GYN

Question 1

Cervical Screening

Answer 1

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

Question 2

Cervical Staging

Answer 2

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

Question 3

Cervix 1A1 no LVI treatment

Answer 3

(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)

Question 4

Cervix IA2

Answer 4

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)

Question 5

Cervix IB1-2 and IIA1

Answer 5

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)

Question 6

Cervix IB3, IIA2+

Answer 6

Cervix IB3, IIA2+ ie >4 cm or advanced

CRT ->brachy boost

Question 7

Cervix Post op Whole Pelvis RT indications

Answer 7

Sedlis 2 of 3 factors:
LVSI
> 4cm
>1/3 stromal invasion

Question 8

Cervix Post op Chemo RT

Answer 8

(Peters)
Positive margins (<3 mm)
Positive nodes
Parametrial inv (surprise FIGO IIB)

Question 9

Cervix pelvic targets

Answer 9

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

Question 10

3DCRT fields (postop or definitive): All to 45 Gy (50.4Gy if EBRT alone)

Cervix

Answer 10

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!)

Question 11

Cervix post op dose

Answer 11

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

Question 12

Cervix Treatment flow

Answer 12

CRT - > exam/MRI at 4 weeks -> Brachy twice weekly after EBRT separated by 72 hours, finish all in 8 weeks

Question 13

Cervix HDR goals

Answer 13

Target

D90 > 100% Rx (>80-85Gy EQD2)

Point A >65Gy (for CT/MR guided/optimized brachy)

Question 14

Cervix OAR constraints

Answer 14

• Small Bowel: D2cc <65Gy EQD2
• Rectum: D2cc <65Gy EQD2
• Sigmoid: D2cc <65Gy EQD2
• Bladder: D2cc <80Gy EQD2
• • Cumulative:
• Vagina:
• -upper < 120 Gy
• -mid < 80 Gy
• -lower < 60 Gy
• • Fem head < 45

Question 15

Endometrial staging

Answer 15

• 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

Question 16

Endometrial Stage IA G1-2

Answer 16

Observation

Question 17

Endometrial Stage IA G3 / IB, G1-2

Answer 17

VBT

Question 18

Endometrial IB G3

Answer 18

Pelvic RT

Question 19

Endo Stage II

Answer 19

Pelvic RT + VBT

Question 20

Endo Stage III-IV

Answer 20

CRT or chemo +/- RT

Stage III: post-op RT w cisplatin (50 mg/m^2, Day 1 and Day 29) à carbo/tax x 4 cycles

Question 21

Endometrial Serous or Clear Cell management by stage

Answer 21

IA non-invasive(polyp): if neg washings: VBT, + washings: chemo and VBT

IA-IV: Chemo +/- EBRT +- VBT

Question 22

Endometrial RT volumes / fields

Answer 22

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+

Question 23

Endo VBT dose

Answer 23

Brachy VBT alone: 6G x 5 to surface or 7 x 3 to 0.5mm

EBRT boost: 5-6Gy x 3 to surface

Question 24

Uterine Sarcoma IB-IV

Answer 24

chemo +/- RT

Question 25

Endometrial constraints

Answer 25

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.

Question 26

Endometrial inoperable treatment

Answer 26

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

Question 27

Vuvlar staging

Answer 27

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**

Question 28

Vuvlar IA

Answer 28

IA: WLE with 1 cm margin (no LND)

Question 29

Vulvar IB/II

Answer 29

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%

Question 30

Vulvar Stage III-IV

Answer 30

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%)

Question 31

Vulvar IMRT volumes

Answer 31

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

Question 32

Vulvar dose

Answer 32

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)

Question 33

vulvar constraints

Answer 33

* 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

Question 34

Vaginal Staging

Answer 34

* I – vagina * II: paravaginal * III: pelvic sidewall, N+ * IVA: bladder, rectum * IVB: mets

Question 35

Vaginal Stage I

Answer 35

: Surgery (vaginectomy and nodal dissection) or definitive RT alone (EBRT + brachy)

Question 36

Vaginal Stage II

Answer 36

II: Surgery, if can; chemoradiation or RT alone (if small)

Question 37

Vaginal Stage II+

Answer 37

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