Principles and Practice of Radiation Therapy Chapter 36 Gynecological Tumors Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Gynecological Anatomy Ovaries Fallopian tubes Uterus Vagina External genitalia

Ovaries Anatomy Function Structure Gonads Size Location Ligaments Dual purpose Structure Primordial follicles

Fallopian Tubes General Function Anatomy Infundibulum Ampulla Isthmus

Uterus General Function Anatomy Uterine wall Cervix Perimetrium Myometrium Endometrium Cervix

Vagina General Function Anatomy Mucosal lining Vaginal orifice Fornix pH Vaginal orifice Fornix

External Genitalia Vulva Mons pubis Labia Clitoris Perineum Also called pudendum Mons pubis Labia Labia majora Labia minora Vestibule Clitoris Anatomy Function Perineum

Gynecological Cancers Ovaries Uterus Cervix Vagina Vulva Epidemiology Etiology Clinical presentation Detection and diagnosis Pattern of spread Disease classification Treatment Survival

Ovarian Epidemiology Incidence Age Race Deaths 22,000 new cases Most deadly gynecological cancer

Ovarian Etiology Cause Risk factors Unknown BRCA1 and BRCA2 Hereditary nonpolyposis colorectal cancer (HNPCC) Risk factors Obesity Reproductive history Fertility drugs

Ovarian Etiology Risk factors (cont.) Family history of certain cancers Breast cancer Talcum powder Estrogen replacement therapy (ERT) Smoking and alcohol

Ovarian Prevention Oral contraceptives (OC) Tubal ligation or hysterectomy Pregnancy and breastfeeding Analgesics Oophorectomy

Ovarian Clinical Presentation Symptoms Back pain Fatigue Bloating Constipation

Ovarian Detection and Diagnosis Screening Blood test Cancer antigen-125 Papanicolau (Pap) test Transvaginal ultrasound

Ovarian Detection and Diagnosis Types Epithelial tumors Benign epithelial ovarian tumors Tumors of low malignant potential Epithelial ovarian cancers

Ovarian Detection and Diagnosis Types Primary peritoneal carcinomas Extraovarian primary peritoneal carcinoma (EOPPC) Germ cell tumors Teratoma Immature teratoma Dysgerminoma Endodermal sinus tumor Stromal tumors Ovarian cysts

Ovarian Pattern of Spread Direct extension Intraperitoneal dissemination Lymphatics Metastasis

Ovarian Disease Classification Tumor Node Metastasis/International Federation of Gynecology and Obstetrics (TNM/FIGO) T1a T1b T1c T2a T2b T2c T3a T3b T3c

Ovarian Treatment Surgery Chemotherapy Oophorectomy Cytoreduction Intraperitoneal

Ovarian Treatment Radiation therapy Indications Whole abdomen Borders Moving strip vs. open field Borders Superior Inferior Lateral

Ovarian Treatment Radiation therapy Dose Brachytherapy 2500 to 3000 cGy in 150-cGy fractions Pelvic boost Brachytherapy Intraperitoneal radioactive phosphorus

Ovarian Survival Overall 5-year survival – 45% Stage IA – 92.7% Stage IB – 85.4% Stage IC – 84.7% Stage IIA – 78.6% Stage IIB – 72.4% Stage IIC – 64.4% Stage IIIA – 50.8% Stage IIIB – 42.4% Stage IIIC – 31.5% Stage IV – 17.5%

Uterine Cancers Types of uterine cancer Endometrial cancer Cervical cancer Uterine sarcoma

Endometrial Epidemiology Incidence 39,000 new cases Most common gynecological cancer Age Race Deaths 7400 deaths

Endometrial Etiology Cause Risk factors Unknown Total length of menstruation Infertility or nulliparity Obesity

Endometrial Etiology Risk factors Tamoxifen ERT Ovarian disease Diet Diabetes

Endometrial Etiology Risk factors Family history HNPCC Breast or ovarian cancer Radiation Smoking

Endometrial Clinical Presentation Symptoms Unusual bleeding Pelvic pain Asymptomatic

Endometrial Detection and Diagnosis Screening Pap test Types Adenocarcinoma Type 1 Type 2 Uterine sarcoma

Endometrial Pattern of Spread Localized Direct extension Lymphatics Metastases Lung Liver Bone Brain

Endometrial Disease Classification FIGO Stage IA Stage IB Stage IC Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IVA Stage IVB

Endometrial Treatment Surgery Hysterectomy Total abdominal hysterectomy (TAH) Vaginal hysterectomy Radical hysterectomy

Endometrial Treatment Chemotherapy Hormone therapy Progestins Tamoxifen

Endometrial Treatment Radiation therapy Indications Borders Anteroposterior/posteroanterior (AP/PA) Superior Inferior Lateral Laterals Anterior Posterior

Endometrial Treatment Radiation therapy Blocking Step wedge Dose 4500 to 5000 cGy

