GYN Questions

What is the risk of pelvic lymph node involvement with G1 cancer of the uterus confined to the endometrium as seen in GOG 33? (2014,5) A) 0% B) 3% C) 7% D) 11%

A) 0% Rationale: Based on GOG 33 the following risks (pelvic/PA node) for G1, G2, and G3 Endometrium only: 0/0%; 3/3%; 0/0% Inner Third: 3/1%; 5/4%; 9/4% Middle Third: 0/5%; 9/0%; 4/0% Outer Third: 10/5%; 20/15%; 35/25%

What was the frequency of inguinal recurrence at two years in the radiation arm of GOG 37 study for vulvar cancer with pathologically positive inguinal nodes randomized to postoperative radiation to inguinal and pelvic nodes versus pelvic lymphadenectomy? (2014, 19) A) 5% B) 10% C) 15% D) 20%

A) 5% Rationale: GOG 37 (Homesley) Patients with positive groin nodes after vulvectomy and groin dissection randomized to: --45-50 Gy to bilateral groin and pelvis (with midline block) --Pelvic node dissection Results: 2 yr OS: 68 v 54%; benefit confined to 2+ nodes or ECE 6 yr groin recurrence: 5 v 24% 6 yr OS: 51 v 41% Lymphedema: 16 v 22% (NS)

What is the estimated risk of fracture at 5 years for vulvar cancer patient if the femoral neck received 50 Gy when treating the inguinal nodes? (2013, 100) A) 5% B) 10% C) 20% D) 25%

A) 5% Rationale: TD 5/5 for femoral neck is 50 Gy .

When treating PALN in cervical cancer with conventional fractionation, the TD 5/5 for the duodenum should be: (2014, 210) A) 50 Gy B) 55 Gy C) 60 Gy D) 65 Gy

A) 50 Gy Rationale: Emami estimated that the TD5/5 for 1/3 of the bowel is 50 Gy; 3/3 is 40 Gy. TD 50/5 for 1/3 is 60 Gy and 3/3 is 50 Gy. Stanic and Mayadev recommended that the maximum dose to the small bowel should be kept less than 55 Gy and agreed with the TD 5/5 as reported by Emami.

What is considered to be a close surgical margin in fixed tissue for carcinoma of the vulva? (2013, 279) A) 8 mm B) 10 mm C) 15 mm D) 18 mm

A) 8 mm Rationale: Surgical margin is the most powerful predictor of LR in vulvar cancer. Margin < 8 mm is associated with 50% chance of recurrence Study: 153 patients with SCC of the vulva were treated at UCLA between 1957-85. 62 cases were stage I, 48 stage II, 18 stage III, and 7 stage IV. 21 patients had surgical tumor-free margin greater than or equal to 8 mm on tissue section, 0 had local recurrence. 44 patients had margin < 8 mm, 21 had LR.

The entire course of EBRT and brachytherapy for cervical cancer should be completed within: (2013, 146) A) 8 weeks B) 9 weeks C) 10 weeks D) 11 weeks

A) 8 weeks Rationale: Several retrospective analyses have suggested an adverse effect of prolonged duration on outcome overall. Extension of treatment time beyond 6-8 weeks can result in 0.5% to 1% decrease in pelvic control and disease specific survival for each day of extended treatment time. Although no prospective randomized trials have been done, it is generally accepted that the entire course should be completed within 8 weeks. Delays and splits should be avoided when possible

Which of the following trials of concurrent chemoradiation and brachytherapy permitted the use of HDR in the treatment of cervical cancer? (2013, 101) A) NCIC B) GOG 120 C) GOG 123 D) RTOG 90-01

A) NCIC Rationale: NCIC: WP 45 Gy + LDR 35 Gy x 1 or HDR 8 Gy x 3; weekly cisplatin during during EBRT

Per NCCN guidelines, what is the MOST appropriate postoperative care for a Stage I endometrial stromal sarcoma? (2015, 215) (A) Observation (B) Chemotherapy (C) Brachytherapy (D) External beam radiation

A) Observation Rationale Observation is recommended for postoperative stage I ESS. Postoperative hormone therapy (with or without radiation) is recommended for stages II-IV ESS. Radiation is considered an option (category 2 B) for stage I only. Typical hormonal therapy includes megestrol acetate or medroxyprogesterone. Hormonal therapy is also recommended for recurrence or unresectable disease. Series of ESS suggest long DSF in the absence of specific therapy and offer less support for the use of adjuvant radiation. Adjuvant radiation has been demonstrated to reduce local recurrence rates with limited effect on survival.

What is the inferior border of the parametria for cervical cancer treatment planning? (2013, 44) A) Urogentital diaphragm B) Top of the broad ligament C) Posterior border of external iliac vessel D) Medial edge of the internal obturator muscle

A) Urogenital diaphragm Rationale: Boundraies are: Anterior: Posterior wall of the bladder or posterior border of the external iliac vessel; Posterior: Uterosacral ligaments and mesorectal fascia; Lateral: medial edge of internal obturator muscle/ischial ramus bilaterally ; Superior: Top of fallopian tube/broad ligament (Depending upon the degree of uterine flexion this may also be the anterior boundary); Inferior: urogenital diaphragm.

23. Which AJCC stage is most appropriate for a patient who has a 2.0 cm, grade 3 endometrioid adenocarcinoma of the uterus that invades 2 mm of 9 mm of the myometrium, a positive cytology, 0/15 positive pelvic lymph nodes, and 1 out of 3 positive para-aortic lymph nodes? (2012, 23) A. T1aN1M0 B. T1aN2M0 C. T1bN1M0 D. T1bN2M0

B

What is the 5-year rate of isolated vaginal recurrences for high-intermediate risk endometrial cancer treated with adjuvant vaginal brachytherapy (PORTEC-2)? (A) 1.6% (B) 1.8% (C) 2.1% (D) 5.1%

B) 1.8% Rationale: PORTEC-2 randomized high-intermediate risk endometrial carcinoma patients to pelvic radiation or vaginal brachytherapy. The primary endpoint of vaginal recurrence risk was not statistically significant between the two groups at 1.8% (vaginal brachytherapy) and 1.6% (pelvic radiation). The 5 year local regional relapse (pelvic, vaginal or both) was 5.1% (vaginal brachytherapy) and 2.1% (pelvic radiation). The interpretation was that vaginal brachytherapy is effective in ensuring vaginal control, with fewer GI toxic effects than with external beam. The authors concluded that vaginal brachytherapy should be the adjuvant treatment of choice for patients with endometrial cancer of high-intermediate risk.

The risk of vaginal recurrence at 5 years for patients randomized to vaginal brachytherapy in PORTEC-2 was: (2013, 248) A) 0.6% B) 1.5% C) 1.9% D) 3.3%

B) 1.9% Rationale: Inservice key has it wrong. The patients that got VBT alone had a 1.8% chance of vaginal recurrence. Those that had WPRT had 1.6% chance. Not sure how this is so wrong..

Which of the following was a finding of the GYNECO 02 study that compared hysterectomy with no hysterectomy in patients that had a clinical and radiographic CR after chemoradiation for stage IB2 and II cervical cancer? (2014, 222) A) Local failure rate was high without hysterectomy B) 1/3 had residual disease in the hysterectomy specimen C) Hysterectomy improved survival in patients with residual disease D) MRI and clinical exam are an accurate measure of response after CRT

B) 1/3 of patients had residual disease in the hysterectomy specimen Rationale: The trial was conducted by the Federation Nationale des Centres de Lutte Contre le Cancer in France. The main endpoint of the study was the 3 year EFS. Unfortunately the trial closed to poor accrual. Although the study was underpowered, it is important because some of the interesting results that were observed. The first important finding is that nearly one third of the patients undergoing hysterectomy (10 of 31) with a cCR were found to have residual disease in the surgical specimen. 5 had active tumor, the remainder had microscopic residual. This was interpreted as the lack of accuracy of MRI combined with clinical exam. Most of the recurrences were nodal rather than paracentral.

