GYN Flashcards
1
Q
Cervical Screening
A
Age <21: no screening regardless of 1st coitus age
- Age 21-29: cytology q.3 yrs w/o HPV co-test
- Age 30-65: co-test q.5 yrs (cytology+HPV) or cytology q.3yrs.
- Age 65+: No further testing if 3 prior negative cytologies or 2 negative prior co-tests
2
Q
Cervical HPV
A
16, 18
95% related
3
Q
Cervical LN Risk
A
IB: 15% P 10% PA
II: 30% P 20% PA
III: 45% P 30% PA
4
Q
Cervical H/P script
A
I would start with a complete history and physical focusing on the presenting symptoms as well as the GYN history including any **prior abnormal Pap smears**, abnormal vaginal bleeding or discharge, and pelvic pain. I would also ask about Sexual, Social and Family History.
I would then perform a full physical exam including LN palpation for inguinal and **supraclavicular nodes**. I would perform an abdominla exam followed by pelvic exam consisting of speculum, bimanual, and rectovaginal exam (to evaluate the **cervical os, cervical mass, vaginal vault size, vaginal extension, parametrium, pelvic side wall extension, adexa, and uterus**) and PAP Smear.
5
Q
Cervical Workup
A
Labs: CBC with diff, CMP, LFTs, HIV, pregnancy test
Imaging (IB2+)
- PET/CT or CT
- MRI – smudgy border = parametrial invasion
- cystoscopy and sigmoidoscopy if suspicion for bladder/bowel
Biopsy:
- EUA with gyn onc
- Colposcopy w biopsy. If no gross lesion noted, conization.
**If stage > IIIB: RENAL STENT prior to definitive chemoRT (creat > 3 → no cis!)
Fertility Evaluation (egg harvesting) and oophoropexy
6
Q
Cervical Staging
A
IA1: <3mm depth
IA2: 3-5mm
IB1 – macro < 2 cm (and >5 mm depth)
IB2 – macro 2-4 cm
IB3 – macro > 4cm (bulky!)
IIA1: upper 2/3 vagina < 4cm: (small size therefore group with IB1 for tx)
IIA2: upper 2/3 vagina > 4cm
IIB - parametria
IIIA – lower 1/3 vagina
IIIB – pelvic SW, hydro, kidney dysfunction
IIIC1 – pelvic nodes
IIIC2 – PA nodes
IVA/T4: bladder, rectum, or beyond true pelvis
IVB/M1: distant organs
7
Q
TAH
A
uterus, cervix, and small rim of vagina cuff
8
Q
Mod radical hyst
A
uterus/cervix/1-2 cm of vagina, some of parametrium
9
Q
Radical hysterectomy
A
uterus/cervix/upper 1/3-1/2 of vagina, dissection of parametrium to sidewall, PA/pelvic LND
10
Q
Rad trachelectomy –
A
removes cervix, parametria + LN sampling
- Preserves fertility.
- Only for tumor < 2 cm, no LVI (not meeting Sedlis!)
