CRO Exam 3
Which techniques are used to treat the vulvar area, and what are their advantages and drawbacks?
*3D "firebird"* technique uses relatively large fields with electrons to boost the nodes. Bolus may be used to boost the dose to the skin. Though there is good coverage, electrons may not reach disease in obese patients. Also, too much bowel and rectum in the traditional firebird technique fields can result in diarrhea which will contaminate raw vulvar surfaces. Skin exposure can cause desquamation, stenosis, and hyperpigmentation. *IMRT* can also be used and is preferred because it can incorporate a concurrent boost, it protects the femoral heads, bowel, and skin from excessive dose.
What brachytherapy device is used to treat the vaginal cuff?
*Dome cylinders* are used for homogeneous irradiation of the vaginal cuff
What are the two types of endometrial cancer and their hallmark characteristics? age range histology
*Estrogen-related* : younger women, better prognosis, 75% of cases; adenocarcinoma *Non-estrogen related* : older women, 25% of cases; clear cell
Subtypes of Vulvar cancer
*keritaznizing* no associated with HPV but found with lichen sclerosis (thin, white patches of skin, usually in the genital area), found in older women. *Classic/Bowenoid* most common in younger women exposed to HPV 16,18,33
Describe the epidemiology of esophageal cancer including the two main histologies and their causes.
*squamous cell carcinoma* caused by smoking and alcohol use. Limited to upper esophogus *adenocarcinoma* caused by reflux, barretts esophagus, limited up lower esophagus. more common in US
When should brachy start in relationship to EBRT when treating cervical cancer?
1st insertion: within 4-6 weeks of intital EBRT or after 20Gy EBRT 2nd insertion: 1-2 weeks later. *all therapy should be complete within 8 wks*
What dose does sterilization occur?
2-3Gy
The whole abdominal RT doses for Ovarian cancer are
30 Gy/20 fx to the abdomen nodal boost (12 Gy/8 fx) two additional boosts *totaling 58.2 Gy.*
What are the RT techniques and doses used to treat vaginal cancer?
40-50 Gy followed by brachytherapy to 75-80 Gy total dose using either ALTO (after-loading tandem and ovoids) or a vaginal cylinder.
What are the usual RT dose and technique(s) for endometrial cancer?
45 Gy/25 fx Sim both full and empty bladder, but treat with a full bladder.
The usual RT doses and techniques for cervix cancer at MDACC are:
45 Gy/25 fx with a 4-field box if the uterus is present. Otherwise, the patient will receive IMRT. This initial therapy is then followed up with brachytherapy:
What are the prescription and dose fractionation used to treat gastric cancer?
45-50.4 Gy 180 cGy/day
What are the dose limits for the ovaries?
5-10 Gy ovarian failure 2-3 Gy sterilization
At what dose does Ovarian failure occur?
5-10Gy
The standard RT dose and possible techniques for esophageal cancer are: margins for field?
50.4 Gy in 28 fx delivered by 3D, IMRT, or protons.
What are the prescription and dose fractionation used to treat esophageal cancer?
50.4-54Gy 180 cGy/fx
The tolerance for the distal vagina is
60Gy
What is the most common histology of gastric cancer?
90% adenocarcinoma *from the cells that secrete substances*
What type of women DO NOT require cervical cancer screening
<21 years old >65 years old had a hysterectomy
The stomach and small bowel dose constraint
<50GY
ALTO
After Loading tandem and ovoids
What are the patient profile and risk factors for vulvar cancer?
Age (>70 years old) smoking lichen sclerosus (chronic vulvar inflammation) HPV infection history of cervical cancer immunosuppression northern European descent intraepithelial neoplasia
What are the patient profile and risk factors for vaginal cancer?
Age; most patients >60 years old High number of sexual partners (HPV exposure) Early onset of intercourse Smoking Exposure to DES (diethylstilbestrol) in utero- related to clear cell adenocarcinoma.
Describe the dose regimen (at MDACC) for vaginal cuff brachytherapy.
All doses are prescribed to the vaginal surface; with just the cuff itself (NO EBRT): *30 Gy/5 fx, every other day; After EBRT: 15 Gy/3 fx, every other day.*
How is the bladder simmed for endometrial cancer?