What is the tolerance dose (Gy) of the distal vagina (2014, 184) A) 45-50 B) 60-70 C) 80-90 D) 120-150

B) 60-70 Gy Rationale: The distal and mid vagina are substantially more sensitive to RT compared to the upper vagina. As such, the location of the tumor must be taken into consideration during RT planning.

What is the recommended PTV margin around the nodal CTV for IMRT in PORT of pelvis for cervical cancer? (2014, 59) A) 5 mm B) 7 mm C) 10 mm D) 15 mm

B) 7 mm

What was the 5 year pelvic control rate for FIGO stage I vaginal cancers treated with definitive RT, as reported by Frank et al (MDACC)? (2014, 169) A) 79% B) 86% C) 89% D) 92%

B) 86% Rationale: The 5 year pelvic control rates were 86%, 84%, and 71% for stages I, II and III-IV

When performing LDR brachytherapy for carcinoma of the cervix, the ABS recommends limiting the vaginal surface dose to what percent of the dose at point A? (2013, 86) A) < 100% B) <150% C) >150% D) >200%

B) <150% No rationale

What is the T stage of a fallopian tube cancer that has pelvic extension with malignant cells in the peritoneal washings? (2013, 45) A) T1b B) T2c C) T3b D) T3c

B) A T2c fallopian tube cancer involves one or both fallopian tubes with pelvic extension and has malignant cells in ascites or peritoneal washings

What is the FIGO stage for a 4.5 cm adenocarcinoma of the uterus that invades 6/10 mm of myometrium and the endocervical glands but not the cervical stroma? (2013, 68) A) IA B) IB C) IIA D) IIB

B) IB Rationale: The most recent AJCC manual no longer considers endocervical glandular involvement in the staging of endometrial cancer. In the previous edition, this would be considered stage IIA disease. Since the tumor invades more than 1⁄2 of the myometrium and does not extend to cervical stroma, it should be staged IB. The tumor size is not one of the criteria used to stage endometrial carcinoma.

What is the FIGO stage of a fallopian tube cancer with pelvic extension? (2014, 200) A) I B) II C) III D) IV

B) II Rationale: FIGO stage II is a fallopian cancer that involves one or both tubes and has pelvic extension to the uterus and/or ovaries (IIA) or other pelvic structures (IIB)

Stage II tumors of the vulva involve the: (2014, 279) A) Cervix, vagina, or anus B) Lower urethra, vagina or anus C) Cervix, lower urethra or vagina D) Bladder, vagina or lower urethra

B) Lower urethra, vagina, or anus Rationale: I (T1) Confined to vulva and perineum (IB if > 2 cm) II (T2) Distal third of vagina or urethra; anal involvement IIIA (N1): 1-2 nodes < 5 mm or 1 node >/= 5 mm IIIB (N2): 3+ nodes < 5 mm or 2+ nodes >/= 5 mm IIIC (N3): Extranodal extension IVA (T3) : Proximal 2/3 of vagina or urethra, cervical involvement, bladder/rectal mucosal involvement/ fixed to pelvic bone

Stage II tumors of the vulva involve the: (2015, 64) (A) cervix, vagina, or anus. (B) lower urethra, vagina, or anus. (C) cervix, lower urethra, or vagina. (D) bladder, vagina, or lower urethra.

B) Lower urethra, vagina, or anus Rationale: Stage II tumors are defined as lesions involving the lower urethra, vagina, or anus.

Which of the following T stage groups is appropriate for a 5.5 cm endometrial stroma sarcoma that invades through the myometrium into the serosa (2013, 254) A) T1a B) T1b C) T2a D) T3a

B) T1b Rationale: Uterine sarcomas now have a separate staging from uterine carcinomas. The tumor described in this example is confined to the uterus and is greater than 5 cm. Therefore, the T stage should be T1b

Which of the following criteria is considered intermediate risk for recurrence in uterine cancer (GOG 99)? (2014, 276) A) Tumor size B) Tumor grade C) Extension to the cervical glands D) Middle 1/3 myometrial invasion

B) Tumor Grade Rationale: GOG 99 randomized early stage, intermediate risk patients to observation or adjuvant pelvic RT after surgery. Criterion used was age, moderate to poor tumor grade, LVSI and outer 1/3 myometrial invasion. A benefit was shown for patients with high intermediate risk disease: age > 70 with 1 or more risk factors or age > 50 with 2 or more risk factors

Which gynecologic malignancy is MOST likely in a 72-year-old woman with 3 months of intermittent vaginal bleeding? (2015, 30) (A) Ovarian (B) Uterine (C) Vaginal (D) Cervical

B) Uterine Rationale: Rationale: All of these conditions can lead to vaginal bleeding in a postmenopausal woman, however uterine cancer is the most common female reproductive tract malignancy in the United States. There were an estimated 40,000 new cases in 2008 compared to 21,000, 11,000, and 2,000 for ovarian, cervical and vaginal cancers, respectively.

What is an appropriate adjuvant treatment for a Stage IA uterine cancer with < 50% myometrial invasion, incompletely surgically staged, G2 endometrioid adenocarcinoma with high-risk intrauterine features and negative postoperative imaging? (2015, 32) (A) Chemotherapy (B) Vaginal brachytherapy (C) Chemotherapy with vaginal brachytherapy (D) Chemotherapy with external beam radiation

B) Vaginal Brachytherapy Rationale: A Stage IA, G1-2 (myometrial invasion <50%) that is incompletely surgically staged and has high-risk intrauterine features should undergo post-operative imaging. If the imaging is negative then the patient may be observed or have vaginal brachytherapy with or without EBRT.

A woman with a history of TAH has a FIGO stage II SCC involving the upper vagina. She has a complete response on clinical exam and vaginal US after 45 Gy of pelvic RT. Which is the MOST appropriate next treatment option? (2013, 123) A) No further therapy B) Vaginal cylinder brachytherapy C) Interstitial brachytherapy D) Boost field with IMRT

B) Vaginal cylinder or D) Boost field with IMRT Rationale: Although the patient has had an excellent response to EBRT, 45 Gy is not an adequate dose to control stage II vaginal cancer. Although EBRT could be used to treat the microscopic residual disease, this technique would lead to substantially more dose to the bladder and rectum compared to brachytherapy. Since any residual disease is < 0.5 cm, the optimal treatment is brachytherapy using a vaginal cylinder

What was the risk of vaginal recurrence at 5 years with intermediate-high risk endometrial cancer following PORT to pelvis in PORTEC-2? (2014, 295) A) 0.6% B) 1.5% C) 1.9% D) 3.3%

C) 1.9% Rationale: In PORTEC-2 patients with high-intermediate risk endometrial carcinoma were randomize to receive pelvic RT or vaginal brachytherapy after surgery. The risk of vaginal recurrence was 1.9% and 1.5% for pelvic radiation and brachytherapy, respectively

What is the expected 2-year overall cumulative incidence of both symptomatic and asymptomatic pelvic insufficiency fractures after definitive RT for early stage cervical cancer? (2014, 212) A) 10% B) 25% C) 35% D) 40%

C) 35% Rationale: The 2 year pelvic insufficiency fracture cumulative occurrence rate was 36.9%. Patients with advanced age and low body weight may be at increased risk.

What was the pCR rate in GOG 205, a phase II study of concurrent weekly cisplatin and RT in advanced carcinoma of the vulva? (2014, 237) A) 30% B) 40% C) 50% D) 60%

C) 50% Rationale: This chemoradiation therapy study demonstrated a high pCR in patients with locally advanced vulva carcinoma who otherwise would have required major surgery.