11
Q
Cervix 1A1 no LVI treatment
A
(only group not needing nodal management)
1) Cold knife cone, if negative margins, then simple hysterectomy (if fertility not desired)
2) Fertility sparing: CKC (want margins ≥3mm, no LVI) if positive margins repeat cone or trachelectomy
3) Inoperable: definitive brachy (7.5 x5)
12
Q
Cervix IA2
A
1) Mod rad hyst + pelvic LND/SNB > risk stratified RT/CRT (Sedlis/Peters)
2) Fertility sparing: Rad trach + PLND/SNB, or CKC with neg margins and PLND/SNB
3) Definitive RT (pelvic RT+brachy, 75Gy)
13
Q
Cervix IB1-2 and IIA1
A
1) Rad hyst + PLND + PA sampling > risk stratified RT/CRT (Sedlis/Peters)
2) Last fertility sparing option for IB1, up to 2cm, no LVI, path node neg: rad trachelectomy+ PLND/SND
3) Definitive RT (80+Gy)
14
Q
Cervix IB3, IIA2+
A
Cervix IB3, IIA2+ ie >4 cm or advanced
CRT ->brachy boost
15
Q
Cervix Post op Whole Pelvis RT indications
A
Sedlis 2 of 3 factors:
LVSI
> 4cm
>1/3 stromal invasion
16
Q
Cervix Post op Chemo RT
A
(Peters)
Positive margins (<3 mm)
Positive nodes
Parametrial inv (surprise FIGO IIB)
17
Q
Cervix interstitial indications
A
- tumor >4cm after EBRT (poor responder)
- residual tumor extends to lateral parametria or sidewall (redundant with above)
- extensive or distal vaginal involvement
- narrow distorted vagina that would not accommodate applicator
18
Q
Cervix finish treatment within
A
8 weeks
19
Q
cervix chemo
A
Cisplatin: 40 mg/m^2 weekly
20
Q
Cervix Simulation
A
SIM:
- 3DCRT (4-field box) positioned prone on belly board
- IMRT: extended field, or SIB to nodes, supine
- CT sim, IV and small bowel contrast
- anal marker
- gyn marker: vaginal if post-op, if intact fiducial to mark extent of vaginal disease
- full bladder, empty rectum (IMRT – full and empty bladder scan – to generate uterus and cervix ITV)
21
Q
Cervix pelvic targets
A
Targets (definitive or postop):
- gross disease (cervix and entire uterus if definitive), vagina, parametria/uterosacrals, and pelvic LN
- always: Pelvic LN: obturator, internal/external iliac, presacral
- Cover common iliacs if pelvic LN + (to bifurcation of aorta)
- Extended field to level of renal vessels (or higher, ~5cm above highest LN) if common iliacs or PA involved
- Inguinal nodes if IIIA (distal vagina involved)
IMRT? indicated for SIB to gross nodes, extended field, or postop (TIME-C trial for postop cervix and endometrial, IMRT reduced pt reported acute GI and GU toxicity). Otherwise, prob safest to say 3DCRT.
*parametria positive – 45, then boost parametria to 54
22
Q
3DCRT fields (postop or definitive): All to 45 Gy (50.4Gy if EBRT alone)
Cervix
A
AP/PA:
sup: L4/L5 at int/ext iliac nodes (bifurcation of common iliacs)
- if pelvic nodes +, tx common iliac nodes (L3/4 – bifurcation of aorta)
inf: 3 cm below inf vaginal inv or inferior obturator (whichever is lower)
lat: 2 cm on pelvic brim (don’t block SI joints or femoral head)
Lat field:
- anterior: 1 cm anterior to pubic symphysis
- posterior: entire sacrum (don’t split!)
23
Q
Cervix Nodal Boost
A
- Nodes <2cm à 60 Gy (SIB in 25 fractions to 54-56 Gy/2.16-2.24Gyfx à sequential boost in 2 Gy fx to 60Gy) – wait to do sequential dose until after brachy
- Nodes >2cm à 63Gy or higher depending on OARs (usually limited by bowel dose); as above, do SIB to 54-56Gy in 25 fx then sequential bode post to 63Gy
- Don’t forget brachy throw-off (important for obturator nodes, get about 1 Gy/fx)
24
Q
Cervix post op dose
A
Post-op
- Treating for Sedlis criteria, negative margins and negative LN: 45 Gy to pelvis
- Treating for Positive margins: 45 Gy to pelvis, parametrial boost as above to 54 Gy, vaginal cylinder boost 4Gy x 3 to surface (EQD2 62.4-67Gy) – goal 60-66Gy to areas of concern for positive margins
