1
Q
What is a type I hysterectomy?
A
- Simple hysterectomy
- Peritoneal washings prior to resection
- Removal of
- Fascia of cervix
- Lower uterine segment
- Full uterus
- Ovaries removed for staging and to stop estrogen production
2
Q
Type II hysterectomy
A
- Modified radical hysterectomy
- Removal of
- Uterus
- Lower uterine segment and cervix
- Upper 1/3 (1-2 cm) of the vagina
- Unroofing ureters to resect parametrial tissue and paracervical tissue
- Lymphadenectomy
- Uterine vessels ligated medial to ureters
- Uretosacral ligament ligated midway between uterus and sacrum
3
Q
Type III hysterectomy
A
- Radical hysterectomy
- All Type II parts
- Ureters mobilized as well as bladder and rectum
- Resected parametrial tissue to pelvic side wall
- Resection of 1/3 to 1/2 of vagina
4
Q
Which cancers get Type I hysterectomy
A
Most endometrial
Some 1A1 cervix
5
Q
What cancer get Type II hysterectomy
A
Cervical cancer IA2
Endometrial cancer with cervical involvement
6
Q
Which cancers need type III hysterectomies
A
Most cervical cancers IB+
7
Q
Which histologies need omental biopsy
A
Serous endometrial
Clear cell
Carcinosarcoma
8
Q
What are the procedures for cervical sampling?
A
- Conization
- LEEP (Loop Electrosurgical Excision Procedure)
- Trachelectomy
9
Q
What is conization
A
En bloc removal of ectocervix and endocervix canal
10
Q
What is a trachelectomy
A
All cancer removed with margin
Internal os remains and stitches closed
Can carry pregnancy with c-section for delivery
11
Q
How can fertility be spared for women getting gyn RT
A
Ovarian transposition
12
Q
What is the target ovarian dose for maximal fertility sparing
A
8 Gy
13
Q
How many strains of HPV does current vaccine protect against
A
9
14
Q
What is the current recomendation for HPV vaccination
A
- Both boys and girls
- Age 11-14: 2 shots, 6-12 months apart
- Age 15-26: 3 shots q1-2m
15
Q
What aged women should get cervical cancer screening
A
21-65
16
Q
What is screening guideline for women 21-29
A
Pap q3 years
17
Q
What is screening rec for woman age >30
A
Pap and HPV testing q5 years
18
Q
How to manage ASCUS
A
- Most resolve spontaneously
- Get HPV test
- If + do colposcopy
- If - get repeat Pap and HPV test in 12 months
19
Q
What is acute toxicities of gyn RT
A
Epilation
Hyperpigmentation
Urethritis/Cystitis
Erratic bowel function
Tenesmus
Light bleeding
Pruritis
Vag discharge
20
Q
Late toxicity of gyn RT
A
Vaginal stenosis, thinning, dryness
Fistulas
Bowel obstruction
Bladder injury
Pelvic fractures
Sterilization (2-3 Gy)
Ovarian failure (8-10 Gy)
Lymphedema after inguinal nodal surgery/RT
21
Q
History for cervix cancer
A
Sexual history
HIV/STDs
Smoking
DES exposure
22
Q
Exam for cervix cancer
A
- Abdominopelvic exam
- PE to assess inguinal nodes
- Gyn exam
- Speculum to assess tumor size, vaginal involvement, PM and sidewall involvement
- Bimanual to assess rectal involvement / fixed
- Pap smear
23
Q
Labwork for cervix cancer
A
Pap smear
CBC
CMP
HIV
UA
24
Q
How to obtain tissue for diagnosis
A
EUA with biopsy
Perform cystoscopy and proctoscopy if concern for inavsion
25
What imaging to obtain for cervix cancer
* Stage I: CXR
* Stage II+
* PET or CT CAP
* Pelvic MRI
26
How to approach woman with symptomatic bleeding with cervix cancer
Pack the vagina
Transfuse Hgb \> 10
Embolize if possible
Palliative RT (6 Gy in 2 fx) and incorporate into definitive dose
27
What is the general goal for cervix cancer treatment
Avoid tri-modality therapy
28
Which patients tend to be cured with surgery alone
Less than FIGO IB2
Surgery preferred for younger woman
29
In FIGO 2018 staging, what tests can be included for stging
All clinical and imaging modalities, including MRI to assess for parametrial invasion
Can include exploratory surgery
30
What is FIGO cervical stage: I
confined to cervix
31
What is FIGO cervical stage: IA
Microscopic tumor \< 5 mm
* IA1: \<3 mm DOI
* IA2: 3-5 mm DOI
32
What is FIGO cervical stage: IB
* Visible cervical tumor
* IB1: \<2cm
* IB2: 2-4 cm
33
What is FIGO cervical stage: II
Beyond cervix but not lower 1/3 of vagina or to pelvic side wall
34
What is FIGO cervical stage: IIA
* IIA1: \<4 cm out of cervix
* IIA2: \>4 cm beyong cervix, in upper 2/3 of vagina
35
What is FIGO cervical stage: IB3
\>4 cm (bulky, visible, confined to cervix)
36
What is FIGO cervical stage: IIB
Parametrial involvement
37
What is FIGO cervical stage: III
More advanced, lower vagina, pelvic side wall, N+
38
What is FIGO cervical stage: IIIA
Lower 1/3 vaginal involvement
39
What is FIGO cervical stage: IIIB
Pelvic side wall involvement
40
What is FIGO cervical stage: IIIC
N+
41
Risk of pelvic LN for IB
15%
42
Risk of pelvic LN for cervical stage II
25%
Reminder stage II is outside cervix but not to pelvic side wall or lower 1/3 of vagina
43
Risk of pelvic LN for stage III
50%
Reminder: stage III is lower 1/3 vagina, pelvic side wall or N+
44
Rule of thumb for risk of PA nodal involvement for cervix cancer
pelvic nodal risk / 2
45
Stages of cervix cancer
![]()IA- microscopic, confined to cervix
IB- macroscopic, confined to cervix
II - outside of cervix but not to lower 1/3 of vagina
IIIA - lower 1/3 vagina
IIIB - pelvic sidewall
IIIC - nodes
IV - bladder, rectum etc.
