Vulvar/vaginal cancer

Question 1

Vaginal RT indications

Answer 1

Stage I (if no surgery) to stage IVA

Question 2

Vaginal RT dose and technique

Answer 2

EQD2 of 75-90 with EBRT + interstitial or intracavitary 45 Gy to pelvis with 5Gy x 5 boost to HR-CTV

Brachy alone 50-60 Gy EQD2 - 8 Gy x 5 to surface twice weekly ..

Target vaginal and paravaginal tissue with 3 cm distal margin on gross disease + nodes

Concurrent cisplatin

Question 3

Vaginal cancer staging FIGO

Answer 3

I - tumor confined to vagina
II - tumor invading paravaginal tissues but not pelvic sidewall
III - tumor extends to pelvic sidewall/hydronephrosis/nodes
IVA - tumor invades bladder or rectum
IVB - distant disease

Question 4

Vulvar staging FIGO

Answer 4

IA - tumor </= 2 cm and stromal invasion </= 1mm
IB - tumor > 2 cm or stromal invasion > 1 mm
II - tumor extends to lower 1/3 of urethra, vagina or anus
IIIA - tumor extension to upper 2/3 uretha or vagina, bladder mucosa, rectal mucosa or regional LN mes < 5 mm
IIIB - regional nodes > 5 mm
IIIC - regional nodes with ECE
IVA - disease fixed to pelvic bone or ulcerated regional lymph nodes
IVB - distant mets

Question 5

RT indications vulva

Answer 5

when resectable - post-op RT for stage IB and up if positive margins (re-excision preferred) or for multifocal, recurrent, LVSI, close margin (< 5 mm) tumor size > 4 cm or > 5 mm stromal invasion
Pelvic PORT for nodes with ENE or > 2 groin nodes

Unresectable or nodal disease

Question 6

RT volumes and doses post op vulva

Answer 6

Vulva - negative margins 45-50 Gy
>1-2 mm but < 5 mm margin 50-54 Gy
< 1-2 mm margin 54-56 Gy
positive margin > 60 Gy

Nodes - mic disease 45-50 Gy
Enlarged 50-56 Gy
ECE 60-66
Gross residual - 60-70 Gy

CTV = Vulva and tumor bed with 2 cm margin

Question 7

RT volumes and doses definitive vulva

Answer 7

Vulva - 60-66 Gy
Nodes: < 1 cm 56-60 Gy
102 cm 60-66 Gy
> 2 cm 64-70 Gy
Bulky or fixed 66-70 Gy

CTV = GTV + entire vulva + 1 cm margin on dz outside of vulva, 3 cm vaginal and 2 cm anorectal/urethral or bladder involvement

Question 8

RT volumes for Vulvar nodes

Answer 8

N0 - inguinal to bifurcation of common iliac
N+ inguiinal - mid SI joint and treat bilaterally
N+ pelvis - aortic bifurcation
N+ common or PA - include PA nodes
proximal vaginal - add pre sacral nodes
anal involvement - add mesorectal and pre sacra

Question 9

Vulvar constraints: Bladder

Answer 9

V45< 50%

Question 10

Vulvar constraints: Rectum

Answer 10

V45 < 80%

Question 11

Vulvar constraints: Femoral heads

Answer 11

V40 < 15%

Question 12

Vulvar constraints: Kidney

Answer 12

V20 < 33%, V15 < 50%

Question 13

Vulvar constraints: Small bowel

Answer 13

V40 <15%

Question 14

Vulvar constraints: Duodenum

Answer 14

V55 < 15 cc, V60 < 2cc

Question 15

Vulvar constraints: Spinal cord

Answer 15

< 45 Gy max

Question 16

Vulvar constraints: bone marrow

Answer 16

V10 gy < 90%

Question 17

Vaginal brachy + EBRT constraints: Rectum

Answer 17

Max < 75 D2cc (65 preferred)

Question 18

Vaginal brachy + EBRT constraints: Bladder

Answer 18

Max < 90 D2cc (75-80 preferred)

Question 19

Vaginal brachy + EBRT constraints: Sigmoid

Answer 19

Max < 75 D2cc (<70 preferred)

Question 20

Vaginal brachy + EBRT constraints: Bowel

Answer 20

Max < 75 D2cc (< 70 preferred)

Question 21

Vaginal brachy + EBRT constraints: urethra

Answer 21

0.1 cc less than prescription dose