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Principles and Practice of Radiation Therapy
Chapter 36 Gynecological Tumors Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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Gynecological Anatomy
Ovaries Fallopian tubes Uterus Vagina External genitalia
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Ovaries Anatomy Function Structure Gonads Size Location Ligaments
Dual purpose Structure Primordial follicles
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Fallopian Tubes General Function Anatomy Infundibulum Ampulla Isthmus
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Uterus General Function Anatomy Uterine wall Cervix Perimetrium
Myometrium Endometrium Cervix
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Vagina General Function Anatomy Mucosal lining Vaginal orifice Fornix
pH Vaginal orifice Fornix
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External Genitalia Vulva Mons pubis Labia Clitoris Perineum
Also called pudendum Mons pubis Labia Labia majora Labia minora Vestibule Clitoris Anatomy Function Perineum
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Gynecological Cancers
Ovaries Uterus Cervix Vagina Vulva Epidemiology Etiology Clinical presentation Detection and diagnosis Pattern of spread Disease classification Treatment Survival
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Ovarian Epidemiology Incidence Age Race Deaths 22,000 new cases
Most deadly gynecological cancer
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Ovarian Etiology Cause Risk factors Unknown BRCA1 and BRCA2
Hereditary nonpolyposis colorectal cancer (HNPCC) Risk factors Obesity Reproductive history Fertility drugs
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Ovarian Etiology Risk factors (cont.)
Family history of certain cancers Breast cancer Talcum powder Estrogen replacement therapy (ERT) Smoking and alcohol
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Ovarian Prevention Oral contraceptives (OC)
Tubal ligation or hysterectomy Pregnancy and breastfeeding Analgesics Oophorectomy
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Ovarian Clinical Presentation
Symptoms Back pain Fatigue Bloating Constipation
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Ovarian Detection and Diagnosis
Screening Blood test Cancer antigen-125 Papanicolau (Pap) test Transvaginal ultrasound
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Ovarian Detection and Diagnosis
Types Epithelial tumors Benign epithelial ovarian tumors Tumors of low malignant potential Epithelial ovarian cancers
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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
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Ovarian Pattern of Spread
Direct extension Intraperitoneal dissemination Lymphatics Metastasis
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Ovarian Disease Classification
Tumor Node Metastasis/International Federation of Gynecology and Obstetrics (TNM/FIGO) T1a T1b T1c T2a T2b T2c T3a T3b T3c
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Ovarian Treatment Surgery Chemotherapy Oophorectomy Cytoreduction
Intraperitoneal
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Ovarian Treatment Radiation therapy Indications Whole abdomen Borders
Moving strip vs. open field Borders Superior Inferior Lateral
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Ovarian Treatment Radiation therapy Dose Brachytherapy
2500 to 3000 cGy in 150-cGy fractions Pelvic boost Brachytherapy Intraperitoneal radioactive phosphorus
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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%
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Uterine Cancers Types of uterine cancer Endometrial cancer
Cervical cancer Uterine sarcoma
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Endometrial Epidemiology
Incidence 39,000 new cases Most common gynecological cancer Age Race Deaths 7400 deaths
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Endometrial Etiology Cause Risk factors Unknown
Total length of menstruation Infertility or nulliparity Obesity
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Endometrial Etiology Risk factors Tamoxifen ERT Ovarian disease Diet
Diabetes
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Endometrial Etiology Risk factors Family history
HNPCC Breast or ovarian cancer Radiation Smoking
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Endometrial Clinical Presentation
Symptoms Unusual bleeding Pelvic pain Asymptomatic
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Endometrial Detection and Diagnosis
Screening Pap test Types Adenocarcinoma Type 1 Type 2 Uterine sarcoma
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Endometrial Pattern of Spread
Localized Direct extension Lymphatics Metastases Lung Liver Bone Brain
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Endometrial Disease Classification
FIGO Stage IA Stage IB Stage IC Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IVA Stage IVB
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Endometrial Treatment
Surgery Hysterectomy Total abdominal hysterectomy (TAH) Vaginal hysterectomy Radical hysterectomy
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Endometrial Treatment
Chemotherapy Hormone therapy Progestins Tamoxifen
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Endometrial Treatment
Radiation therapy Indications Borders Anteroposterior/posteroanterior (AP/PA) Superior Inferior Lateral Laterals Anterior Posterior
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Endometrial Treatment
Radiation therapy Blocking Step wedge Dose 4500 to 5000 cGy
