Download vulva - RadTherapy

VULVA
Epidemiology and Etiology
 Rare- usually older women, peaks at 65 yrs
 Three times more common as vaginal cancer
 Associated with diabetes and sexually transmitted diseases
 Atrophic dysplastic changes in the normal vaginal lining
 Loss of hormone stimulation
 Poor hygiene
Anatomy:
 Vulva: Outermost portion of the gynecologic tract
o Major parts include the labia majora, labia minora and clitoris
 Vestibule- area bound by these three, triangular
o Located anterior to the vaginal opening and usually contains the urethral
meatus
 Perineum: the area between the vulvovaginal complex and anal verge
Clinical presentation
 Subcutaneous lump or mass
 More advanced disease- ulcerative exophytic mass
 Unifocal- with the labia majora as the most common location
 Occult disease is common, as is inflammation, so a high level of false
negatives and false positives are based on the examination and clinical
suspicion alone
Symptoms
 Long history of irritation
Lymphatic spread
 Lymphatic spread predictable, involving the superficial inguinal nodes, then
the deep femoral nodes and eventually the pelvic nodes; falsely enlarged in
about 40%
Prognostic features
 The size of the lesion, depth of invasion and histologic subtype
 Presence and extent of lymph node involvement is the strongest predictor of
overall survival rates
Clinical workup
 Biopsy
 Cytologic examination, history, physical examination, blood counts and
chemistries, a urinalysis, chest radiographs, an intravenous pyelogram and or
a CT scan, and a cystoscopy
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Liver scans, bone scan sigmoidoscopy, and pelvic CT usually performed if
the tumor is advanced clinically or found on the other staging studies.
Pathology
 Squamous cell carcinomas account for more than 90% of vulvar cancers, and
adenocarcinomas represent the remaining cases
Treatment
 Radically vulvectomy with a groin node dissection
 Pelvic node dissection or pelvic irradiation for stage III disease
 Wide local excision with external irradiation of the primary and inguinal
nodes produces similar tumor control
 Radiation therapy may be administered postoperatively
 Radiation therapy may be administered preoperatively: seldom used as sole
treatment: usually given after a simple vulvectomy (50 Gy) and wide local
excision (60 Gy) plus a 5-10 Gy boost if margins are positive for tumor
 With radiation therapy alone doses of 65 to 70 Gy are delivered
 The vulva and perineum usually develop significant moist desquamation as a
result of the decreased thickness of the region, the parallel delivery of the
external beam and the need for bolus
 AP/PA with frog legs position
 Overall 5 yr survival rate 70%
Radiation Tolerance
 Vulva and perineum usually show the most acute short term side effects,
partly because of their radiation sensitivity and the often parallel and
tangential nature of the treatment beams applied to them
 Doses above 40 Gy at standard fractions (180 to 200 cGy) often cause
significant acute erythema and desquamation
 Doses above 50 Gy cause late telangiectasis
 Significant fibrosis can result from doses approaching 70 Gy
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VAGINA
Epidemiology and Etiology
 Vaginal cancer is a malignancy that arises in the vagina and does not extend
to the vulva or cervix
 Accounts for approximately 2% of all gynecologic cancers
 No etiologic associations are definite, except for the rarer clear cell variant
seen in women exposed to DES while they were in utero
 Rare- usually older women
 If cervix involved classified as a cervical cancer with vulvovaginal spread
Anatomy:
 Vagina: muscular tube that extends 6 to 8 inches superiorly from the vulva
and is located anterior to the rectum and posterior to the bladder
Clinical presentation
 Squamous cell carcinomas occur in older women median age of 65, whereas
clear cell carcinomas occur in young women between the ages of 15 and 27
(average 19 yrs)
Symptoms
 Abnormal vaginal bleeding and or painful intercourse are the usual
presenting symptoms
 The most common location is the posterior upper third of the vagina
Lymphatic spread
 The risk of lymphatic involvement increases with the depth of invasion
 Pelvic lymphatic involvement is similar to cervical cancer, with lesions of the
lower third of the vagina also involving the inguinal nodes.
Clinical workup
 Biopsy
 Cytologic examination, history, physical examination, blood counts and
chemistries, a urinalysis, chest radiographs, an intravenous pyelogram or
abdominopelvic CT scan, and a cystoscopy
 Liver scans, bone scan, sigmoidoscopy, and pelvic CT usually performed if
the tumor is advanced clinically or found on the other staging studies.
