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%