What further treatment is recommended for a pathologic stage T1b1N1 cervical cancer treated with radical hysterectomy, pelvic lymph node dissection, and para-aortic lymph node sampling? (2015, 151) (A) No further treatment (B) Adjuvant RT (C) Adjuvant chemoRT (D) Adjuvant chemotherapy

C) Adjuvant chemoRT Rationale: Rationale: Patients with clinical stage IA(2), IB, and IIA carcinoma of the cervix, initially treated with radical hysterectomy and pelvic lymphadenectomy, and who had positive pelvic lymph nodes and/or positive margins and/or microscopic involvement of the parametrium were eligible for this study. Patients were randomized to receive RT or RT + CT. Patients in each group received 49.3 GY RT in 29 fractions to a standard pelvic field. Chemotherapy consisted of bolus cisplatin 70 mg/m(2) and a 96-hour infusion of fluorouracil 1,000 mg/m(2)/d every 3 weeks for four cycles, with the first and second cycles given concurrent to RT. Between 1991 and 1996, 268 patients were entered onto the study. Two hundred forty-three patients were assessable (127 RT + CT patients and 116 RT patients). Progression-free and overall survival are significantly improved in the patients receiving CT. The hazard ratios for progression-free survival and overall survival in the RT only arm versus the RT + CT arm are 2.01 (P =.003) and 1.96 (P =. 007), respectively. The projected progression-free survivals at 4 years is 63% with RT and 80% with RT + CT. The projected overall survival rate at 4 years is 71% with RT and 81% with RT + CT.

How does the quality of cervical cancer brachytherapy impact the local recurrence and DFS? (2014, 112) A) Symmetry of ovoids to tandem has no impact B) Inappropriate placement of packing has a higher DFS C) Displacement of ovoids from OS has increased risk of LR D) Tandem in midpelvis has decreased DFS and increased LR

C) Displacement of ovoids from OS has increased risk of LR Rationale: Patients with unacceptable symmetry of ovoids to the tandem had a significantly higher risk of LR than patients in the acceptable group. Patients with displacement of ovoids in relation to the cervical os had a significantly increased risk of LR and a lower DFS rate. Inappropriate placement of packing resulted in a lower DFS rate. The tandem in midpelvis did not impact these outcomes.

Per consensus guidelines, what comprises the CTV for IMRT pelvic radiotherapy for the definitive treatment of IB2 cervical cancer? (2015, 66) (A) GTV, cervix, parametrium, upper half of vagina (B) GTV, cervix, lower uterine segment, parametrium (C) GTV, cervix, entire uterus, parametrium, upper half of vagina (D) GTV, cervix, lower uterine segment, parametrium, upper half of vagina

C) GTV, cervix, entire uterus, parametrium, upper half of vagina Rationale: CTV= entire GTV, entire cervix, entire uterus, entire parametrium including ovaries (include the entire mesorectum if the uterosacral ligament involved), for minimal or no vaginal extension such as this case then the upper half of the vagina is included.

A 71-year-old with deep myometrial invasion is considered what endometrial risk stratification (GOG)? (2015, 82) (A) Low (B) Low-Intermediate (C) High-Intermediate (D) High

C) High-intermediate Rationale: Low risk defines women with G1 endometrial cancer confined to the endometrium and are at a very low risk for cancer recurrence following surgery alone. Intermediate risk patients have cancers that invade the myometrium or demonstrate occult cervical stromal invasion. Other adverse prognostic factorsareusedtostratifythemintolow-andhigh-intermediaterisk. Thesefactorsincludeouter1/3 myometrial invasion, grade 2 or 3 differentiation, or the presence of LVI in the cancer. High- intermediate risk is based on a combination of age and number of prognostic factors present. High-intermediate risk==per GOG if they are ≥ 70 with one risk factor, 50-69 with 2 risk factors or ≥18 with all 3 factors. Otherwise they are classified as low-intermediate if they meet some of the criteria but do not fully fit these criteria. A high risk patient is one with Stage III disease regardless of histology or grade in addition to uterine serous carcinoma or clear cell at any stage. NCCN guidelines for adjuvant therapy recommendations for Stage I cancers considers the adverse risk factors.

Which of the following accurately describes a patient with FIGO stage III vaginal cancer? (2013, 140) A) Mass in the lower vagina extending to the clitoris B) Mass in the upper vagina extending to the exocervix, paravaginal tissues and pelvic sidewall C) Mass in the mid vagina involving the paravaginal tissues that are fixed to the left pelvic sidewall D) Mass in the mid vaginal involving the paravaginal tissues without extension to the pelvic sidewall

C) Mass in the mid vagina involving the paravaginal tissues that are fixed to the left pelvic sidewall. Rationale: Vaginal cancers that extend to the pelvic sidewall are considered stage III disease. If the cancer is confined to the vagina and the para-vaginal tissues, then it is stage II. Vaginal tumors that involve the cervix or vulva are staged as arising from those structures, not as vaginal cancer (vagina gets no respect).

A T3 cancer of the endometrium invades the: (2014, 225) A) Bladder B) Rectum C) Parametrium D) Deep myometrium

C) Parametrium Rationale: The most recent staging criteria gives T3 designation to tumors that involve the series, adnexa, vagina or parametria

128. Definitive therapy for patients with advanced unresected vulvar cancer should involve: (2012, 128) A. concurrent 5 FU or cisplatin with radiation therapy. B. a curative radiation dose of >70 Gy to the gross tumor. C. chemoradiation therapy for a complete pathologic response rate of 90%. D. chemoradiation therapy not followed by resection.

Correct Answer is A. RATIONALE: Curative radiation dose to the vulva is usually between 62-65 Gy. Higher doses can cause tissue necrosis. The complete response is usually 50% in most reported series following chemoradiation. Either cisplatin or 5 FU is acceptable for concurrent treatment with radiation.

239. The radiation field for primary cancer of the posterior upper one third of the vagina should include which lymph node group? (2012, 239) A. Pelvic only B. Pelvic and para-aortic only C. Pelvic and inguinal/femoral only D. Pelvic, para-aortic, and inguinal/femoral

Correct Answer is A. RATIONALE: Primary vaginal cancers most commonly involve the upper one third of the vagina. The primary drainage to this portion of the vagina is to the pelvic lymph nodes. The inguinal lymph nodes should be treated if there is involvement of the lower one third of the vagina or if there is evidence of positive inguinal nodes on exam or staging studies. Para-aortic lymph node involvement of vaginal cancer is rare.

270. What is the expected 5-year pelvic control rate for a 4 cm, FIGO stage I vaginal cancer treated with definitive radiation therapy? (2012, 270) A. 85% B. 75% C. 65% D. 50%

Correct Answer is A. RATIONALE: This patient has a FIGO stage I vaginal cancer. The 5-year pelvic control rates were 86%, 84%, and 71% for stages I, II, and III-IV, respectively.

72. A stage II fallopian tube cancer is best described as: (2012, 72) A. being limited to one or both tubes without ascites. B. involving one or both tubes with pelvic extension and/or metastasis to the uterus or ovary or extension to other pelvic tissues. C. involving one or both tubes with peritoneal implants in the pelvis and/or pelvic lymph nodes. D. having distant metastasis inside the peritoneal cavity.

Correct Answer is B. RATIONALE: Tumor staging helps residents to categorize patients and interpret outcomes appropriately based on the literature. REFERENCE: AJCC Staging Manual.

