Vaginal, Vulvar, Misc. Flashcards
Which site of recurrence post definitive CRT for vaginal cancer has the worst prognosis?
- Groin
What is the most important prognostic factor for a pt w/ new vulvar cancer?
LN status
Which pathologic features of vulvar cancer s/p surgery confer the highest risk of LR and should receive RT to the primary site?
Pathological factors and their associated LR Rates
- Margins < 8 mm (strongest factor)
– < 8 mm → 48%
– ≥ 8 mm → 0%
- +LVSI → LR 39%
- DOI > 9.1 mm → 15%.
What is the pt population, randomization, and primary end-point of GOG 37 for vulvar cancer?
Pts:
- Invasive SqCC
- s/p vulvectomy and b/l inguinal lymphadenectomy
- Inguinal LN+
Randomization:
- 🏆 RT 45-50 Gy to b/l inguinal and pelvic nodes (but not vulva/primary)
- PLND
Primary end-point
- OS
What are the results of GOG 37 for vulvar cancer?
RT vs. PLND
- 2-yr OS 68% vs. 54% (p=0.03)
– On subanalysis, effect only in ECE and ≥2 nodes
- 6-yr OS 51% vs. 41% (NS)
– benefit only in palpable N+, ECE, ulcerated, or ≥2 nodes, or >20% nodal positivity
- 6-yr groin recurrence 5% vs. 24% (p=0.02)
- Lymphedema 16 vs. 22% (NS)
What is the primary RO interpretation of GOG 37 for vulvar cancer?
- Adjuvant RT improves OS in palpable N+, ECE, ulcerated, and ≥2 nodes, vs. PLND after radical vulvectomy and inguinal LND
- Trial was closed early as 2-yr results showed an improvement in LR and OS w/ RT
What is the rate of groin recurrence in vulvar cancer pts following WLE and SLNBx showing micro vs. macrometastases who subsequently receive RT w/o inguinal LND?
GROINSS V-II study
- Micro vs. macro: 2% vs. 22%
What is the rate of lymphedema in vulvar cancer pts s/p WLE and SLNBx f/b ± RT ± inguinal LND?
- GROINSS V-II: LE at 6 / 12 mos
– SLNBx alone: 5.1% / 4.1%
– SLNBx + RT: 16.4% / 10.7%
– Inguinal LND ± RT: 32% / 22.9%(p < 0.001).
What are the field borders for a vulvar cancer pt being tx w/ 3D CRT, including to the inguinal LNs?
-
Wide AP field to tx pelvic and inguinal LNs
– Sup: L5/51 or L4/L5 for positive or suspicious pelvic LNs
– inf: flash vulva
– Lat: greater trochanter -
Narrow PA field to tx pelvic LNs and spare femoral heads
– Sup and inf as above
– Lats: 2 cm beyond pelvic inlet - e- can be used to supplement inguinal dosing
What RT doses are recommended for vulvar cancer s/p resection w/ -margins, close margins (<8mm), +margins, or gross disease?
- RT Dosing:
– -Margins: 45-50
– Close (<8mm): 56 Gy for close
– +Margins: 63 Gy
– Gross disease: 65-70 Gy
What is the T staging for vulvar cancer?
- Tx: Cannot be assessed
- T0: No evidence of tumor
- T1a (IA): confined to the vulva or perineum, ≤ 2 cm in size, ≤ 1.0 mm DOI
- T1b (IB): confined to the vulva or perineum, > 2 cm in size, > 1.0 mm DOI
- T2 (II): Any size with extension to adjacent perineal structures
– lower/distal 1/3 urethra
– lower/distal 1/3 vagina
– Anal involvement - T3 (IIIA): Tumor of any size with extension to any of the following:
– upper/proximal 2/3 of urethra
– upper/proximal 2/3 vagina
– bladder mucosa
– rectal mucosa
– Fixed to pelvic bones (IVA)
What is the N staging for Vulvar cancer?
- NX: Regional lymph nodes cannot be assessed
- N0
- N1a (IIIA): 1-2 LNs, each < 5 mm
- N1b (IIIB): 1 LN >= 5 mm
- N2a (IIIB)
– 3+ LNs < 5 mm
– 2+ LNs > 5 mm - N2c (IIIC): ECE
- N3 (IVA): Fixed or ulcerated regional LN(s)
What is the risk of LN involvement for a pt w/ FIGO IA vulvar cancer?
- < 8%
- No SLN assessment required
What is the risk of pathologic LN+ for a vulvar cancer pt w/ clinically LN-?
~30%
What are the most common indications for post-op RT to the pelvic and inguinal LNs for vulvar cancer?
- Per GOG 37 unplanned post-hoc analysis:
– Clinically palpable or matted LNs
– ≥ 2 pathologic LN+
— In practice, even 1 LN+ is tx w/ RT given the poor prognosis of inguinal LN recurrence
– LN+ ratio ≥ 20%
– ECE
What is the pattern of LN drainage for the vagina?