Both full and empty (2 scans)
What are the risk factors for vaginal cancer?
Carcinoma in situ HPV Vaginal irritation hysterectomy exposure to DES (synthetic estrogen)
What is the leading cause of cancer mortality in women in developing countries?
Cervical Cancer
What is the preferred treatment at MDACC for resectable gastric disease?
Chemo + RT followed by surgery
What type of vaginal cancer is associated with in utero exposure to diethylstilbestrol (DES)?
Clear cell adenocarcinoma
How is vaginal cancer treated?
EBRT to the pelvis for the majority of lesions in Stage I disease. Stage II+ receives EBRT and chemo.
Cervical Cancer risk factors
Early 1st Intercourse Multiple partners Smoking Immunosuppression Prenatal DES (clear cell CA) STDs High Parity (high # of pregnancies)
What is the most common gynecological cancer in the US?
Endometrial
What is the most common pathology of ovarian cancer?
Epithelial
T/F Depth of invasion DOES NOT directly influence the risk of metastasis in Vulvar cancer.
False, it does.
What is the strongest risk factor for developing ovarian cancer?
Family history
Name the risk factors for ovarian cancer:
Family history, HRT, 1st parity >35 yo
Dose constraints Femoral head/neck Heart Liver Mean
Femoral head/neck *45Gy* Heart *V40 < 40%* Liver Mean *30Gy* ; V30 <30%*
What virus is associated with Cervical cancer?
HPV 16, 18 are high risk
What version of HPV is associated with benign warts?
HPV 6 & 11
HDR
High Dose rate brachytherapy commonly used to treat cervix cancer in addition to EBRT
How is cervical cancer treated?
Hysterectomy for the smallest tumors; hysterectomy plus chemoradiation for most other cases. Stage IV receives palliation.
What is the risk of lymph node involvement?
Inguinal LN and pelvic LN disease. Depth of invasion directly influences the risk of metastasis.
Source typically used with tandem and ovoids is
Ir-192 (Iridium 192)
How does vulvar cancer present?
Itching Postmenopausal spotting/bleeding Discharge Palpable mass
Dose constraints Kidney Liver
Kidney: 20Gy 1/3 of kidney Liver: 22.5Gy
When using intracavitary (IC) brachytherapy to treat vaginal cancer, what size cylinder is used and why?
Largest size to improve the ratios of mucosa to tumor dose
What is LEEP?
Loop electrosurgical excision procedure essentially "burns" layers of cells from the cervix if there is a finding of pre-malignant cells during screening. These cells are then examined for histology.
What is the least common histology of vulvar cancer?
Melanoma (5%)
How does cervical cancer present?
Most women are asymptomatic, but there may be post-coital vaginal bleeding and discomfort, discharge, difficult or painful intercourse, and (in advanced cases) pelvic pain or fistula. Disease is generally detected during screening.
What are the acute complications for a patient receiving radiation for gastric cancer?
Nausea anorexia fatigue myelosuppression with chemo
Describe the epidemiology of gastric cancer including its main histological type.
Nearly as uncommon as esophageal cancer Ages 60-70 High sale diet, H. pylori, Japanese/Chinese *Adenocarcinoma* most common histology
What is the leading cause of gynecological cancer death? Median age at diagnoses?
Ovarian cancer, 63 years old
What decreases the mortality of cervical cancer?
Pap smear screening decreases mortality by about 80%
When ovarian cancer spreads to the lymphatics, which lymph nodes are mainly involved?
Pelvic/Paraaortic
Define Point A
Point A= 2cm from midline
Where does vaginal cancer most commonly occur within the vagina?
Posterior wall of the upper 1/3 of the vagina is the most common site (50%).
Acute complications associated with radiation therapy for cervical cancer
Pruritus Dry/moist desquamation Nausea Colitis (inflammation of the colon lining) Cystitis Vaginitis
During simulation for gastric cancer, should the stomach be full or empty? What instructions would you give the patient before simulation?
Pt instructed to fast for 3 hrs before simulation and all treatments
PDR
Pulsed Dose rate brachytherapy
Most common histology of cervical cancer?