140. What is the posterior anatomical boundary of the parametrium? (2012, 140) A. Posterior border of the external iliac vessel B. Uterosacral ligaments and mesorectal fascia C. Medial edge of the internal obturator muscle D. Urogenital diaphragm

Correct Answer is B. RATIONALE: Anatomical boundaries of parametria — Anteriorly: Posterior wall of bladder or posterior border of external iliac vessel. Posteriorly: Uterosacral ligaments and mesorectal fascia. Laterally: Medial edge of internal obturator muscle/ ischial ramus bilaterally. Superiorly: Top of fallopian tube/ broad ligament. Depending on degree of uterus flexion, this may also form the anterior boundary of parametrial tissue. Inferiorly: Urogenital diaphragm

9. According to the PORTEC-2 (Nout, et al.) trial, what is the estimated 5-year risk of isolated vaginal recurrence after vaginal brachytherapy? (2012, 9) A. 0.5% B. 2% C. 5% D. 10%

Correct Answer is B. RATIONALE: At median follow-up of 45 months (range 18-78), three vaginal recurrences had been diagnosed after vaginal brachytherapy (VBT) and four recurrences after EBRT. Estimated 5-year rates of vaginal recurrence were 1.8% (95% CI 0.6-5.9) for VBT and 1.6% (0.5-4.9) for EBRT (hazard ratio [HR] 0.78, 95% CI 0.17-3.49; p=0.74). Five-year rates of locoregional relapse (vaginal or pelvic recurrence, or both) were 5.1% (2.8-9.6) for VBT and 2.1% (0.8-5.8) for EBRT (HR 2.08, 0.71-6.09; p=0.17). 1.5% (0.5-4.5) vs. 0.5% (0.1-3.4) of patients presented with isolated pelvic recurrence (HR 3.10, 0.32-29.9; p=0.30), and rates of distant metastases were similar (8.3% [5.1-13.4] vs. 5.7% [3.3-9.9]; HR 1.32, 0.63-2.74; p=0.46). No differences in overall survival (84.8% [95% CI 79.3-90.3] vs. 79.6% [71.2-88.0]; HR 1.17, 0.69-1.98; p=0.57) or disease-free survival (82.7% [76.9-88.6] vs. 78.1% [69.7-86.5]; HR 1.09, 0.66-1.78; p=0.74). Rates of acute grade 1-2 gastrointestinal toxicity were significantly lower in the VBT group than in the EBRT group at completion of radiotherapy (12.6% [27/215] vs. 53.8% [112/208]). Interpretation VBT is effective in ensuring vaginal control, with fewer gastrointestinal toxic effects than with EBRT. VBT should be the adjuvant treatment of choice for patients with endometrial carcinoma of high-intermediate risk. REFERENCE: Nout RA, et al. Lancet. 2010;375:816-23.

301. Which gynecologic cancer is most likely to be diagnosed in an 85-year-old woman who has had 6 months of intermittent vaginal bleeding? (2012, 301) A. Ovarian B. Endometrial C. Cervical D. Vaginal

Correct Answer is B. RATIONALE: Endometrial cancer is the most common female genital tract malignancy in the United States. An estimated 43,000 new cases of endometrial cancer were diagnosed in 2010 (compared to 22,000, 11,000, and 2,000 new cases of ovarian, cervical, and vaginal cancers diagnosed in 2010, respectively). Although patients with endometrial, cervical, and vaginal cancers usually present with vaginal bleeding, the presentation of vaginal bleeding is rare for patients with ovarian cancer.

308. What is the most appropriate workup for a 67-year-woman with vaginal bleeding, a normal exam, and a non-diagnostic endometrial biopsy result? (2012, 308) A. Pap smear B. Dilation and curettage C. CT scan of the abdomen and pelvis D. Observation with follow-up in 3 months

Correct Answer is B. RATIONALE: Endometrial cancer should be considered in any woman presenting with postmenopausal bleeding until proven otherwise. Although an endometrial biopsy (EMB) has a high sensitivity and specificity, it has a false-negative rate of 10%. Since the EMB did not provide an adequate sampling of the endometrial lining, the patient should proceed to dilation and curettage. CT scan of the abdomen and pelvis is generally reserved for patients with documented high-grade endometrial cancers or suspicion of extrauterine disease. Less than 5% of patients will have malignant cells on a pap smear.

223. EBRT and brachytherapy for cervical cancer should be completed within how many weeks? (2012, 223) A. 4 B. 8 C. 10 D. 12

Correct Answer is B. RATIONALE: In general, extending the overall treatment time beyond 6 to 8 weeks can result in approximately a 0.5% to 1% decrease in pelvic control and cause- specific survival for each extra day of overall treatment time. Although no prospective trials have been done, it is generally accepted that the entire radiation course including both external-beam radiation therapy and brachytherapy components should be completed in a timely fashion (within 8 weeks); delays or splits in the radiation treatment should be avoided whenever possible.

Which factor is most important in determining the prognosis of a patient diagnosed with fallopian tube cancer? (2012, 41) A. Age at diagnosis B. Stage at diagnosis C. Histology of tumor D. Dose of adjuvant radiation

Correct Answer is B. RATIONALE: The most common histology of this tumor is papillary serous. Adjuvant radiation therapy does not have a defined role in managing fallopian tube cancer. Younger patients have slightly better outcomes, but the stage of disease is the most important factor in determining a patient's prognosis.

114. Which of the following treatments would be most appropriate for primary ovarian cancer? (2012, 114) A. Whole abdominal irradiation for stage I or II epithelial cancer B. Surgery combined with radiation therapy for stage I or II dysgerminoma C. Surgery, radiation therapy, and chemotherapy for stage III epithelial cancer D. Whole abdominal irradiation for stage III dysgerminoma

Correct Answer is B. RATIONALE: Understanding the role of radiation therapy in the treatment of ovarian cancer is important for the radiation oncologist. Radiation is most appropriate for early-stage dysgerminoma. Chemotherapy is the preferred treatment for epithelial cancers and more advanced dysgerminomas.

315. What percentage of women with adenocarcinoma of the endometrium will have disease confined to the uterus at diagnosis? (2012, 315) A. 25% B. 50% C. 75% D. 90%

Correct Answer is C. RATIONALE: Since the majority of women present with postmenopausal bleeding while the disease is at an early stage, approximately 75% of these women will have disease confined to the uterus.

87. Which of the following presentations or patterns of spread most accurately describes fallopian tube cancer? (2012, 87) A. Direct extension rarely occurs. B. Peritoneal cytology is rarely involved. C. Peritoneal implants usually do not occur with an intact tube. D. Pelvic and para-aortic lymph node involvement is common.

Correct Answer is D.

211. According to NCCN cervical cancer guidelines, what is the most appropriate treatment for positive para-aortic lymph nodes found during surgical staging with a negative postoperative PET-CT scan? (2012, 211) A. Cisplatin B. Para-aortic irradiation C. Pelvic and para-aortic irradiation D. Cisplatin with pelvic and para-aortic irradiation

Correct Answer is D. RATIONALE: If positive para-aortic lymph nodes are found during surgical staging, patients must undergo further screening with chest CT or combined PET- CT scan. For patients without distant metastases, recommended treatment is extended-field irradiation (including pelvis and para-aortic lymph nodes) and concurrent cisplatin-based chemotherapy with (or without) brachytherapy.

251. What histology of vaginal cancer is most likely to occur in an 80-year-old woman? (2012, 251) A. Botryoid B. Melanoma C. Clear cell adenocarcinoma D. Squamous cell carcinoma

Correct Answer is D. RATIONALE: Squamous cell histology comprises >80% of vaginal cancers in adults. Although about 78% of vaginal melanomas are diagnosed in women >60 years old, they only account for 3-4% of all vaginal malignancies. Botryoid variant of embryonal rhabdomyosarcoma is the most common vaginal cancer in children. Clear cell adenocarcinoma tends to arise in young women who received in utero exposure to diethylstilbestrol (DES).

156. According to the American Brachytherapy Society guidelines for LDR implants for cervical cancer, the lateral vaginal dose should be reported for the: (2012, 156) A. unilateral vaginal surface only. B. bilateral vaginal surface only. C. unilateral vaginal surface and 0.5 cm deep to the vaginal surface. D. bilateral vaginal surface and 0.5 cm deep to the vaginal surface.