46
How to obtain cervical tissue for diagnosis
* Gross lesion --\> punch bx and endocervix curettage
* No lesion --\> colposcopy and directed bx
* If both above are negative --\> conization
47
What is the treatment approach for stage IA cervical cancer?
* Treatment approach is SURGERY alone
* Type of surgery depends on stage IA1 or IA2
* Reminder
* IA1 = \<3 mm DOI
* IA2 = 3-5 mm DOI
48
Management options for IA1 cervix
* In general surgery is best
* Type I hysterectomy WITHOUT PLND
* Other options include:
* Conization
* LEEP
* Cyrosurgery
* Radical trachelectomy
* Brachy alone (7.5 Gy x 5)
49
If for IA1 cervix woman has simple hysterectomy and found to have risk factors, next step
Consider Type II and PLND
50
Management options for IA2 cervical cancer
* Type II (modified radical) hysterectomy and BSO
* Adjuvant therapy based on Sedlis/Peters criteria
* Typically 50.4 Gy in 28 daily 1.8 Gy fractions
* RT alone
* 45 Gy pelvic EBRT + cervical BT (Point A dose = 80 Gy)
51
If a young woman is getting RT alone for cervix cancer, how to prevent ovarian failure?
Oophoropexy
52
What is 5 year OS for stage IA1 and IA2 cervix cancer
IA1: 95%
IA2: 85%
53
What are the criteria for women who are candidates for radical trachelectomy
* Size \< 2cm
* No LN
* No LVSI
54
Following surgery for cervical cancer, what dictates adjuvant therapy options?
* Intermediate risk per Sedlis criteria --\> RT alone (50.4 Gy)
* Size \> 4 cm
* LVSI
* Depth of cervix invasion
* High risk per Peters criteria --\> Pelvic RT to 50.4 Gy with weekly cisplatin (40 mg/m2)
55
What stages of cervical cancer can we consider for surgery or RT
Early stages only
IA, IB1, IB2 and select IIA1
56
What stages of cervix cancer can get less than radical hysterectomy
IA1 - simple hys
IA2 - modified radical
Everything else should get radical hys
57
Treatment options for stage IB1, IB2, IIA1
* In general, these patients can be managed with either surgery or RT alone, with adjuvant therapies as dictated by risk factors
* Surgery
* Type III hysterectomy +/- PLND +/- PA dissection
* Adjuvant therapy per risk factors
* Adjuvant EBRT +/- vaginal brachy per Sedlis
* Adjuvant CRT per Peters
* Radiation alone
* 45 Gy pelvic EBRT + Brachy (point A dose of 80 Gy)
* Fertility sparing option (if \<2 cm)
* Radical trachelectomy + PLND
58
What should be considered for IB2 patients?
In trials, nearly 90% needed adjuvant RT so probably makes sense to consider definitive RT
59
What side effects are higher with surgery --\> adjuvant therapy for GYN malignancies?
Urinary
SBO
Sexual toxicity
60
For definitive cervix RT, early stage, what is the RT doses
EBRT of 45 Gy
Brachy therapy to Point A dose of **80 Gy**
61
What defines intermediate risk Cervical Cancer?
