Gyn Question

[RadtionVacation]

If you have a IIB patient, does everyone use a parametrial boost? Is 85 Gy to point A still the desired dose?

---

Members don't see this ad.

 

[deleted4401]

Yeah, it's always recommended, but haven't found standardization of it...

5.4 - 10.8 Gy or some people have said that the total point B dose should be 60 Gy or greater...

A few ways, technique-wise...

1) "Standard field" - 4.5cm midline block (if only tx'ing ipsilateral, than start 2-2.5cm ipsi to midline, and then block the other side completely. Superior is mid to bottom SI joint. Inferior is mid-bottom obturator. 1.5-2cm laterally on pelvis

2) Use your brachy 50% isodose line as the block. Same lateral, sup, inf borders as above

3) What I do - contour out parametrium on afflicted side, and then either AP/PA or slightly oblique to completely block out rectum.

-S

 

[Palex80]

Provided you can administer a brachytherapy boost, which is not always the case unfortunately.

I've also found out, that with the introduction of imaging-based 3D-planning for brachytherapy administering textbook-like high brachytherapy boost doses has become increasingly difficult, when you actually see the isodose spreading into the small bowel.

 

[deleted4401]

Ha... and who know you would be quoting The Bieb....

-S

 

[BraggPeak]

If you have IIB disease and you have no gross disease after EBRT (on EUA when doing first brachy fraction), would you still give boost to parametrium?

 

[BraggPeak]

Also, how do most people treat early endometiral (Vaginal Cuff versus Cuff + EBRT)

 

[Palex80]

If you have IIB disease and you have no gross disease after EBRT (on EUA when doing first brachy fraction), would you still give boost to parametrium?

I would go with the GEC-ESTRO guidelines for this, defining an IR-PTV and a HR-PTV. Quite a lot of work was put into creating these guidelines and a I find them the best set of recommendations in image-based brachytherapy.

http://www.ncbi.nlm.nih.gov/pubmed/15763303
http://www.ncbi.nlm.nih.gov/pubmed/16403584

 

[seper]

"Early endometrial" is usually broken down into 4 categories - low risk, high risk, LIR and HIR. Each of these is approached differently. So please clarify.

Also, how do most people treat early endometiral (Vaginal Cuff versus Cuff + EBRT)

I have a question too: what are the accepted indications to treat the primary site in vulvar Ca?

 

[deleted4401]

Primary vulva tx: close (<8mm) or positive margins, >4cm disease, LVSI, or 2 or more of other Heaps' factors: depth of invasion (9 mm), tumor thickness (1cm), infiltrative growth, increasing keratin (??), >10 mitoses (??).

Early endometrial - for stage I, follow T.I. - "Whatever You Like". All patients surgically treated can be observed, and this is recommended for IA, Gr1-2. 1B, Gr3 - pelvis + brachy + discussion about chemo. Cuff brachy for everybody else. If no nodes dissected, consider pelvic RT, but no great evidence for that. But, if you look at NCCN grid, basically dealer's choice except for 1A/Gr1.

For stage II - pelvic RT + cuff brachy. If high grade and deep muscle invasion, discuss chemo. Pelvic field should involved upper presacral (S1-S3) if stage II.

-S

 

[Gfunk6]

Sounds like someone is set to take their oral boards.

 

[deleted4401]

I hate the idea of it. I wish pestilence and famine on the ABR.
S

 

[medgator]

Early endometrial - for stage I, follow T.I. - "Whatever You Like". All patients surgically treated can be observed, and this is recommended for IA, Gr1-2. 1B, Gr3 - pelvis + brachy + discussion about chemo. Cuff brachy for everybody else. If no nodes dissected, consider pelvic RT, but no great evidence for that. But, if you look at NCCN grid, basically dealer's choice except for 1A/Gr1.

For stage II - pelvic RT + cuff brachy. If high grade and deep muscle invasion, discuss chemo. Pelvic field should involved upper presacral (S1-S3) if stage II.

-S

or pap serous.

 

[BraggPeak]

Would you use age as a criteria for early endomoetrial. For example, a 49 yo with 1A, G2, ++LVSI-- how would you treat? VC or observation? According to Keys criteria, if <50, you should have all 3 factors (LVSI, G2/3, deep muscle invasion).

 

[seper]

IAG2 is most often termed "Low-intermediate risk". @ MDA, these are usually observed, unless 1 additional risk factor is present - either LVSI or age >60 (?>70)

 

[deleted4401]

That's the joy/pain of this. The NCCN says you can do either VC or obs.

She doesn't meet the HIR criteria because only 2 risk factors, so ...

~15% risk of recurrence. ~11% of those are cuff recurrences. Can reduce it to a total recurrence rate (pelvic + vag) of ~3%, with no benefit for survival. Ask the patient how they feel about it.

I tend to say they could whatever they want, but 3 insertions are pretty easy and won't make her sick. Most women prefer to be treated.

-S

 

[Palex80]

~15% risk of recurrence. ~11% of those are cuff recurrences. Can reduce it to a total recurrence rate (pelvic + vag) of ~3%, with no benefit for survival. Ask the patient how they feel about it.

I tend to say they could whatever they want, but 3 insertions are pretty easy and won't make her sick. Most women prefer to be treated.

I agree with this approach.

Look at it this way:

We are treating women with 5 weeks of EBRT for DCIS, who also often have a comparable risk of relapse of about 15%, with the aim to lower this risk to something like 6%. And all that with no survival benefit.
Risking pulmonary complications, long term cardiac morbidity, sometimes worsening cosmetic aspects of the operated breast and with a low (but still present) risk of secondary tumor induction.

I would definetely advise a patient to VC-brachytherapy. It's a procedure with little morbidity and carried out fast and easy.

 

[RadRadRad]

HR for LRR recurrence pretty similar in GOG 99 btwn LIR and HIR...roughly 0.46 vs 0.42. Absolute difference at 48 mo is 4-5% for LIR. Most are cuff failures. Presumably LRR risk is a spectrum...ie patients with some, but not all, risk factors probably fall somewhere in between (probably why MDACC looks at LVSI, age, etc for the 1AG2). Would not observe all pts with 1A G2 disease (Assuming we're talking about new staging where some 1A pts have myometrial invasion <50%). This should be an informed decision and patients should be willing to accept higher (albeit small) percent chance of LRR with observation.

Agree that vast majority of pts tolerate cuff brachy well and really need to be looking for reasons to omit VC brachy, particulary in pts with myometrial invasion and G2.