Correct Answer is D. RATIONALE: The ABS recommends reporting the dose at the lateral vaginal surface (mucosa)/(points Vs) and at 0.5 cm deep to the vaginal surface (point Vd). Points Vs and Vd shall be specified separately for the right and left side. The ABS suggests limiting the Vs dose to less than 150% of the point A dose. REFERENCE: The American Brachytherapy Society (ABS) Recommendations for Low-Dose-Rate Brachytherapy for Carcinoma of the Cervix.

56. Which statement about the GOG (Homesley) trial comparing radiation therapy with pelvic lymph node dissection for vulvar cancer is true? (2012, 56) A. Pelvic lymph node dissection provides better local control. B. Inguinal lymph node dissection should be recommended for >5 mm of invasion. C. Both inguinal lymph node dissection and groin irradiation are equally acceptable for control of the disease. D. Pelvic irradiation improves survival in patients with positive lymph nodes in the groin.

Correct Answer is D. REFERENCES: Kunos C, Simpkins F, Gibbons H, Tian C, Homesley H. Radiation therapy compared with pelvic node resection for node-positive vulvar cancer: a randomized controlled trial. Obstet Gynecol. 2009 Sep;114(3):537-46. Homesley HD, Bundy BN, Sedlis A, Adcock L. Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes. Obstet Gynecol. 1986 Dec;68(6):733-40.

What is the percentage of false negative clinical examination for groin mets by palpation in vulvar cancer? (2013, 28) A) 5% B) 10% C) 15% D) 20%

D) 20% Rationale: From 1977 to 1984 the GOG conducted a prospective clinical and surgical staging protocol for SCC of the vulva (n = 637). The subject of this report was on factors that predict groin node mets based on all patients. Groin node mets was 18.9% for <2 cm tumors and 41.6% for > 2 cm tumors. The inaccuracy of clinical palpation of the groin nodes (23.9% false negative) largely accounted for underestimation of extend of disease

What ratio of positive ipsilateral groin nodes to total nodes resected predicts contralateral groin mets in vulvar cancer? (2013, 53) A) 5% B)10% C) 15% D)20%

D) 20% Rationale: GOG 37 enrolled 114 patients randomly allocated to PORT to pelvis and groin (45-50 Gy) or to ipsilateral pelvic node resection after radical vulvectomy and inguinal lymphadenectomy. Retrospective analysis for enrolled patients included both risk of progression and death after treateatment and assessment of toxicity. A ratio of more than 20% positive ipsilateral groin nodes (number positive/number resected) was significantly associated with contralateral lymph node mets, replace and cancer related deaths.

The 5 year cause specific survival for patients with medically inoperable FIGO stage I endometrial carcinomas treated with definitive RT is approximately: (2013, 179) A) 10-20% B) 40-50% C) 65-75% D) 80-90%

D) 80-90% Rationale: Several retrospective studies have shown that brachytherapy alone or in combination with EBRT are very effective in treating stage I-II endometrial carcinoma. The cause-specific survival at 5 years has ranged between 80-87% with most patients dying of intercurrent disease and not endometrial cancer.

What was the approximate 5 year pelvic control rate of FIGO stage II vaginal cancers treated with definitive RT, as reported by Frank et al (2013, 191) A) 55% B) 65% C) 75% D) 85%

D) 85%. Rationale: The 5 year pelvic control rates were 86%, 84%, and 71% for stages I, II and III/IV, respectively

When treating cervical cancer with EBRT and HDR brachytherapy, the EQD2 D2cc for the bladder (minimum dose in the MOST irradiated 2 cc normal tissue volume) should not exceed (2014, 62): A) 60 Gy B) 70 Gy C) 80 Gy D) 90 Gy

D) 90 Gy Rationale: None

What is an established risk factor for fallopian tube cancer? (2013, 29) A) Nulligravida B) Late menarche C) Early menopause D) BRCA gene mutation

D) BRCA gene mutation Rationale: BRCA mutation is the most established risk factor for fallopian tube and primary peritoneal carcinoma. BRCA mutations, primarily BRCA1, have been identified in 16 to 43% of women with primary fallopian tube cancer. Therefore, BRCA mutation testing should be offered to ALL women with these tumors and risk-reduction surgery for BRCA carriers includes salpingectomy

Which of the following is a CONTRAINDICATION to unilateral, rather than bilateral, groin dissection for stage IB vulvar cancer? (2013, 206) A) Unifocal lesion B) No palpable nodes in either groin C) Lateral location > 1 cm from midline D) Cancer located in the anterior portion of the labia minora

D) Cancer located in the anterior portion of the labia minora Rationale: Unilateral LND was associated with < 1% risk of contralateral groin node mets for stage IB disease that meets all of the requirements: -Unifocal -Lateral, > 1 cm from midline -NOT located in anterior portion of labia minora (just posterior to clitoris, which may have contralateral lymph flow) -No palpable adenopathy in groin -No lymph node mets seen at time of unilateral LND

Per NCCN guidelines, what is the appropriate adjuvant therapy for a T1B serous carcinoma of the uterus that has undergone complete surgical staging? (2015, 65) (A) Vaginal brachytherapy (B) Pelvic external beam RT (C) Whole abdominopelvic RT (D) Chemotherapy with or without tumor directed RT

D) Chemotherapy with or without tumor directed RT Rationale: Chemotherapy with or without tumor directed radiation is recommended for serous carcinomas as the preferred adjuvant therapy. For the 2014 update, whole abdominopelvic radiation with or without brachytherapy is no longer recommended as a primary treatment option. Tumor-directed radiation is treatment to sites of known or suspected tumor involvement and may include external beam and/or vaginal brachytherapy.

According to the GEC ESTRO recommendations, when developing a 3D based treatment plan for cervical brachytherapy, which of the following targets should receive the prescription dose? (2013, 42) A) Point A B) Point B C) Low risk CTV D) High risk CTV

D) High risk CTV Rationale: Per the GEC ESTRO recommendations, when generating a volume based treatment plan, the HR CTV should receive the prescription dose. The LR CTV is typically treated by surgery and/or EBRT, not brachytherapy. Traditionally, the prescription point for patients receiving cervical brachytherapy has been Point A, and most centers in the US continue to prescribe to this point. Point B has traditionally been recorded to monitor dose fall offs with distance from the implant

Per NCCN guidelines, which ovarian cancer histology may be considered for RT or platin-based chemotherapy for Stages II to IV tumors? (2015, 58) (A) Epithelial (B) Low malignant potential (C) Malignant mixed Mullerian (D) Malignant sex cord-stromal

D) Malignant sex cord-stromal Rationale: For patients with Malignant Sex Cord-Stromal Tumors with high-risk stage I (tumor rupture, stage IC, poorly differentiated tumor, tumor size >10-15 cm) recommendations include observation or consideration of platinum based chemotherapy. Those with surgical findings of low risk disease should be observed. For patients with granulosa cell tumors who are being observed inhibin should be followed if they were initially elevated. For patients with Stage II-IV tumors, recommended options include RT for limited disease or platinum-based chemotherapy. However in 2013 the NCCN panel added surveillance recommendations for malignant sex-cord stromal tumors which are based on the SGO recommendations. Prolonged surveillance was recommended for granulosa cell tumors because they recur later (30 years). For recurrences then options include clinical trial or targeted recurrence strategies.