* Sedlis criteria
* Eligibility criteria
* \>4 cm
* LVSI
* Deeper than 1/3 invasion
* Need _2 of these criteria_ to warrant adjuvant therapy
62
What is the adjuvant treatment for intermediate risk cervical cancer
EBRT to 50.4 Gy to full pelvis
Improves PFS, LR, _NOT OS_
63
What modality to deliver post op RT for cervix cancer
IMRT, decreases GI/GU tox
64
What defines high risk post-op patients after hysterectomy for cervical cancer?
* Peters Criteria
* Positive margin
* Positive Lymph nodes
* Parametrial extension
65
What is the adjuvant treatment for high risk cervix cancer post op
* CRT
* IMRT to 50.4 Gy in daily 1.8 Gy fractions
* Weekly cisplatin 40 mg/m2
66
What is the advantage of adjuvant CRT for high risk cervical ca
OS benefit: 10%
67
Treatment options for stage IB3 and IIA2 cervix cancer
* Reminder
* IB3: \>4 cm (bulky) in cervix
* IIA2: \>4 cm beyond cervix in upper 2/3 vag
* These patients should get definitive CRT
68
Definitive CRT regimen for locally advanced cervix cancer
* Weekly cisplatin 40 mg/m2
* EBRT to 45 Gy (using 3DCRT, 4 field)
* Cervix brachytherapy to _Point A dose of 85 Gy_
* 7 Gy x 4 (BID, spaced one week apart)
69
Schedule for interventions if getting EBRT then brachy
* Finish 25 fx of EBRT
1. Next day get HDR brachy inserted
2. First treatment that evening
3. Admit to hospital
4. Next treatment following morning
5. Removal and discharge
* Return and repeat 1-5 one week later
70
5 year OS for IB3 or IIA2 cervix cancer
70%
71
Treatment of stage IIB cervical cancer
* Parametrial involvement
* CRT
* 45 Gy to pelvis with weekly cis 40 mg/m2
* Parametrial boost 540 cGy
* Brachytherapy to point A dose of 85 Gy
72
Treatment of stage IIIA cervical cancer
* Reminder: lower 1/3 of the vagina
* Definitive CRT
* EBRT to 45 Gy with weekly cisplatin
* Parametrial boost?
* Brachytherapy to Point A dose of 85 (consider using vaginal cylinder or implant for vaginal disease)
* **Cover inguinal nodes**
73
Treatment of stage IIIB cervix
* Pelvic sidewall involvement or hydronephrosis
* Definitive CRT
* **Stent for hydronephrosis**
* Boost pelvis with 540 cGy
* HDR brachy 7 Gy x 4
74
Treatment of stage IIIC cervical cancer
* IIIC1 - pelvic nodes
* IIIC2 - PA nodes
* Definitive CRT
* Consider boosting affected nodes to 225 x 25 = 5625 cGy
75
Treatment of Stage IVA cervical cancer
Definitive CRT
5 year OS of 10%
76
Cervix ca patients who don't need parametrial boost
* Earlier stage (IA-IIA) without parametrial involvement
* Significant pelvic nodes getting boosted
* Bulky parametrial disease likely to get interstitial implant
77
Where is Point A
2 cm superior and lateral to Os
78
Point A doses
80 Gy for cervix confined disease or IIA
85 Gy for anything more advanced
79
General follow-up for GYN malignancies after treatment
* H&P q3-6 months x2 years, q6 months through 5 years, annual after
* PET 3-6 months post
* Cervix and vaginal cytology screening
* Dilator usage
* Risk reduction education
80
Simulation for intact cervix (endometrial or cervix)
* Supine in alpha cradle (if IMRT)
* Consider prone if doing 3DCRT
* IV and small bowel contrast
* Vaginal barium or marker
* Full bladder scan
* Fuse PET and/or MRI for disease delineation
81
3D superior border of intact pelvic field
Typically L5-S1
Consider L4-L5 if common iliacs are involved
82
For 3D pelvic field inferior extent
3 cm below tumor or bottom of obturator foramen
83
3D pelvic field, lateral extent
1.5-2 cm lateral to pelvic brim
Ensure good margin on obturator nodes
84
3D pelvic field, anterior extent
1 cm anterior to the pubic symphysis
85
3D pelvic field - posterior extent
Behind sacrum
86
Should femoral heads be blocked with 3D pelvic field
No
87
If doing a parametrial boost what is the dose
5.4 Gy in 3 fractions of 1.8 Gy
88
What is the total dose to parametrial or pelvic sidewall
60 Gy
45 Gy whole pelvis
5.4 Gy parametrial boost
20% of HDR boost
89
What is Point B
surrogate for pelvic sidewall
90
Describe parametrial block
Sup/inferior block extending from inferior edge of the field to roughly isocenter blocking the cervix/uterus (about 9-12 cm)
Block should be ~4 cm wide at midline
91
If treating common iliac nodes, how high should you treat
L1/L2
92
If treating PA nodes, how high should you treat
Renal vessels or ~T12
93
Why should IMRT be chosen for intact cervical fields
* Covering PA or inguinal nodes
* SIB for nodes or sidewall
* Decreases GI/GU and bone marrow tox
* Decreases pelvic fractures
94
How to contour intact cervical volumes for IMRT
* Create CTV1 = GTV, cervix, uterus
* PTV1 - 2 cm expansion with daily IGRT
* Create CTV2 = parametria and vaginal CTV
* PTV2 - 1 cm expansion