Parametrial Boost – 54 Gy, if involved, with IMRT
-3D borders – AP/PA – lower sup border to bottom of SI joint, 4-4.5 cm wide midline block – all other borders stay the same
25
Cervix Treatment flow
CRT - \> exam/MRI at 4 weeks -\> Brachy twice weekly after EBRT separated by 72 hours, finish all in 8 weeks
26
cervix Brachy script
**Applicator selection**: T&O – safe to say
- in OR, anesthesia à dorsal lithotomy position
- EUA: primary, parametria, rectovaginal septum, mucosal involvement; select T&O size
- place fiducials to mark any vaginal disease and at cervix to evaluate applicator placement – at cervix, inferior extent of vaginal involvement
- place foley in bladder
- sound uterus (to determine tandem length)
- serially dilate cervical os under US guidance
- place tandem and ovoids (want snug fit – largest possible ovoids)
- set flange at end of uterine cavity
- pack: start posterior, then anterior
- insert dummy wire into tandem
- image: CT scan or film – to ensure placement
- fuse to diagnostic MRI for contouring guidance
\*each fraction separated by at least 72 hrs\*
Film evaluation:
Anterior
- Tandem bisects ovoids
- Tandem not rotated
- Flange close to marker seeds
- Ovoids high in fornices \<1 cm from marker seeds, with ~1 cm spacing between them
Lateral
- Tandem bisects ovoids, not rotated
- Tandem midway between sacrum & bladder, at least 3 cm from sacral promontory
- Packing is ant & post to ovoids, but not sup to ovoids
- Foley balloon pulled down
27
Cervix Brachy Volumes
- contour on T2 based sequences, fuse diagnostic MR to planning CT
- HRCTV= entire cervix, GTV w/ parametrial/vaginal/uterine extension **at time of brachy**
- IRCTV=HRCTV+ 0.5-1.5cm (excluding OARs) + also includes initial extent of disease; should get 60% of Rx
Dose: HDR 1;5.5 Gy x 5, Ir-192, dose rate 12 Gy/hr (~equal to 35-40 LDR). **80-85 Gy EQD2 total**
Points (images at end of sheet):
A: 2cm superior to cervical OS and 2cm lateral (uterine vessels cross ureter)
B: 3cm lateral to point A (parametrium/ obturator); receives 33% point A dose
C: 4cm lateral to point A (sidewall), 20% dose
Bladder – posterior surface of foley balloon on lat and center on AP film
Rectal – 5mm behind posterior vag wall between ovoids
Vaginal point – AP film lateral edge of ovoid, Lat – mid-ovoid
28
Cervix HDR goals
Target
D90 \> 100% Rx (\>80-85Gy EQD2)
Point A \>65Gy (for CT/MR guided/optimized brachy)
29
Cervix OAR constraints
* Small Bowel: D2cc \<55-60Gy EQD2
* Rectum: D2cc \<65Gy EQD2
* Sigmoid: D2cc \<70Gy EQD2
* Bladder: D2cc \<80Gy EQD2
* * Cumulative:
* Vagina:
* -upper \< 120 Gy
* -mid \< 80 Gy
* -lower \< 60 Gy
* * Fem head \< 45
30
Cervix not meeting normals
1. Check packing
2. Replan
3. Change fractionation (use more fractions, lower dose per fraction)
31
Cervix Side effects
Vaginal stenosis with 50-60 Gy
_Side effects_
Acute: cystitis, diarrhea, vaginal discharge, dysuria, decreased counts
Late: Vaginal stenosis, stricture, fibrosis, ureteral stricuture, cystits, SBO, proctitis, thinning mucosa, ovarian failure, painful intercourse, femoral neck fx (5%)
Tandem specific:
Uterine perf (\<3%), vaginal laceration (1%)
32
Cervix 5 year OS
IA - 90%
IB - 80%
II - 60%
III - 30%
IV - 10%
33
Cervix Follow-up
H&P with pap every 3 months x 1 year, 6 months x 2 years, annually; PET at 3 months then CT annually
-Use vaginal dilator
34
Endometrial risk of pelvic LN and PA
IF Pel - PA 2%
if Pel + PA 40%
**Risk of Pelvic LN+**
**MMI**
**G1 0, 5, 10**
**G2 5, 10, 15**
**G3 10 15 35**
**Inner 1/3**
0%
5%
10%
**Mid 1/3**
5%
10%
15%
**Deep 1/3**
10%
15%
35%
35
Endometrial risk factors