The majority of the vulva's first line of lymphatic drainage is to which nodal group? (2015, 132) (A) Obturator (B) External iliac (C) Deep inguinal (D) Superficial inguinal

D) Superficial Inguinal Rationale: The majority of the vulva is drained by lymphatics that pass laterally to the superficial inguinal nodes then the flow is to the deep inguinal group. The clitoris and anterior labia minora may also drain directly to the deep inguinal or external iliac lymph nodes. While vulvar cancer most commonly spreads initially to the superficial inguinal nodes immediately lateral to the pubic tubercles, formal evaluation of the distribution of sentinel lymph nodes in patients with vulvar cancer show that 100% of sentin el lymph nodes lie over or medial to the femoral vessels. In one study that included 59 women with a vulvar cancer <4 cm, the sentinel nodes were superficial in about 85% and in 15% laid deep to the cribriform fascia. These observations have important implications for the extent of inguinofemoral lymphadenectomy as well as the selection of radiotherapeutic target volumes and techniques.

Which of the following represents a consensus definition by the RTOG when contouring for treatment planning of carcinoma of the cervix? A) The cervix and uterus contoured as separate structures. B) The sigmoid begins at the anal verge and stops at the ascending colon laterally. C) The bladder from the base to the dome including the adjacent 5 cm of ureters. D) The femoral heads from the lowest level of the ischial tuberosities to the top of the ball of the femur, including the trochanters.

D) The femoral heads from the lowest level of the ischial tuberosities to the top of the ball of the femur, including the trochanters

Regarding postoperative IMRT for cervical cancer with concurrent weekly cisplatin chemotherapy (RTOG 0418), which median percentage of bone marrow volume receiving treatment is the BEST predictor of higher hematological toxicity? (2015, 99) (A) V10 > 96% (B) V20 > 84% (C) V30 > 61% (D) V40 > 37%

D) V40 > 37% Rationale: The median percentage of bone marrow receiving 10, 20, 30, 40 Gy was 96%, 84%, 61%, and 37% respectively. Among cervical cancer patients with a V40>37%, 75% had grade 2 or higher hematologic toxicity compared with 40% of patients with a V40 ≤ 37%. Cervical cancer patients with a median marrow dose of >34.2 Gy had higher rates of grade 2 hematologic toxicity than those ≤ 34.2 Gy. The authors concluded that the V40, rather than the V10 or V20 is the best predictor of hematologic toxicity in patients receiving pelvic IMRT and chemotherapy.

Which of the following represents a dosimetric predictor of duodenal toxicity after IMRT for treatment of para-aortic nodes in gynecologic cancers? (2015, 150) (A) V40 > 15 cm3 (B) V45 < 15 cm3 (C) V50 < 15 cm3 (D) V55 > 15 cm3

D) V55 > 15 cm3 Rationale: 3-year actuarial rates of duodenal toxicity with V55 above and below 15 cm3 were 48.6% and 7.4%, respectively (p <.01) In Cox, univariate analysis of dosimetric variables, V55 was associated with duodenal toxicity (P=0.29). In recursive partitioning analysis, V55 less than 13.94% segregated all patients with duodenal toxicity.

183. Which exam best delineates the high-risk CTV when performing image-based contouring with IV contrast for cervical cancer brachytherapy? (2012, 183) A. MRI before and at the time of the implant B. CT scan before and at the time of the implant C. MRI before the implant only D. CT scan before the implant only

Key: A

47. Ovoid positioning was evaluated for the cervical cancer trials RTOG 0116 and 0128. What is the impact on LR and DFS if the ovoids are displaced away from the OS? (2018, 47) a. Increase, decrease b. Increase, unchanged c. Decrease, increase d. Unchanged, decrease

Key: A Rationale: Patients with displacement of ovoids in relation to the cervical os have a significantly increased risk of local recurrence with decreased DFS as evaluated in RTOG 0116 and 0128.

228. What is the estimated risk of LRR (%) at 5 years without adjuvant radiation for a 75 year old with G2 endometrial cancer, < 50% myometrial invasion, and no LVSI or nodes? (2016, 228) (A) 10 (B) 15 (C) 20 (D) 25

Key: A Solution: Although favorable pathology the patient still has a risk of local recurrence of 10% at 5 years. The above citation provides a nomogram to assist in estimating the risks based on patient age and pathologic features. VB is estimated to cut the risk to < 5% in these circumstances with minimal risk of toxicity. References: Nomograms for Prediction of Outcome With or Without Adjuvant Radiation Therapy for Patients With Endometrial Cancer: A Pooled Analysis of PORTEC-1 and PORTEC-2 Trials Creutzberg, et al, IJROBP Vol. 91, No. 3, pp. 530e539, 2015.

107. A patient with N3 vulvar cancer has: (2016, 107) (A) an ulcerated LN. (B) 1 LN with ECE. (C) 2 LNs with <5 mm of disease. (D) 3 LNs with <5 mm of disease.

Key: A Solution: An ulcerated LN is N3; 1LN with extranodal spread is N2c; 2 LNs with < 5mm of disease is N1a; 3 LNs with < 5mm of disease is N2a.

217. Following concurrent chemoRT and brachytherapy for a cT2bN0M0 cervical cancer, a patient should undergo: (2016, 217) (A) observation. (B) hysterectomy. (C) laparoscopic LN sampling. (D) maintenance chemotherapy.

Key: A Solution: Currently, no therapeutic or diagnostic interventions are known to improve outcomes of patients with locally advanced cervical cancer after standard chemoradiation. In addition, total hysterectomy after "full dose" brachytherapy is technically challenging. Yield of node sampling for initially radiographically node-negative patient is low after radiotherapy. Use of consolidative chemotherapy is currently being studied in a randomized North American trial.

144. Per ASTRO Evidence-Based Guidelines (2014), patients with endometrioid endometrial cancer may be observed after hysterectomy with which pathologic features? (2016, 144) (A) G1 or G2 and < 50% myometrial invasion (B) G2 and < 50% myometrial invasion and LVSI (C) G2 and > 50% myometrial invasion and age > 60 (D) G3 and > 50% myometrial invasion and extension to cervical stroma

Key: A Solution: Patients with grade 1 or 2 cancers with either no invasion or <50% myometrial invasion (Ml), especially when no other high risk features are present, can be safely observed after hysterectomy. Vaginal cuff brachytherapy is as effective as pelvic radiation therapy at preventing vaginal recurrence for patients with grade 1or 2 cancers with 50% Ml or grade 3 tumors with <50% Ml. Patients with grade 3 cancer with 50% Ml or cervical stroma invasion may benefit from pelvic radiation to reduce the risk of pelvic recurrence.

179. What is your recommendation for a pT1b2 N0 adenocarcinoma of the cervix with negative margins and + LVSI? (2016, 179) (A) EBRT alone (B) Brachytherapy alone (C) Chemotherapy alone (D) ChemoRT

Key: A Solution: Patients with intermediate risk for recurrence after radical hysterectomy (at least two of the following risk factors (Sedlis Criteria): >1/3 stromal invasion, LVSI, and palpable tumor diameter >4cm) benefit from postoperative external beam radiotherapy. The GOG 92 study randomized 237 such patients to observation vs. pelvic radiotherapy to 46 or 50.4 Gy. Radiotherapy was associated with statistically significant reduction in any recurrence and with a trend towards improved overall survival. While concomitant radio sensitizing chemotherapy can be also considered with this regimen, a randomized study of chemotherapy is still ongoing.

35. Regarding the National Cancer Data Base analysis (Gynecologic Oncology, 2015), what is the reduction in risk of death with the addition of chemotherapy to postoperative radiation for pathologic node positive vulvar cancer patients? (2016, 35) (A) 5-15% (B) 25-40% (C) 50-65% (D) 70-85%

Key: B Solution: For pathologic node-positive vulvar cancer, adjuvant radiotherapy has an established benefit, whereas the impact of chemotherapy in the adjuvant setting was previously not known. A National Cancer Data Base (NCDB) analysis was conducted to determine patterns of care and evaluate the survival impact of adjuvant chemotherapy. The NCDB was queried for vulvar cancer patients diagnosed from 1998-2011 who underwent extirpative surgery with confirmed inguinal nodal involvement treated with adjuvant radiotherapy.