* Create CTV3 = nodes which are vessels + 7mm (exlcude bowel, bone, muscle)
* Cover obturator, Int Iliac, Ext. Iliac, Common Iliac, Pre-Sacral to S3
* If involved - common iliac to L1
* If involved - PA nodes to T12
* PTV3 - 7 mm expansion
95
Determining vaginal coverage for CTV2 (intact cervix) IMRT
* No vaginal involvement = cover upper half
* Upper vaginal involvement = cover upper 2/3
* Extensive vaginal involvement = cover full vagina
96
When should parametrial boost be given
Can do it SIB or sequential after the 45 Gy between the two brachy insertions
97
Contouring postop cervix IMRT
* Create CTVp
* Vaginal ITV (full and empty bladder)
* Parametria
* At least 3 cm of vagina
* Create CTVn
* 7 mm expansion of vessels off bone/bowel/muscle
* Include obturator, internal iliac, external iliac, common iliac
* Inguinals if lower vagina involved
* GTV nodes (not resected)
* PTV margins
* 7 mm for CTVp and CTVn
* 3 mm for nodes
98
Combined Point A dose if adjuvant
75 Gy
99
When contouring gyn cases, OARs should be contoured on which scan
full bladder
100
When is the optimal time from surgery to perform vaginal cuff brachy
When it is healed
Pref 4-6 weeks
101
How should a vaginal cylinder be selected?
Largest diameter to minimize mucosal surface dose
102
Typical vaginal brachy dose
For cylinders \>3 cm: 700 cGy x3 prescribed to 0.5 cm depth
For cylinders \<3 cm: 600 cGy x 3
like 500 x 5
103
What is total length of typical vagina
~ 10 cm
104
How much of vagina to treat for vaginal brachy
upper 4-7 cm determined by risk profile of the cancer
105
How to check vaginal brachy films
* Cylinder should be perpendicular to the pelvis (AP or PA film)
* On lat film, \<5 degrees
* Consistent with prior images
106
If vaginal brachy prescribed to 0.5 cm from vaginal surface, what is the dose at the surface
140%
107
What patient is best suited for tandem and ovoid
Deep fornices
108
What patient is best suited for tandem and ring
* shallow fornices
* effaced cervix
109
What patient is best suited for tandem and cylinder
narrow vagina or vaginal disesae
110
Best candidate for tandem and needles
* Asymmetric tumor
* Lateral tumor
* Thick upper vaginal dz
* Bulky disease \>5 cm
111
Describe how to perform a Tandem and ovoid procedure
* Bring patient to OR and induce general anesthesia
* Place patient in dorsal lithotomy position
* Perform EUA and rectal exam to note extent of disease - parametrial extension
* Prep and drape
* Insert foley and place 7cc of 30% constrast in the balloon
* Place gold marker into OS
* Grab cervix with tenaculum and dilate using serially larger dilators
* Place smit sleeve into dilated os and suture into place
* Place tandem through sleeve into the uterus with the flange flush against the os. Tandem should reflect angle of uterus
* Dissasemble speculum
* Place ring over the tandem or ovoids into the fornices to maximum depth and affix to tadem
* Place packing rubbed in aerated lubricating gel to displace bladder and rectum and to stabilize the implant
* MRI simulation
* Evaluate implant placement
* Contour --\> intraop planning
* Hook up catheters --\> deliver treatment
112
How to approach if the tandem perforates the uterus
* Readjust back into the uterus
* Give prophylactic antibiotics
* Resim and treat
113
Current planning approach for tandem and ovoid
Volume based
114
Strategies if constraints cannot be met
* Adjust packing
* Fill bladder more to push away bowel
* Re-implant
* Add free hand needles
115
How much constrast goes into Foley balloon for cervical brachy
7 cc of 30% constrast
116
What are the GTVs for cervical brachy
GTVD = macroscopic tumor seen at diagnosis
GTVB1, B2 = tumor seen clinically or on MRI at brachy insertion 1, 2
117
How to define brachy high risk CTV
Includes GTVB1 + whole cervix + presumed extra cervical extension
This is the volume receiving total Rx dose
118
Goal dose to HR CTV for cervical brachy
D90: 90-95 Gy (combined EBRT and brachy)
D98 \> 75 Gy
119
What is the intermediate risk CTV for cervical brachy
* GTVD (initial disease)
* High risk CTV + margin
* 5 mm AP
* 10 mm Sup/Inf/Lateral
120
What is the goal dose for the IR CTV
60 Gy
121
Specific process for interstitial implant
* After Smit Sleeve, place obturator over tandem and advace to full length of vaginal canal
* Template placed over obturator and sutured to perineum
* Catheters inserted with transrectal US image guidance for maximal coverage
* MRI simulation
122
Intact cervix and BT total dose constraint to bladder
D2cc \< 90 Gy
123
Intact cervix and BT total dose constraint to rectum
D2cc \< 70 Gy
124
Intact cervix and BT total dose constraint to Sigmoid
D2cc \< 70 Gy
125
What is the V45 for bladder, rectum, sigmoid for cervix + BT?