-risk factors: tam, unopposed estrogen, fam hx (HNPCC, Lynch Syndrome)
36
Endometrial Workup
**Labs**: CA-125 (normal \< 35), CBC, CMP
**Imaging:**
- transvaginal U/S (\> 4mm is thickened stripe)
- MRI if inoperable, cervical invasion on exam
\*Grade 3 patients – do CT before surgery
**Biopsy:**
- endometrial biopsy
- D&C under anesthesia if initial biopsy nondiagnostic
**Other:** genetic counseling if young or history suggestive of HNPCC
37
Endometrial Pathologic staging procedure
Pathologic staging:
1. Laparoscopic inspection: peritoneal cavity/pelvis, adnexa, omentum bx (G3/HR histology)
2. Pelvic washings for cytology
3. Extrafascial hysterectomy and BSO w/ nodal assessment
* Bilateral SNB for all
* Otherwise, use Mayo criteria (below) to determine whether to do b/l PA-PLND (want 12+ nodes – at least one from each of 5 stations bilat; PA, CI, EI, II, obturator)
Per LL – can just do SLNBx
**Mayo**
Do **_NOT_** need to perform nodal dissection if ***_all_*** apply:
* G1-2 endometrioid
* MMI \<50%
* Tumor 2cm or less
OR 0% MMI
38
Endometrial what do you want to see on Pathology report
- Histology
- Grade
- Myometrial invasion
- LVSI
- Cervical involvement
- Margins
- #LN dissected and involved (pelvic vs PA)
- Cytology of washings
39
Endometrial staging
* IA: endometrium or \<50% MMI
* IB:_\>_50% MMI
* II – cervical stromal inv
* IIIA – serosa, adnexa
* IIIB – vagina or parametrial involvement
* IIIC1 - PLN : N1
* IIIC2 - PALN : N2
* IVA – bladder, bowel
* IVB – distant met
40
Endometrial Stage IA G1-2
Observation
41
Endometrial Stage IA G3 / IB, G1-2
VBT
42
Endometrial IB G3
Pelvic RT
43
Endo Stage II
Pelvic RT + VBT
44
Endo Stage III-IV
CRT or chemo +/- RT
## Footnote
Stage III: post-op RT w cisplatin (50 mg/m^2, Day 1 and Day 29) à carbo/tax x 4 cycles
45
46
Endometriod Stage III CRT chemo
chisplatin 50 mg/m2 D1/29
47
Endometrial Serous or Clear Cell management by stage
IA non-invasive(polyp): if neg washings: VBT, + washings: chemo and VBT
IA-IV: Chemo +/- EBRT +- VBT
48
Endometrial sim
**WP 45 Gy (50.4 if using EBRT alone)**
4 field vs IMRT
- IMRT: sim w bladder full and empty – vaginal ITV. Plan and daily tx w full bladder
- PO and IV contrast
- place vaginal cuff markers
- prone – 3D
49
Endometrial RT volumes / fields
CTV = int iliac, ext iliac, obturator, pre-sacral if cervical involvement (7mm margin on vessels excluding muscle, bone, and bowel), proximal ½-1/3 of vagina
PTV\_nodes=CTV+ 7mm
PTV\_vagina=ITV+ 1-1.5 cm
sup: L4/L5
- if PLN+: L3/L4 (cover commons to aorta bifurcation)
- if PALN+ - cover 5 cm above highest node or EFRT (T12/L1 or renal vessels)
inf: obturator foramen, include upper half of vagina
lat: 2cm on pelvic brim
ant: 1 cm ant to pubic symph
post: split sacrum to S3 (include entire sacrum if cervical involvement)
\*LL – cover pre-sacrals if N+
50
Endo VBT dose
Brachy VBT alone: 6G x 5 to surface or 7 x 3 to 0.5mm
EBRT boost: 5-6Gy x 3 to surface
51
Uterine Sarcoma IB-IV
chemo +/- RT
52
VBT technique
VC HDR brachy:
* 4-8 weeks post-op
Technique (single channel cylinder)
- Examine – confirm cuff healed, estimate cylinder diameter (2-3.5 cm)
- Insert cylinder in vagina flush against vaginal vault, secure on brachy board
- Plan: divide vagina length in half, so if 8 cm treat 4 cm = 9 dwells (4 x 2 + 1)
- Do CT scan to confirm placement, review plan
- Note: VSD relative to 5 mm depth=160%
- Ir-192, 74 days half life
- largest cynlinder size to decrease vaginal surface dose
53
Endometrial constraints
Bladder: V45 \< 40%
Rectum: V40 \< 80%
BM: V10\<95%; V40\<37%
Bowel: V45 \< 200cc
V45\<25% - femoral heads
Keep rectum and bladder to \<75% of full dose. Anterior surface of the rectum receives full dose.