SCC
The most common histology of vulvar cancer is
SCC
What is the most common histology of vaginal cancer?
SCC
HPV 16 & 18 are associated with which histological type of vaginal cancer?
SCC (most common)
What histology of esophageal cancer is associated with tobacco, alcohol, or prior history of head and neck cancers?
Squamous cell carcinoma
Possible side effects of vaginal RT include:
Stenosis (narrowing and/or loss of flexibility of the vagina) Proctitis (inflammation of anus/rectum lining)
How would esophageal perforation present?
Substernal chest pain increased heart rate fever hemorrhage
T/F Endometrial cancer is treated with a full bladder.
T
T/F Single modality therapy has poor local control for esophageal cancer
T
Where are the majority of vulvar cancers located?
The labia (2/3 of cases)
What is the typical treatment for operable disease?
Total Hysterectomy (uterus, cervix, tubes, ovaries) Post Op RT for stage1 with vaginal cuff brachy
What is RT's role in treating ovarian cancer?
Uncommonly, whole abdominal RT (WART) is used if chemo cannot be used. Typically, though, *RT is used for palliation.*
Which lymph nodes does the vagina drain to (differentiate based on location in the vagina)?
Upper 2/3 drains to pelvic lymph nodes Lower 1/3 drains to inguinal/femoral nodes
Vagina dose constraints
Upper: 120-140 Mid: 80-90 Lower: 60-70
HPV vaccination is recommended for
all pre-teens (boys and girls) beginning at age 11.
Describe the nutrition needs of the patient during radiation treatment of gastric cancer.
at least 1500 Cal/d. Patient may require a feeding tube (preferably placed at the time of surgery).
Most common met site for esophageal cancer?
bone, liver, lung
What is unique about endometrial cancer among all GYN diseases?
curable, best prognosis for GYN cancers
What is the diagnostic gold standard for endometrial cancer?
endometrial biopsy
What are the acute side effects of radiation treatment for esophageal cancer?
esophagitis weight loss fatigue anorexia
When treating with brachy for cervical cancer tandem and ovoids are use for
intact uterus, treatments separated by two weeks
The endometrium comprises
lining of the uterus
Barretts esophogus
metaplasia (abnormal change in tissue) of the esophageal epithelial lining *squamous becomes columnar*
What is packing and why is it used in intracavitary brachy for cervical cancer?
packing is uses to stabilize the implant and to minimize bladder neck, urethral,vaginal mucosa, and rectal doses.
Most common site of metastasis in cervical cancer?
pelvic lymph nodes
Where does endometrial cancer typically metastasize to?
pelvic/paraaortic LN
When treating with brachy for cervical cancer vaginal cylinder or cuffs are used for
post surgical patients
Why is pre-op chemo + RT preferred over post-op chemo + RT?
shrink tumor have less morbid surgery effects
Which stage benefits most from pelvic RT for endometrial cancer?
stage3
What is the treatment recommendation for all endometrial cancer patients?
surgery
The mainstay of treatment for ovarian cancer is
surgery (or maximal debulking) plus chemo.
How is vulvar cancer treated?
surgery for small lesions vulvectomy for advanced disease Stages 3/4, chemo may be used.
The standard of care for T2 and more advanced cases is:
surgery, chemo, and RT.
A good tandem and ovoid insertion viewed laterally should include
tandem 1/2 way between sacrum and bladder ovoids centered on and against cervix (adjacent to markers seeds) tandem should bisect ovoids bladder/rectum packed AWAY packing should NOT be sup to tandem and ovoid
Where does local disease typically recur for endometrial cancer?
vaginal apex
Ovarian cancer is highly curable if diagnosed at an early stage, but 75% present with stage III or IV disease. Why is early diagnosis difficult?
vague abdominal symptoms at presentation and lack of a good screening test
When treating with brachy for cervical cancer interstitial needles are used for
very lateral disease
Current screening recommendation for cervical cancer
women with a cervix regardless of sexual history ---starting at age 21 Pap every 3 years -Women ages 30-65 Pap + HPV testing every 5years