- Vaginal LN drainage:
– Upper 2/3 → internal iliacs, external iliacs, and obturator (pelvic nodes)
– Lower 1/3 → Inguinofemoral nodes.
What is the pattern of LN drainage for the vulva?
- Vulvar LN drainage
– Superficial inguinal/femoral LNs,
– f/b deep femoral LNs
– f/b external and common iliac lymph nodes -
Clitoris
– Can bypass the superficial nodes and drain directly to the deep femoral nodes and pelvic lymph nodes (obturator and external iliac)
What is the FIGO staging for ovarian cancer?
-
I:
– IA: Tumor limited to 1 ovary, capsule intact, ovarian surface -ve; no malignant cells in ascites or peritoneal washings
– IB: Tumor limited to 2 ovaries, capsules intact, ovarian surfaces -ve; no malignant cells in ascites or peritoneal washings
– IC: Tumor limited to one or both ovaries with one of the following: surgical spill (IC1), capsule rupture before surgery or tumor on the ovarian surface (IC2), or malignant cells in ascites or peritoneal washings (IC3) -
Il: Extension to
– IIA: Uterus and/or fallopian tubes
– IIB: Other pelvic intraperitoneal tissues -
III: Spread to the peritoneum outside the pelvis and/or retroperitoneal LNs
– IIIA: Retroperitoneal LN+ only
– IIIB: Macroscopic, extrapelvic, peritoneal metastasis 2 cm or less in greatest dimension ± retroperitoneal LNs+. Includes extension to capsule of liver or spleen
– IIIC: Macroscopic, extrapelvic, peritoneal metastasis more than 2 cm in greatest dimension ± retroperitoneal LNs+. Includes extension to capsule of liver or spleen -
V:
– IVA: Pleural effusion with positive cytology
– IVB: Hepatic and/or splenic parenchymal metastasis, metastasis to extra-abdominal organs (including inguinal nodes and nodes outside the abdominal
What is the preferred management of all stages of ovarian cancer?
- Maximal surgical cytoreduction for all stages
– Adjuvant CHT
– Neoadjuvant CHT for pts for whom complete cytoreduction might otherwise be unlikely - OS improved from 17 to 37 mos w/ optimal surgical cytoreduction/debulking
- RT is used in the palliative setting only
What is the most common histology for fallopian tube cancers?
- Serous
What is the FIGO and TNM staging for vaginal cancer?
- Figo Stage (TM classification)
– Stage I (T1a ≤2cm, T1b > 2cm): Tumor confined to vaginal mucosa
– Stage II (T2a ≤2cm, T2b >2cm): Submucosal infiltration into the parametrium; not extending out to the pelvic wall
– Stage III (T3): Tumor extends to the pelvic wall, defined as muscle, fascia, neurovascular structures, or skeletal portions of the bony pelvis, lower 1/3 vaginal involvement, and or hydronephrosis as a result of obstruction. Also nodal involvement
– Stage IVA (T4): Tumor invades mucosa of bladder or rectum or is growing out of the pelvis
– Stage IVB (M1): Cancer has spread to distant organs - There is no N classification for vaginal cancer
What are the usual duodenal constraints when treating PA nodes?
Verma et al., IJORBP, 2014
- D2cc < 60 Gy
– ≥ G2 tox with D2cc < 60 Gy vs. > 60 Gy→ 4.4% vs. 18.6% (p- 0.07)
- V55 < 15 cc
– ≥ G2 tox with V55 < 15cc vs. > 15cc → 7.4% vs. 48.6^% (p- 0.05)
Why is the duodenum especially vulnerable to RT compared to other parts of the small and large bowels?
- Duodenum is relatively immobile, leading to consistent exposure to RT doses
- Most of the duodenum is retroperitoneal, lying in close proximity to the PA nodes
What are the pt population, design, and primary end-point of GOG 205 for vulvar cancer?
- Pt:
– T3, T4, N+ - Phase II:
– RT 57.6 Gy/ 32 fx + weekly cisplatin → resection - cCR defined by biopsy, pCR defined by surgical resection
What were the results of GOG 205 for vulvar cancer?
- cCR 64%
- pCR 50%
– compared to 40% in GOG 101
What are the pt population, design, and primary end-point of the UCLA HEAPS study for vulvar cancer?
- Pt:
– s/p surgical resection - Retrospective review
– Path factors related to recurrence
What were the results of the UCLA HEAPS study for vulvar cancer?
- Factors a/w local recurrence in order of significance
– Stage
– Margin
— Margin <8mm had LR of 48%
— Margin <5mm had LR of 57%
– Depth
– Growth pattern
– Vascular invasion
– Keratin amount
– Mitotic activity - NOT: Tumor size, Nucleoli, grade
Which muscles form the lateral boundaries of the inguinal LN contours?