54
Endometrial OS
IA – 90%
IB – 80%
II – 70%
III – 60%
55
Endometrial Followup
H&P with vaginal canal exam
- Imaging as clinically indicated (except routine CT chest for sarcoma)
- CA-125 if initially elevated
- pap smears not rec’d on NCCN
56
Endometrial inoperable treatment
IA, G1-2: brachy alone (EQD2 80-90, 7.5 x 5)
IA, G3, IB-II: WP (45) + brachy (5 x 5) – prescribed to serosa (so cavity is hotter) – include cervix in volume, along with upper 2/3 of vagina
III-IV: ChemoRT (WP) + interstitial brachy
Brachy device: Y-applicator
-target: uterus, cervix, top 1-4 cm of vagina
Consider progestin-based hormone therapy if ER/PR positive and not candidate for RT
57
Uterine sarcoma treatment
## Footnote
- leiomyo
- endo stromal
- high grade undiff
Surgery (LND not indicated!)
- ESS: adj hormone therapy (megesterol, NOT TAM)
- leiomyo or undiff: adj chemotherapy (docetaxel/gem)
58
* Pt had simple hysterectomy & found to have IA2 cervical or higher disease. What do you do?
* Re-stage w/ labs, PET, & CT/MRI
* Options
* Take back to OR for radical parametrectomy & pelvic LND
* Postop RT for deep stromal invasion, \>4 cm, or LVSI
* Postop chemoRT for +margin, +LN, +parametria
* Or, post-op RT or chemoRT with same indications as above
59
Vulvar drainage pattern
Nodal drainage:
- inguinal (1st)
- external iliac and pelvis (2nd) – clitoris may drain directly to iliac)
60
Radical Vulvectomy
Removal of vulva to deep fascia of thigh with removal of periostem of the pubis and 2cm margin. +/- uni or bilat groin LND
61
Vulvar H/P
**History:** young and HPV+, or old and lichen sclerosis
**Physical:** proximity to central structures (urethra, clitoris, anus, vagina), synchronous lesion, pap smear, inguinal node
62
Vulvar subsites
SUBSITES:
1. Labia majora
2. Labia minora
3. Clitoris
4. Urethral meatus
5. Introitus
6. Bartholin’s gland
\*Skene’s is periurethral
63
Vuvlar staging
Pathologically staged:
* **I:** confined to vulva:
* IA: ≤2cm and ≤1mm inv
* IB: \>2cm or \>1mm inv (\>1mm = 10+% risk of LN involvement)
* II: invades **lower** urethra, vagina, or anus
* IIIA: **upper** urethra, vagina or rectum
* IIIB: Node + \>5mm
* IIIC: ECE
* * IVA: fixed to bone or ulcerated nodes
* IVB: mets, **inc pelvic LN**
64
Vuvlar IA
IA: WLE with 1 cm margin (no LND)
65
Vulvar IB/II
IB/II: WLE + inguinal LND
Lateral lesion, cN0, pN0, \<2cm: unilateral LND
Central lesion (_\<_ 1 cm of midline), cN+, pN+: bilateral LND
RT to primary, LNs as indicated (see below):
\*if positive SLN -\> recommend dissection\*
_RT to primary: (based on Heaps surgical review)_
1) \>5 mm depth of invasion
2) close (\<8 mm fixed, 1 cm gross) or positive margin
3) LVSI
\*note: if close/pos margin is only indication, re-resect
_RT to LNs:_ any positive nodes
_ChemoRT:_ any positive nodes
\*\*\*SLNB – GOG 173 (Levenback JCO 2012) showed 92% sensitivity. If tumor \< 4 cm, false neg rate \<2%
66
Vulvar Stage III-IV
1) Preop ChemoRT (cisplatin 40mg/m^2 weekly, RT to 57.6) -\> surgical excision of residual disease -\> if not resectable continue chemoRT to definitive dose
2) Def chemoRT (unresectable): weekly cisplatin (40 mg/m^2) + RT to 64.8
3) Radical vulvectomy – may require pelvic exenteration
\*\*for positive pelvic nodes, treat with curative intent (even though M1; survival ~45%)
67
vulvar Sim
CT simulation:
- supine, frog leg, vac-lok
- wire the tumor, scar, palpable nodes, and place a BB at the vaginal introitus.