All are 50%
126
What dose causes ovarian sterilization
2-3 Gy
127
What dose causes ovarian failure
5-10 Gy
128
If you get a complex interstitial case how to reply
Refer to high volume brachytherapy center
129
What is a typical dose for interstitial implant
5x5
130
History for endometrial cancer
* Post menopausal bleeding - history, severity
* Abdominal, rectal exam
* Gyn exam
* Speculum
* Bimanual
* Rectovaginal
* Pap smear
131
Labwork for endometrial cancer
* CBC
* CMP
* CA-19-9
* Pap smear
* B-hCG if pre-menopausal
132
Imaging workup for endometrial cancer
* TVUS
* CXR/CT chest for high grade, serous, CC
* IF ADVANCED DISEASE SUSPECTED
* MRI/CT
* Cystoscopy/Sigmoidoscopy
133
Normal TVUS result
* Pre-menopausal varies with cycle
* Post-menopausal
* \<5 mm if no PMB
* Up to 11 mm for no PMB
134
Approach to get tissue diagnosis for endometrial
* Start with in office EMB
* If non-diagnostic --\> D&C
135
Type I histology endometrial
* Majority of cases
* Estrogen driven
* Well diff
* Superficial
* Endometrioid histology
* PTEN mutation
136
Type II endometrial cancer
Older age
Poor differentiation
Deeper disease
Non-endometrioid histology
High stage
p53 and HER2+
137
Which endometrial patients should get a SLNBx
Everyone except very early stage disease
Tumor \< 2cm
G1-2
\<50% MMI
138
For endometrial ca, if pelvic LN + what is the risk of PA LN
33%
139
For endometrial if pelvis is negative, risk of PA nodes
1%
140
What anatomic location has greater risk of PA LN
Fundus
141
For early stage endometrial what is the risk of pelvic nodes for G3, deep MMI?
25%
142
FIGO stage I for endometrial is...
Confined to uterus
143
FIGO stage II endometrial is...
involving cervix or corpus
144
What is FIGO stage IA?
\<1/2 MMI
145
Treatment options for FIGO IA endometrial
* TAH/BSO
* SLNBx
* Adjuvant therapy
* G1: observation
* G2: VCBT
* G3: VCBT
* LVSI: VCBT
146
What if stage IA patient endometrial is non operative candidate
Intracavitary HDR with vaginal cylinder
Dose of 7 Gy x 5 to uterus and upper 2/3 of vagina
147
If higher stage (IB+) endometrial patient is non operative candidate, what is the treatment plan
* EBRT to 45 Gy (pelvis)
* Brachytherapy (6.3 Gy x 3)
148
In general, what is the treatment strategy for local endometrial cancer
TAH/BSO followed by adjuvant RT (either vaginal brachy or EBRT pelvis)
149
What is the surgical recommendation for endometrial cancer
* In general:
* Type I extrafascial TAH/BSO with Pelvic SLNBx
* Visual inspection of the peritoneal, diaphragmatic and serosal surfaces
* Peritoneal washings
* Consider Type III rad hys if cervix involvement
150
What to look at on path report for endometrial
* Histology
* Grade
* MMI depth
* LVSI
* Cervix involvement
* Margins
* Peritoneal cytology
* #LN involved/dissected
151
What are the treatment options for recurrent endometrial cancer
* If no prior RT: EBRT 45 Gy plus VBCT (6x3 cylinder) or 5x5 interstitial implant if tumor \>5 mm thick
* If prior EBRT or VBCT - consider surgery, maybe EBRT
152
Of the endometrial histologies, which is most aggressive
serous - 5 year OS of 45%
153
What is outcome for FIGO IA endometrial
Excellent LRC and OS 95%
154
What is FIGO IB endometrial?