20. Which is the best treatment option for a medically inoperable 61 year old with clinical stage T1b1 squamous cell carcinoma of the cervix? (2016, 20) (A) Conization (B) EBRT + brachytherapy (C) ChemoRT + brachytherapy (D) Chemotherapy followed by brachytherapy

Key: B Solution: For patients with cervical cancer treated with definitive radiotherapy, brachytherapy is central to cure. In addition, for stage IB1, prophylactic treatment of pelvic lymph nodes is required. There is yet no evidence to support use of radiosensitizing chemotherapy with definitive radiotherapy for stage IB1disease. Excisional biopsy is not adequate for invasive cancer meeting the definition of stage IB1.

What is the recommended preoperative dose (Gy) of radiation (LDR equivalent) for gross Stage IIB adenocarcinoma of the endometrium? (2016, 2) (A) 60-65 (B) 75-80 (C) 80-85 (D) 90-95

Key: B Solution: For preoperative therapy for gross stage llB disease a total dose of 75 to 80 Gy LDR equivalent to the tumor volume is recommended.

258. Per PORTEC-1 (Postoperative Radiation Therapy Endometrial Cancer) what is the 3 year OS (%) after salvage radiation for patients who relapsed at the vaginal cuff following observation? (2016, 258) (A) 60 (B) 70 (C) 80 (D) 90

Key: B Solution: In PORTEC-1, the 3-year overall survival was 51% for the 46 control patients who relapsed and were treated with salvage radiation and 73% for patients with recurrence at the vaginal cuff. While reserving radiation in the adjuvant setting potentially prevents overtreatment of patients, salvage radiation is not curative for many patients.

91. Regarding the French multicenter Phase II trial (2014), what is the anticipated grade 2 acute GI toxicity (%) with postoperative 45 Gy pelvic IMRT for Stage I-II endometrial cancer? (2016, 91) (A) 10 (B) 25 (C) 33 (D) 50

Key: B Solution: The phase II RTCMIENDOMETRE trial was designed to test the hypothesis that IMRT could reduce the incidence of grade 2 or more acute GI toxicity toless than 30% in patients irradiated post-operatively for an endometrial cancer. In accordance with the hypothesis, post-operative IMRT resulted in a low rate (27%) of acute GI grade 2 toxicity, in patients with endometrial carcinomas. Whereas "conventional" pelvic irradiation (up to 45-50Gy) following hysterectomy is associated with a high rate of adverse gastro-i References: Barillot I, Tavernier E, Peignaux I, Williaume D, Nickers P, Leblanc-Onfroy M, Lerouge D. Impact of postoperative intensity modulated radiotherapy on acute gastro- intestinal toxicity for patients with endometrial cancer: results of the phase II RTCMIENDOMETRE French multicentre trial. Radiother Oncol. 2014 Apr; 111(1):138-43. Epub 2014 Mar 11.

60. Per PORTEC-2 (Postoperative Radiation Therapy in Endometrial Carcinoma), what is the same for EBRT and vaginal brachytherapy? (2018, 60) a. Long-term QoL b. Pelvic recurrence c. Vaginal cuff recurrence d. Acute grade 1-2 GI toxicity

Key: C Rationale: PORTEC-2 was a randomized study that compared adjuvant external beam radiotherapy to vaginal cuff brachytherapy for patients with intermediate-risk endometrioid adenocarcinomas. While pelvic relapses were more frequent in the brachytherapy arm, vaginal recurrence rates were comparably low in both arms. The toxicity measures strongly favored brachytherapy.

131. The MRC ASTEC trial for Stage I endometrial cancer demonstrated that pelvic lymphadenectomy: (2016, 131) (A) improved OS and RFS. (B) improved OS but NOT RFS. (C) did NOT improve OS or RFS. (D) did NOT improve OS but improved RFS.

Key: C Solution: After a median follow-up of 37 months (IQR 24-58), 191 women (88 standard surgery group, 103 lymphadenectomy group) had died, with a hazard ratio (HR) of 1.16 (95% Cl 0.87-1.54;p=0.31) in favor of standard surgery and an absolute difference in 5- year overall survival of 1% (95% Cl - 4 to 6). 251 women died or had recurrent disease (107 standard surgery group, 144 lymphadenectomy group), with an HR of 1.35 (1.06- 1.73; p=0.017) in favor of standard surgery and an absolute difference in 5-year recurrence- free survival of 6% (1-12). With adjustment for baseline characteristics and pathology details, the HR for overall survival was 1.04 (0.74-1.45; p=0.83) and for recurrence-free survival was 1.25 (0.93-1.66; p=0.14). Interpretation - the authors reported that the results show no evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early endometrial cancer. They concluded that pelvic lymphadenectomy cannot be recommended as a routine procedure for therapeutic purposes outside of clinical trials.

69. What is the best treatment for a 28 year old woman with a 2 cm visible squamous cell carcinoma of the cervix extending onto the posterior vaginal fornix and no other evidence of disease on PET/CT and MRI? (2016, 69) (A) Brachytherapy alone (B) EBRT + brachytherapy (C) Modified radical hysterectomy and pelvic lymph node dissection (D) Loop electrosurgical excision procedure (LEEP) with negative margins

Key: C Solution: For young, healthy patients with stage FIGO IIA disease, radical surgery is preferred to radiotherapy. Main disadvantages of radiotherapy for this situation include risk of secondary malignancy, premature ovarian failure and suboptimal outcomes for sexual function. Excisional biopsy is not appropriate for stage II, as the tumor is demonstrating extension beyond the cervix.

260. A FIGO Stage III of the vagina involves the: (2016, 260) (A) rectum. (B) bladder. (C) pelvic LNs. (D) paravaginal tissues but not the pelvic side wall.

Key: C Solution: Rectum and Bladder are FIGO Stage IVA, regional pelvic or inguinal nodes are FIGO Stage Ill, Paravaginal but not pelvic side wall disease is FIGO Stage II.

40. According to GEC ESTRO recommendations for 3D image-based treatment planning for cervical cancer brachytherapy, which volume is used to assess high dose regions? (2018, 40) a. V90 b. V100 c. V120 d. V150

Key: D Rationale: Cumulative DVH are recommended for evaluation of complex dose heterogeneity. DVH parameters for GTV, HR CTV and IR CTV are the minimum dose delivered to the 90% and 100% of the respective volume: D90 and D100. The volume, which is enclosed by the 150% and 200% of the prescribed dose (V150 and V200) is recommended for overall assessment of high dose volumes.

80. According to PORTEC-1, which outcome is associated with adjuvant EBRT over observation? (2018, 80) a. Improved overall survival b. Decreased distant metastases c. Improved physical functioning scores d. Increased incontinence for urine

Key: D Rationale: PORTEC-1 was a randomized study that compared adjuvant external beam radiotherapy to observation for select endometrioid adenocarcinomas. While local control was improved in the EBRT arm, long term follow up shows no improvement of survival by EBRT. Toxicity outcomes for EBRT are markedly worse.

33. In treating vulvar cancer with an involved pelvic lymph node, the superior field border can be raised what distance above the most cephalad-positive node? (2018, 33) a. 2cm b. 3cm c. 4cm d. 5cm

Key: D Rationale: The superior border should be no lower than the bottom of the sacroiliac joints or higher than L4/L5 junction unless the pelvic LNs are involved. If the pelvic LNs are involved the upper border can be raised to 5cm above the most cephalad-positive node.

39. Vaginal tumors are BEST visualized using MRI: (2018, 39) a. T1 images. b. T2 images. c. T1 images with vaginal gel. d. T2 images with vaginal gel.

Key: D Rationale: Vaginal tumors generally are best seen on MRI using T2 images with vaginal gel inserted into the canal which distends the vaginal walls and aids in assessing the tumor's thickness.