- 5mm bolus (if needed – can check with _TLDs_) – often for IMRT you don’t
68
Vulvar IMRT volumes
GTV=gross disease vulva and nodes
CTV\_primary= primary tumor + 2 cm
CTV\_nodes=(inguinal vessels + 2-3 cm) + (external/internal iliacs + 1 cm)
PTV= CTV+1 cm
-average depth of femoral vessels ~ 6 cm
69
Vulvar dose
Boost the primary (+margin or gross disease) or the groins (ECE)
\*Always need to treat nodes if neoadjuvant or definitive\*
Dosing:
Post-op: 50.4Gy
+ margin or + ECE: 59.4
Neoadjuvant: 57.6
Gross disease (definitive): 64.8
-always treat the primary – no central blocking (50% recurrence in the Dusenberry study)
70
vulvar constraints
* Femoral heads
* Max \< 50
* V35 \< 35%
* * Small bowel
* V45 \< 200 cc
* * Bladder
* Max 75
* * Rectum Max 70
* * Skin as tolerated – likely to be dose limiting
71
Vulvar OS
5 yr OS:
I – 95%
II – 80%
III – 60%
IV – 45% for pelvic LN+, 20% hematogenous mets
Predominal failure pattern is LOCAL
72
Vuvlar side effects
Side effects:
Skin and vaginal stenosis
Early skin rxns (before 35Gy) is usually yeast – give diflucan and keep treating!
sitz baths for prevention of infection during RT
73
Vaginal VAIN
treat with WLE, laser or 5-FU topical, progresses to invasive if left alone
74
Vaginal workup
**Imaging:**
-PET/CT
**Biopsy:**
- Remember to colpo w/ biopsies of cervix/vulva to r/o primary cervical or vulvar cancer
- FNA any grossly positive node
If adeno: D/C to r/o endometrial, colonscopy to rule out colon, mammo/chest CT, CA-125
75
76
Vaginal Staging
* I – vagina
* II: paravaginal
* III: pelvic sidewall, N+
* IVA: bladder, rectum
* IVB: mets
77
Vaginal Stage I
: Surgery (vaginectomy and nodal dissection) or definitive RT alone (EBRT + brachy)
78
Vaginal Stage II
II: Surgery, if can; chemoradiation or RT alone (if small)
79
Vaginal Stage II+
II+: Definitive CRT
- EBRT + brachy boost
- Concurrent cisplatin 40 mg weekly x 6
If after EBRT, disease is \< 5 mm deep by exam and MRI, can do VC alone. Otherwise do IS (Syed).
IVA: brachy can cause fistula! Consider exenteration
80
Vaginal CA 5 y DFS
5 yr DFS
I/II- 80%
III/IVA - 60%
Local failure very similar to cervix
81
Vaginal Radiation technique
EBRT target: primary + pelvic nodes; treat inguinals if lower 1/3 vagina involved
Need beam and brachy
- beam to 45
- sup/border: L5/S1
- lateral: pelvic brim + 2 cm, parametria
- inferior: vaginal canal
\*if involvinig lower 1/3 of vagina – inguinals
- brachy total to 75-80 Gy, 6 Gy x 3
- interstital vs. Syed
- use multi-channel
- again, need repeat exam and pelvic MRI
- prescribe to 5mm depth – if surface, won’t get deep enough dose
\*dose forget for fiducials\*
**Dose:**
45 Gy
Boost positive LN (III) and parametria (II) to 59.4 Gy
Boost primary w EBRT instead of Syed if involving rectovaginal septum/bladder: ~ 70 Gy
**Syed: single insertion; 5 Gy x 5 fraction BID (EQD2 75-80)**
One week prior to insertion, do CT/MRI sim with template in place
82
challenging T/O issues
Perforation:
Anteverted Uterus
High bowel dose
high bladder dose
Perforation: withdraw, oral antibiotic, re-try with US guidance
Anteverted Uterus: Fill bladder, US guidance
High bowel dose: fill bladder, reduce tandem loading length
high bladder dose: alternate full/empty bladder