\>50% MMI
155
Treatment of FIGO IB endometrial
* TAH/BSO
* Pelvic SLNBx
* Adjuvant treatment
* G1: Obs vs. VBCT
* G2: VBCT
* G3: Depends - WPRT
156
What is the workup for recurrent endometrial cancer
H&P
Prior RT records
Bx
CTCAP or PET
157
What are the high risk features for endometrial cancer
Age \> 60
LVSI
Lower uterine segment involvement
Depth of invasion
Size \>2cm
158
How do higher risk features change stage I management
If multiple risk factors, and planning for VBT, consider WPRT
159
What is FIGO stage II endometrial
Cervical stroma involvement
160
Treatment of stage II endometrial cancer
* TAH/BSO + SLNBx
* Pelvic RT to 45 Gy
* VCBT to 5 Gy x 3 prescribed to 5 mm depth
\*\*If full type III hysterectomy was performed, consider just VCBT
161
What is stage IIIA endometrial
Involves serosa or adnexa
162
What is stage IIIB endometrial
Vaginal involvement or parametrial involvement
163
What is stage IIIC endometrial
Positive nodes
164
What is stage IIIC1 endometrial
Pelvic nodes
165
What is stage IIIC2 endometrial
PA nodes
166
What is stage IVA endometrial
Bladder or bowel
167
What is stage IVB endometrial
Distant mets including inguinals or **peritoneum**
168
Treatment of stage III or IV endometrial
Concurrent chemoRT
* WPRT + weekly cisplatin 40 mg/m2
* Adjuvant carbo-taxol x4
169
Dose of carbo taxol for endometrial cancer
Carbo AUC 5
Taxol 175 mg/m2
170
How to approach serous or clear cell endometrial histology
Doesn't matter the stafe, approach with CRT
* RT dependent on the specific situation
* Chemo is weekly cis 40 mg/m2 and adjuvant carbo-taxol
171
WPRT fields for endometrial - superior
Superior: L4/L5 or L5/S1 at common iliac bifurcation
172
WPRT fields for endometrial - inferior
below obturator foramen including lower 1/2 to 2/3 vagina
173
WPRT fields for endometrial - anterior
1 cm anterior pubic symphysis
174
WPRT fields for endometrial - posterior
Typically can split sacrum but if cervix is involved --\> posterior to entire sacrum since the presacrals are at risk
175
Script for vaginal brachy
* Use the largest vaginal cylinder possible (2.5-3.5 cm) to decrease the relative vaginal surface dose to the dose at Rx depth due to inverse square law
* Target the upper 2/3 of vagina (approx 4 cm) unless stage IIIB, LVSI, poor histology or poorly diff in which case I would consider treating full vagina
176
Dose of vaginal brachytherapy (mono)
If monotherapy: 7 Gy x 3 to 5 mm depth OR 6 Gy x 5 to surface
177
Dose of vaginal brachytherapy (combo)
6 Gy x 2 to vaginal surface
178
If cervix cancer pt is actively bleeding --\> next step
Pack and control bleeding
Ideally Hgb \> 11 for better outcomes
Consider QS if difficult to control
179
ASCUS next step
Repeat Pap in 6 mos --\> abnormal --\> colposcopy
180
LGSIL recommendations
Repeat Pap in 6 months --\> if abnormal --\> colposcopy
181
Recommendation for HGSIL
All get colposcopy and biopsy
182
Biopsy options for cervix pre-invasive disease
Conization
Loop electrosurgical excisional procedure (LEEP)
Laser or cryo ablation
Type I hysterectomy
183
Cervix 1A1 treatment
microscopic \<3mm deep
* If no LVSI --\> type I hysterectomy
* If +LVSI --\> type II + PLND
* If fertility preservation and no LVSI --\> cone bx with close FU
* If fertility preservation and +LVSI --\> radical trachelectomy + PLND
184
Cervix IA2 treatment
3-5 mm depth
* Modified radical hysterectomy (Type II) + PLND +/- PA sampling _OR_
* Pelvic RT (45 Gy) + Brachy (point A dose 80 Gy)
185
Cervix IB1 treatment
\<4 cm macroscopic
* Radical hysterectomy (Type III) + PLND + PA sampling
* Adjuvant RT/CRT per Sedlis and Peters criteria
OR
* Pelvic RT (45 Gy) + HDR brachy (point A dose 85 Gy) +/- weekly cisplatin 40 mg/m2
186
Cervix IIA1 treatment
Upper 2/3 vagina, \<4 cm
* Radical hysterectomy (Type III) + PLND + PA sampling
* Adjuvant RT/CRT per Sedlis and Peters criteria
OR
* Pelvic RT (45 Gy) + HDR brachy (point A dose 85 Gy) + weekly cisplatin 40 mg/m2
187
Cervix IB2 treatment
Macroscopic \>4 cm
* Definitive CRT
* 45 Gy in 25 daily 1.8 Gy fractions
* Dose paint nodes to 2.25 x 25 = 56.25
* Weekly concurrent cisplatin 40 mg/m2
* HDR brachy 7 Gy x 4 (total dose of 85 Gy)
188
Cervix IIA2 treatment
Upper 2/3 vaginal extension - \> 4cm
* Definitive CRT
* 45 Gy in 25 daily 1.8 Gy fractions
* Dose paint nodes to 2.25 x 25 = 56.25