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Endometrial Treatment
Radiation therapy Brachytherapy Indications Treatment technique High dose rate (HDR) vs. low dose rate (LDR)
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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%
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Cervical Epidemiology
Incidence 11,000 new cases Age Race Worldwide Deaths 3700 deaths
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Cervical Etiology Causes Risk factors Human papillomavirus (HPV) HPV
Smoking HIV Chlamydia
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Cervical Etiology Risk factors Diet OC Multiple pregnancies
Low socioeconomic status (SES) Diethylstilbestrol (DES) Family history
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Cervical Prevention Vaccines Gardasil Cervarix Procedure
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Cervical Clinical Presentation
Location Symptoms Asymptomatic Unusual bleeding Pain
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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
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Cervical Detection and Diagnosis
Screening Pap test Procedure Smear vs. liquid-based Increasing accuracy HPV DNA test Indications
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Cervical Detection and Diagnosis
Types Squamous cell carcinoma Adenocarcinoma Adenosquamous carcinoma
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Cervical Pattern of Spread
Pattern of growth Direct extension Lymphatics Metastases
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Cervical Disease Classification
Staging Stage 0 Stage I IA IA1 IA2 IB IB1 IB2
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Cervical Disease Classification
Staging Stage II IIA IIB Stage III IIIA IIIB Stage IV IVA IVB
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Cervical Treatment Surgery Cryosurgery Laser surgery Conization
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Cervical Treatment Surgery Simple hysterectomy Radical trachelectomy
Radical hysterectomy Pelvic exenteration
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Cervical Treatment Chemotherapy Adjuvant therapy Agents
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Cervical Treatment Radiation therapy Indications Beam arrangement
Borders AP/PA Superior Inferior Lateral Laterals Anterior Posterior
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Cervical Treatment Radiation therapy Blocking Dose Brachytherapy
Step wedge Dose Postoperative vs. primary Brachytherapy Indication Technique
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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%
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Vaginal Epidemiology Incidence 2100 new cases Age Deaths 880 deaths
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Vaginal Etiology Cause Risk factors DES Vaginal adenosis HPV
Cervical cancer Vaginal irritation Smoking HIV
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Vaginal Clinical Presentation
Location Symptoms Unusual bleeding Discharge Pain Mass Asymptomatic
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Vaginal Detection and Diagnosis
Types Squamous cell Vaginal intraepithelial neoplasia (VAIN) Adenocarcinoma Melanoma Sarcoma Metastatic disease
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Vaginal Pattern of Spread
Direct extension Lymphatics Metastases
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Vaginal Disease Classification
TNM Tis T1 T2 T3 T4
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Vaginal Treatment Surgery Chemotherapy Indications
Size and stage dependent Vaginectomy Sexual effect Chemotherapy Topical
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Vaginal Treatment Radiation therapy Treatment of choice
Beam arrangement Dose 4500 to 5000 cGy
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Vaginal Treatment Radiation therapy Brachytherapy Indications
Technique Dose Primary vs. boost
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Vaginal Survival Survival by stage Stage 0 – 96% Stage I – 73%
Stage II – 58% Stage III/IV – 36%
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Vulvar Epidemiology Incidence Age Worldwide Deaths 3500 new cases
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Vulvar Etiology Causes Risk factors HPV p53 tumor suppressor gene
Smoking HIV
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Vulvar Etiology Risk factors Vulvar intraepithelial neoplasia (VIN)
Lichen sclerosis Other cancers Melanoma Atypical nevi
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Vulvar Clinical Presentation
Location Symptoms VIN Asymptomatic Itching Tissue changes Carcinoma Others
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Vulvar Detection and Diagnosis
Types Squamous cell carcinoma Melanoma Adenocarcinoma Paget’s disease Sarcoma Verrucous carcinoma Basal cell carcinoma
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Vulvar Pattern of Spread
Direct extension Lymphatics Metastases
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Vulvar Disease Classification
TNM Tis T1 T1a T1b T2 T3 T4
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Vulvar Treatment Surgery Chemotherapy Laser surgery Excision
Vulvectomy Sexual effect Chemotherapy
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Vulvar Treatment Radiation therapy Indications Patient position
Frog-legged Beam arrangement Borders Superior Inferior Lateral Dose 5000 to 6000 cGy
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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%
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