226. What is the appropriate management of a 1cm cT1b1N0M0 cervical cancer patient that desires preservation of fertility? (2016, 226) (A) Cone biopsy (B) Brachytherapy (C) Simple trachelectomy (D) Radical trachelectomy with pelvic node dissection

Key: D Solution: Fertility-sparing surgery for "macroinvasive" stage of cervical cancer, just as in non-fertility sparing approach, must involve removal of medial paracervical tissues and pelvic lymph nodes. Brachytherapy would alter the endometrial environment, not address the lymph nodes, and have potential scatter to the ovaries.

62. All of the following treatment options are appropriate for clinical Stage IA1 squamous cell carcinoma of the cervix without LVSI, EXCEPT: (2016, 62) (A) simple trachelectomy. (B) extrafascial hysterectomy. (C) cone biopsy with 3mm negative margins. (D) radical hysterectomy with lymph node dissection.

Key: D Solution: Microinvasive (FIGO stage IA1) cervical cancer demonstrating no LVSI in the biopsy specimen can be successfully managed without use of radical surgery. Various treatment options are tailored to patient's wishes and considerations on fertility.

106. In what sequence should radiation be administered in the management of Stage III/IV endometrial cancer? (2016, 106) (A) Preoperatively (B) Postoperatively before chemotherapy (C) Preoperatively with concurrent chemotherapy (D) Postoperatively sandwiched between chemotherapy

Key: D Solution: Patients with advanced endometrial cancer benefit from chemotherapy and radiation in the postoperative adjuvant setting. Multiple studies have examined the sequencing of adjuvant therapy. The studies have had some weaknesses limiting absolute recommendation but at this time the sandwich technique has achieved better outcome. Alvarez's group in a multicenter retrospective study compared 3 outcomes: 1) Radiation followed by chemotherapy (3 year PFS/OS =47%/54%); 2) Chemotherapy followed by radiation (3 year PFS/OS =52%/57%); 3) Chemotherapy, radiation followed by more chemotherapy (3 year PFS/OS = 69%/88%). While most guidelines suggest chemotherapy and radiation the sequence is not specified but left to the discretion of the treating physician.

61. Per ABS (2000) guidelines, when using 4 fractions of HDR only in the treatment of inoperable Stage I endometrial cancer, what dose per fraction scheme should be utilized? Specify dose (Gy) at 2 cm from the midpoint of the intrauterine sources. (2016, 61) (A) 5.7 (B) 6.4 (C) 7.3 (D) 8.5

Key: D Solution: The suggested dose using 4 fractions of HDR as a sole treatment modality is 8.5 Gy at 2 cm. The other dose regimens are delivered at higher fractions: 7.3 Gy in 5 fractions, 6.4 Gy in 6 fractions and 7 fractions of 5.7 Gy.

130. What is the total dose (Gy) of radiation used to treat a clinical stage I, 2 cm squamous cell carcinoma located in the lateral mid vagina? (2016, 130) (A) 40-45 (B) 50-55 (C) 60-65 (D) 70-75

Key: D Solution: A total radiation dose of at least 70 to 75 Gy is generally recommended, with 40 to 50 Gy in 20-25 fractions being delivered with EBRT and the additional radiation being delivered with intracavitary or interstitial brachytherapy, depending on the thickness of the primary tumor. The EBRT should include the pelvic lymph nodes, vaginal tumor with a margin, vagina, and paravaginal tissues (and inguinal lymph nodes if the vaginal tumor is in the lower half of the vaginal canal). Brachytherapy should immediately follow the completion of external radiation. Residual vaginal tumors less than 5 mm thick can be potentially treated with vaginal cylinder while tumors thicker than 5 mm require an interstitial treatment for adequate dose. The location of the lesion often impacts the recommended treatment approach. Lesions in the mid vagina if anterior or lateral may be considered for an interstitial implant whereas those on the posterior wall are treated using EBRT for the boost to minimize risk of bowel toxicity associated with a posterior interstitial implant.

What is the stage of a papillary serous carcinoma of the uterus confined to less than 1/2 of the myometrium with negative pelvic and PA nodes, but positive peritoneal washings? (2014, 55) A) IA B) IIA C) IIIA D) IVA

A) IA Rationale: The most recent AJCC manual no longer considered positive peritoneal washings in the staging of endometrial cancer.

What percentage of women with BRCA-1 mutation will develop ovarian cancer by the age of 70? (2014, 211) A) 15-20% B) 25-30% C) 35-45% D) 50-75%

C) 35-45% Rationale: About 50-65% of women with BRCA1 mutation will develop breast cancer by 70 and 35-46% will develop ovarian cancer

What is the recommended minimal surgical margin in fixed tissue for excision of a squamous cell carcinoma of the vulva? (2015, 73) (A) 2 mm (B) 4 mm (C) 8 mm (D) No tumor at ink

C) 8 mm Rationale: A tumor free gross surgical margin of ≥ 1 cm is required due to shrinkage of normal tissue margins consequent to fixation that has been estimated at 20%. Therefore, an 8 mm margin in fixed tissue will correspond to an approximate clinical margin of 1 cm in vivo. For patients with tumor at or <8mm, re-excision is advocated. If re-excision is not feasible then radiation is an alternative.

Which of the following cell types of ovarian cancer may include adjuvant RT as a treatment option for stage I cancers? (2013, 213) A) Serous B) Clear cell C)Dysgerminoma D) Sertoli-Leydig cell

C) Dysgerminoma Rationale: Standard tx options for stage I dysgerminoma include: USO with or without lymphangiography or CT; USO followed by observation; USO with adjuvant RT or chemo. Incompletely staged patients or those with higher stage tumors should probably receive adjuvant treatment (either chemo or RT)

What structures comprise the CTV for a stage IIIA cervical cancer when using definitive IMRT? (2013, 258) A) GTV, cervix, uterus and parametria, including the ovaries B) GTV, cervix, uterus and parametria, excluding the ovaries C) GTV, cervix, uterus and parametria, including the ovaries and entire vagina D) GTV, cervix, uterus and parametria, excluding the ovaries and entire vagina

C) GTV, cervix, uterus and parametria, including the ovaries and entire vagina Rationale: The CTV components include the entire GTV as noted on intermediate/high risk signal seen in T2 MRI. The entire cervix, uterus, and parametrium, including the ovaries and entire mesorectum if the uterosacral ligament is involved. For the vagina: if minimal or no vaginal extension, include the upper half. If upper vaginal involvement, include upper 2/3 of vagina. If extensive vaginal involvement, include the entire vagina

Which of the following parameters predicts a higher risk of local recurrence when using tandem and ovoids for cervical cancer brachytherapy? (2015, 34) (A) Tandem in midpelvis (B) Appropriate vaginal packing (C) Symmetrically placed ovoids to tandem (D) Displacement of ovoids away from cervix

D) Displacement of ovoids away from the cervix Rationale: Patients with displacement of the ovoids in relation to the cervical os had a significantly increased risk of local recurrence and a lower DFS rate in review of quality for RTOG 0116 and 128. Ideally, the tandem should be in midpelvis and bisect the ovoids. The ovoids should rest against the cervix face. Appropriately placed vaginal packing secures the implant while further displacing the bladder and rectum.

Which tumor marker is used to follow granulosa cell ovarian cancers, if elevated at diagnosis? (2014, 75) A) AFP B) CEA C) CA 19-9 D) Inhibin

D) Inhibin No rationale

The spread pattern of fallopian tube carcinoma is similar to which of the following ovarian tumors? (2014, 136) A) Borderline B) Endodermal sinus C) Granulosa-theca cell (D) Malignant epithelial

D) Malignant epithelial Rationale: Fallopian tube cancers spread to the peritoneum, bowel, and momentum similar to the spread of malignant epithelial ovarian tumors