* Weekly concurrent cisplatin 40 mg/m2
* HDR brachy 7 Gy x 4 (total dose of 85 Gy)
189
Cervix IIB treatment
Parametria extension
* Definitive CRT
* 45 Gy to pelvis with concurrent weekly cisplatin 40 mg/m2
* Parametrial boost to 1.8 x 3 = 5.4 Gy
190
Describe parametrial boost
Same inferior and lateral borders of field
Drop sup border to bottom of SI joint to get off bowel
Add 4-5 cm midline block over uterus/cervix
191
Treatment of stage IIIA cervix cancer
Lower 1/3 of vagina
* Definitive CRT
* EBRT to 50.4 Gy including whole pelvis, whole vagina, inguinals
* Concurrent cis 40 mg/m2
* Boost nodes
* HDR to 85 gy
192
Treatment of stage IIIB cervical cancer
Pelvic side wall or hydronephrosis
* Place stent
* Definitive CRT with pelvic RT 45 Gy
* Parametrial boost to 50.4 Gy
* Weekly cisplatin 40 mg/m2
* HDR to Point dose 85 Gy
193
Goal to finish all cervical RT
7-8 weeks
194
Endometrial IA G1
Observe
Assuming no high risk features (LVI, \>60 age)
195
Endometrial IA G2
Observe
OR
Vaginal brachy 7 Gy x 3 5 mm from vaginal surface
196
Endometrial IA G3
VCBT (7 Gy x 3)
197
Endometrial IB G1
VCBT
198
Endometrial IB G2
VCBT
199
Endometrial IB G3
WPRT to 50.4 Gy
200
Endometrial stage II treatment
Surgery --\> WPRT (50.4 Gy)
If medically inoperable 45 Gy WPRT followed by HDR 6x3 to uterine serosa, cervix and upper 2-3 cm of vagina
201
Stage III endometrial treatment
Vaginal, serosal, nodes
* WPRT to 50.4 Gy with concurrent cis weekly 40 mg/m2
* If low vagina, consider inguinals
* Boost nodes
* Adjuvant carbo-taxol x 4 cycles
* AUC 5
* Taxol 175 mg/m2
202
Stage IVA endometrial treatment
Bowel or bladder
* Definitive CRT
* 50.4 Gy EBRT
* Boost nodes
* Weekly cisplatin 40 mg/m2
* hDR to Point dose 85 Gy
203
How to approach serous or clear cell histology
Treat like stage III, integrate adjuvant chemo
204
History questions to ask about vulvar cancer
* Pain
* Pruritis
* Smoking history
* Hx of Pagets disease or Bowen's disease
* Prior vulvar surgery
* Prior leichen planus
205
Exam for vulvar cancer
Targeted physician exam
Gyn exam, speculum
Cervix, Vagina Pap Smear
206
Approach to obtaining tissue for vulvar cancer
* Perform EUA and colposcopy and biopsy
* If a small lesion (\<2 cm) ok to do excisional bx with 1 cm margin
* If larger lesion (\>2 cm) do punch or incisional bx for depth of invasion
* Bx any suspicious nodes (FNA ok)
207
Imaging for vuvlar cancer
CXR
Pelvic MRI
PET/CT better for evaluation of nodal involvement
208
Stage IA vulvar
\<2cm and \<1 mm stromal invasion
209
Stage IB vulvar cancer
\>2 cm or \> 1mm stromal invasion
210
How is staging done for vulvar cancer
surgical
211
What clinical feature of vulvar cancer predicts LN risk
DOI
212
What is treatment for IA vulvar cancer
WLE (if well lateralized) vs. radical vulvectomy
No need to address nodes
213
What is the LN risk for IB vulvar cancer
10%
214
What is the management of stage IB vulvar cancer
* If lesion is \>2cm from midline
* Radical LE or modified Radical vulvectomy with SLNBx of ipsilateral inguinal LND
* If lesion is \<2 cm from midline
* Radical WLE vs. Radical vulvectomy, bilateral SLNBx or bilateral inguinal LND
* **Risk stratified RT**
215
Stage II vulvar
Spread to lower 1/3 of urethra, vagina, anus
216
Treatment of stage II vulvar cancer
If possible: Radical vulvectomy + unlateral or bilateral inguinal LND
+/- postop RT
If non-operative: definitive CRT
217
Stage III vulvar cancer
+inguinofemoral nodes
218
Options for stage III vulvar cancer
* If resectable: radical vulvectomy + unilateral/bilateral inguinal LND + post op RT
* If unresectable
* Neoadjuvant CRT with cis/5FU --\> surgery
* Definitive CRT
219
What is the approach to neoadjuvant treatment for initially unresectable vulvar cancer
* Chemo
* Cis 50 mg/m2 on Day 1 & 29
* 5-FU 1000mg/m2 on Days 1-4 (week 1/5)
* RT
* 180 x 28 to 50.4 then re-eval
* If CR --\> surgery or Obs
* If PR, give boost of 10-15 Gy
220
What is the approach for definitive chemoradiation for vulvar cancer
RT: 66-70 Gy
2 cycles of cis/5-FU
* cis 50 mg/m2 Day 1,29
* 5-FU 1000 mg/m2 Day 1-4 (wk 1,5)
221
Stage IVA vulvar cancer
Spread to upper urethra, bladder, rectal mucosa or pelvic bone
Fixed or ulcerated LN
222
Treatment for IVA vulvar cancer
Definitive CRT
223
For vulvar cancer, pelvic nodes are considered
M1!