Endometrial Treatment Radiation therapy Brachytherapy Indications Treatment technique High dose rate (HDR) vs. low dose rate (LDR)

Endometrial Survival Stage IA – 91% Stage IB – 90% Stage IC – 81% Stage IIA – 79% Stage IIB – 71% Stage IIIA – 60% Stage IIIB – 30% Stage IIIC – 52% Stage IVA – 15% Stage IVB – 17%

Cervical Epidemiology Incidence 11,000 new cases Age Race Worldwide Deaths 3700 deaths

Cervical Etiology Causes Risk factors Human papillomavirus (HPV) HPV Smoking HIV Chlamydia

Cervical Etiology Risk factors Diet OC Multiple pregnancies Low socioeconomic status (SES) Diethylstilbestrol (DES) Family history

Cervical Prevention Vaccines Gardasil Cervarix Procedure

Cervical Clinical Presentation Location Symptoms Asymptomatic Unusual bleeding Pain

Cervical Detection and Diagnosis Screening Recommendations 3 years after intercourse or at 21 years old Annually Until age 30 years, if 3 normal tests Then every 2 or 3 years Women older than 70 years

Cervical Detection and Diagnosis Screening Pap test Procedure Smear vs. liquid-based Increasing accuracy HPV DNA test Indications

Cervical Detection and Diagnosis Types Squamous cell carcinoma Adenocarcinoma Adenosquamous carcinoma

Cervical Pattern of Spread Pattern of growth Direct extension Lymphatics Metastases

Cervical Disease Classification Staging Stage 0 Stage I IA IA1 IA2 IB IB1 IB2

Cervical Disease Classification Staging Stage II IIA IIB Stage III IIIA IIIB Stage IV IVA IVB

Cervical Treatment Surgery Cryosurgery Laser surgery Conization

Cervical Treatment Surgery Simple hysterectomy Radical trachelectomy Radical hysterectomy Pelvic exenteration

Cervical Treatment Chemotherapy Adjuvant therapy Agents

Cervical Treatment Radiation therapy Indications Beam arrangement Borders AP/PA Superior Inferior Lateral Laterals Anterior Posterior

Cervical Treatment Radiation therapy Blocking Dose Brachytherapy Step wedge Dose Postoperative vs. primary Brachytherapy Indication Technique

Cervical Survival Overall 5-year survival – 72% Survival by stage Stage IA – More than 95% Stage IB1 – 90% Stage IB2 – 80% to 85% Stage IIA/B – 75% to 78% Stage IIIA/B – 47% to 50% Stage IV – 20% to 30%

Vaginal Epidemiology Incidence 2100 new cases Age Deaths 880 deaths

Vaginal Etiology Cause Risk factors DES Vaginal adenosis HPV Cervical cancer Vaginal irritation Smoking HIV

Vaginal Clinical Presentation Location Symptoms Unusual bleeding Discharge Pain Mass Asymptomatic

Vaginal Detection and Diagnosis Types Squamous cell Vaginal intraepithelial neoplasia (VAIN) Adenocarcinoma Melanoma Sarcoma Metastatic disease

Vaginal Pattern of Spread Direct extension Lymphatics Metastases

Vaginal Disease Classification TNM Tis T1 T2 T3 T4

Vaginal Treatment Surgery Chemotherapy Indications Size and stage dependent Vaginectomy Sexual effect Chemotherapy Topical

Vaginal Treatment Radiation therapy Treatment of choice Beam arrangement Dose 4500 to 5000 cGy

Vaginal Treatment Radiation therapy Brachytherapy Indications Technique Dose Primary vs. boost

Vaginal Survival Survival by stage Stage 0 – 96% Stage I – 73% Stage II – 58% Stage III/IV – 36%

Vulvar Epidemiology Incidence Age Worldwide Deaths 3500 new cases

Vulvar Etiology Causes Risk factors HPV p53 tumor suppressor gene Smoking HIV

Vulvar Etiology Risk factors Vulvar intraepithelial neoplasia (VIN) Lichen sclerosis Other cancers Melanoma Atypical nevi

Vulvar Clinical Presentation Location Symptoms VIN Asymptomatic Itching Tissue changes Carcinoma Others

Vulvar Detection and Diagnosis Types Squamous cell carcinoma Melanoma Adenocarcinoma Paget’s disease Sarcoma Verrucous carcinoma Basal cell carcinoma

Vulvar Pattern of Spread Direct extension Lymphatics Metastases

Vulvar Disease Classification TNM Tis T1 T1a T1b T2 T3 T4

Vulvar Treatment Surgery Chemotherapy Laser surgery Excision Vulvectomy Sexual effect Chemotherapy

Vulvar Treatment Radiation therapy Indications Patient position Frog-legged Beam arrangement Borders Superior Inferior Lateral Dose 5000 to 6000 cGy

Vulvar Survival Survival by stage Lymphatic involvement Stage I – 93% Stage II – 87% Stage III/IVA – 43% Lymphatic involvement Node negative – 96% Node positive – 64%