DNA) virus.
D. Worldwide, cervical cancer remains the most common gynecologic cancer and the fourth most common malignancy in women.
B
Uterine Cervix
(from inservice bank 2020)
32. The significant predictors of decreased relapse free survival after radical hysterectomy in Cervical Cancer are the following EXCEPT: A. Lymphovascular invasion B. Positive margins C. Tumor Size D. Width of the tumor invasion
D
Uterine Cervix
(from inservice bank 2020)
- Special diagnostic imaging studies may be done to guide treatment planning in carcinoma of the cervix. The following statements are true, EXCEPT:
A. MRI is accurate than CT Scan in determining primary tumor volume, vaginal invasion, parametrial involvement, bladder and rectal involvement.
B. PET scan is more accurate in determining lymph node, extrapelvic metastases, and in detecting recurrence.
C. 2009 International Federation of Gynecology and Obstetrics (FIGO) requires proctosigmoidoscopy and cystoscopy to rule out bladder/bowel invasion and to complete metastatic workup.
D. CT scan has 97% specificity and 25% sensitivity in detecting pelvic node metastases.
C
Uterine Cervix
(from inservice bank 2020)
- Based on the recent Revised FIGO staging for carcinoma of the cervix uteri, the following statements are true, EXCEPT:
A. Imaging and pathological assessment of the pelvis and evaluation of the paraaortic lymph nodes have been formally incorporated into the staging of cervical cancer.
B. The involvement of vascular/lymphatic spaces does not change the staging. The lateral extent of the lesion is no longer considered.
C. As in the previous staging, when in doubt, the higher staging should be assigned.
D. A notation of “r” or “p” is to be given depending on whether the staging was assigned on the basis of imaging or pathology.
C
Uterine Cervix
(from inservice bank 2020)
- The following statements on radiation therapy techniques for cervical carcinomas are true, EXCEPT:
A. External beam is routinely delivered to cervical cancer patients with stages IB2 to IVA in a curative intent.
B. Indications for palliative intent include hemostatic purpose, relieve of pain, or alleviate urethral obstruction from an extrinsic compression.
C. Brachytherapy is a part of a complete radiation therapy which either succeeds or interdigitated with external beam treatment.
D. Rectal contrast and bladder contrast are necessary in CT simulation for contouring of outer wall of the said structures.
D
Uterine Cervix
(from inservice bank 2020)
- Approximately 1% loss of tumor control per day of prolongation of treatment time beyond 30 days is observed in cervical cancer patients treated with radiation alone.
A. True
B. False
A
Uterine Cervix
(from inservice bank 2020)
- There is no difference in the overall survival from concurrent chemo-irradiation treatment between squamous cell and adenocarcinoma.
A. True
B. False
A
Uterine Cervix
(from inservice bank 2020)
- In general, external re-irradiation for recurrent tumor is given to limited volumes (40-45 Gy, 1.8 Gy tumor dose per fraction, preferentially using AP-PA portals).
A. True
B. False
B
laterals
Uterine Cervix
(from inservice bank 2020)
- Higher body mass index (BMI) > 18.5 is correlated with an increase in toxicity.
A. True
B. False
B
lower BMI
Uterine Cervix
(from inservice bank 2020)
- A friend was diagnosed with carcinoma in-situ. Due to the COVID-19 pandemic, she cannot be seen by her elderly, hypertensive & diabetic Gyne-Oncologist for further management. When would you consider RT as an alternative?
A. In patients with strong medical contraindications to surgery
B. When there is extension of the lesion to the vaginal wall
C. With multifocal carcinoma in-situ in both the cervix and vagina
D. All of the above
D
Uterine Cervix
(from inservice bank 2020)
42. Landoni’s study comparing surgery vs. radiation showed that RT had improved A. overall survival B. disease free survival C. local control D. all of the above
D
Uterine Cervix
(from inservice bank 2020)
- Coughlin& Richmond, and Douple suggested that cisplatin enhances radiation cell killing mainly by ____.
A. alteration of DNA binding complexes
B. inhibition of sublethal damage repair
C. formation of crosslinks with purine bases
D. production of reactive oxygen species
B
Uterine Cervix
(from inservice bank 2020)
44. If there is still a large residual tumor, how many weeks can extrafascial hysterectomy be done after completion of chemoradiation (external beam and brachytherapy)? A. 1-2 B. 2-4 C. 4-6 D. 6-12
D
Uterine Cervix
(from inservice bank 2020)
- An institution utilizes image-guided brachytherapy and pelvic MRI was done a day prior to insertion, the following statements are true regarding your target volume delineation based on GEC-ESTRO guidelines, EXCEPT:
A. GTV includes all T2-bright areas of enhancement.
B. HR-CTV includes only region of high to intermediate signal intensity in the parametria, uterus, and vagina.
C. IR-CTV covers the region of potential microscopic seeding of tumor cells, this accounts tumor extension at the time of diagnosis
D. HR-CTV includes the entire cervix and takes into account your radiologic (MRI) and physical examination findings at the time of brachytherapy.
B
Uterine Cervix
(from inservice bank 2020)
- Gilbert Fletcher, a renowned brachytherapist stated that an adequate intracavitary insertion included the following, EXCEPT:
A. Vaginal mucosal, bladder and rectal tolerance must be respected.
B. Sufficient dose must be delivered to the paracervical tissues.
C. The distance between the ovoids and tandem should always be uniform for all insertions.
D. Geometry of the insertion must prevent underdosing around the cervix.
C
Uterine Cervix
(from inservice bank 2020)
- An institution utilizes HDR brachytherapy with a remote afterloader and image guidance via orthogonal radiographs and point-based dosimetry, the following statements are true, EXCEPT:
A. The goal is to treat point A to at least a total LDR Equivalent of 85-90 Gy for this case.
B. 7 Gy per fraction x 4 fractions has an equivalent EQD2 to 6 Gy x 5 fractions.
C. Ultrasound with a transabdominal probe can assist placement of the insertion of tandem.
D. Displacement of ovoids in relation to the cervical os may not affect overall result of the treatment as long as tandem is in place.
D
Uterine Cervix
(from inservice bank 2020)
- If image-guided brachytherapy planning was utilized in item #48, what will be TRUE regarding point A? (I think this is not a valid question)
A. It is no longer required to be reported.
B. The dose to point A may be lower than the D90 HRCTV.
C. It may overestimate the tumor dose.
D. The dose to point A may be higher than the D90 HRCTV.
B (Kim et al.) pero in general, C and D can happen.
Uterine Cervix
(from inservice bank 2020)
- The best regimen to palliate pelvic pain or bleeding is to give 10 Gy per fraction every 3-4 weeks interval for a total of three (3) fractions.
A. True
B. False
A
Uterine Cervix
(from inservice bank 2020)
45. Medium dose rate (MDR) in terms of Gy per hour, according to ICRU Report 38, is defined as \_\_\_. A. 0.4 to 1 B. 1 to 6 C. 2 to 12 D. 6 to 14
C
Uterine Cervix
(from inservice bank 2020)
- The following statements are true regarding the differences in outcomes of HDR and LDR brachytherapy in locally advanced cervical cancer based on the meta-analysis (Wang et al, 2010) of four randomized control trials, EXCEPT:
A. Incidence of distant failure rate was higher than for other causes of failure both in HDR and LDR brachytherapy.
B. No significant differences in OS, DFS, RS, local control and recurrence rates between the two treatments.
C. Despite the differences in follow-up period, the three-, five- and ten-year outcomes were comparable.
D. There was no statistical difference in late complication rates for HDR vs. LDR brachytherapy for bladder or rectosigmoid.
A