Always bx to confirm
224
What is considered well lateralized for vulvar cancer
2 cm from midline
225
Who is eligible for SLNBx for vulvar cancer
Tumor \< 4 cm
cN0
No prior vulvar surgery
226
If SLNBx is negative for vulva --\> next step
Observation (only \<5% chance of recurrence)
227
If SLNBx is positive for vulva --\> next step
* If \<2mm node: EBRT +/- chemo
* If \>2mm node: LND preferred
228
Indications for post op RT for vulvar cancer (primary)
* Primary
* Margin \< 8mm
* LVSI
* DOI \> 5-10 mm
* Size \>4 cm
* Diffuse pattern
229
Indications for postop RT for vulvar cancer (nodes)
\> 1 LN+ (always treat bilateral)
ENE
Clinically LN+
230
If the patient meets criteria for adjuvant nodal RT for vulvar cancer, should vulva be treated?
yes
231
Which vulvar patients should get postop CRT
+margin
+ECE
maybe for \>1 +
232
What chemo should be given postop with RT for vulvar cancer
weekly cis 40 mg/m2
233
How to sim a patient for vulvar cancer
* Supine
* Frog leg
* Wire anus, nodes, tumor, scars
* Vaginal contrast or marker
* Full bladder and oral contrast
* IV contrast
* Fusion with PET or MRI
234
CTV for vulvar cancer
Gross disease plus full vulva (at least 1 cm on GTV)
Add structures involved (vagina, anus etc.)
Nodal volume includes inguinals
235
Definitive vulvar cancer RT doses
* Vulva CTV - 50.4 Gy
* Primary 64 Gy
* Elective nodes: 45 Gy
* Gross nodes
* Most 64 Gy
* Massive or fixed 70 Gy
236
Adjuvant vulvar RT doses
* 50.4 to operative bed, surgical scar, vulva
* Tumor bed to 54-60 Gy
* Nodes with elective or microscopic 45 Gy
* ECE 66 Gy
* Gross residual 70 Gy
237
Outcome for stage I vulva
90% 5 year OS
238
Outcomes for stage II vulva
75%
239
Outcomes for stage III vulva
50% OS
240
Outcomes for stage IV vulva
20% 5 year OS
241
For cervical brachy, where is the dose prescribed to?
HR-CTV
242
What is the HR-CTV?
GTV residual at time of brachy insertion
Whole cervix
Presumed extra-cervical extension
243
What is goal coverage for HR CTV
D90 = 90-95
244
For HDR brachy cervix, what is target Rectum D2cc
Goal is 65 Gy
Limit is 75
245
For hDR brachy cervix what is the target D2cc for bladder
Target - 80
Hard limit is 90
246
Ways to combat proctitis
anusol suppository
carafate enemas
proctifoam
247
ITV--\> PTV for postop pelvis
* Scan first with full bladder
* Then with empty bladder
* FULL BLADDER SCAN is planning scan
* Contour
* Vaginal cuff on both full and empty bladder
* Upper 3 cm of parametrial tissue
* Add 7 mm margin around ITV
248
For vaginal cuff recurrences, what is best treatment strategu
Pelvic RT followed by brachy
249
What brachy should be used after EBRT for pelvic recurrence
If \<5 mm residual --\> vaginal cuff brachy
If \>5 mm residual --\> interstitial
250
What is the dose of brachy for vaginal cuff recurrence
5 Gy x 5
251
What are the indications for postop RT for vulvar cancer
* Primary
* Margins \< 1 cm for fresh or 8mm fixed tissue
* LVSI
* DOI \> 5-10 mm
* Size \> 4 cm
* Diffuse involvement
* Nodal findings
* \>1 LN
* ENE
* Clinically LN+
252
When is postop chemo added for vulva?
+margin
+ECE
Consider for \>1 LN
253
What is SLNBx size cutoff to do RT alone
2mm
If greater, needs lymph node dissection
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