Pathology
 Squamous cell carcinomas account for 80- 90% of vaginal cancers, and
adenocarcinomas represent the remaining cases
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Treatment
 Radiation therapy is the treatment of choice for most vaginal cancers
 Surgery is used for recurrent or persistent squamous cell cancers and in
young women who have early clear cell adenocarcinoma
 Doses of 45 to 50 Gy are given to the pelvis and the entire vagina is included
in the external beam field
 Microscopic disease is treated to 50 Gy and macroscopic to 65 Gy- 80 Gy
 Side effects are similar to vulvar cancer.
Radiation Tolerance
 Vagina more tolerant with the upper vaginal mucosa tolerating up to 140 Gy
and the lower up to 100 Gy before extensive fibrosis
 Early mucositis and later telangiectasis occur with much lower treatment
range doses (60-85 Gy)
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CERVIX
Epidemiology and Etiology
 Incidence: 16%
 Death: 17%
 Ratio of death to new cases: 34%
 More prevalent among younger women
 Invasive cervical cancer rates reach their peak in women aged 50 to 60
 Women of lower socioeconomic status have a greater than average risk
 Early sexual activity, multiple partners, and multiple pelvic infections
(especially genital warts, HPVs, and herpes simplex type 2) associated with
increase risk and earlier onset
 Wives of men with penile cancer
 Increased risk of clear cell adenocarcinoma and abnormalities of the stratified
epithelium in women whose mothers used diethylstilbestrol DES during
pregnancy
 Papanicolaou smears results in early detection- two thirds detected
Anatomy
 Cervix: part of the uterus that extends into the apex of the vagina, firm
rounded structure 1.5 – 3 cm in diameter, protrudes into the vagina
producing lateral spaces in the vaginal apex called the fornices
 Cervical os: canal that extends from the vagina, through the central cervix,
and into the uterine cavity, or pelvic portion of the uterus
Clinical presentation
 Cervical cancer is a slowly progressive disease, with the earliest phase noninvasive carcinoma in situ occurring approximately 10 years earlier than
invasive cancer
Symptoms
 Common signs of invasive cancer are postcoital bleeding, increased
menstrual bleeding, and discomfort with intercourse
 A foul smelling discharge
 Pelvic pain and urinary or even rectal symptoms may accompany more
advanced disease
 Invasive cancer appears as a friable, ulcerative, or exophytic mass
originating from or involving the cervix
 The mass may extend into the vaginal canal and onto the vaginal sidewalls,
or it may invade adjacent tissues such as the parametrium, bladder or rectum
Lymphatic spread
 Lymphatic is usually orderly, involving parametrial modes, followed by
pelvic, common iliac, periaortic, and even supraclavicular nodes
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Prognostic features
 Ureter invasion has been associated with a reduction in 5 yr survival rates
from 92% to 54%
Clinical workup
 Pelvic examination, pap smear, biopsy, physical examination under
anesthesia, dilation and curettage to assess uterine involvement, complete
blood counts, chemistries and a urinalysis
 Chest radiographs, barium enema and IVP are used for FIGO staging
 For more advanced disease, abdominopelvic CT or MRI scans, a cystoscopy,
and a proctoscopy
Pathology:
 Most cervical, vaginal and vulvar cancers are squamous cell types
Staging
 Stage 0: The tumor is carcinoma in situ. It is very superficial (only affecting
the surface), is found only in the layer of cells lining the cervix, and has not
invaded deeper tissues of the cervix.
 Stage I: it has invaded the cervix, but it has not spread anywhere else.
o Stage IA: This is the earliest form of stage I. There is a very small
amount of cancer, and it can be seen only under a microscope.
 Stage IA1: The area of invasion is less than 3 mm (about 1/8-inch)
deep and less than 7 mm (about 1/4-inch) wide.
 Stage IA2: The area of invasion is between 3 mm and 5 mm (about
1/5-inch) deep and less than 7 mm (about 1/4-inch) wide.
o Stage IB: In this stage, the cancer usually can be seen without a
microscope. But this stage also includes cancers that have spread deeper
than 5 mm (about 1/5 inch) into connective tissue of the cervix or are
wider than 7 mm and can only be seen using a microscope.
 Stage IB1: The cancer is visible but no larger than 4 cm (about 1 3/5
inches).
 Stage IB2: The cancer is visible and larger than 4 cm.
 Stage II: In this stage, the cancer has spread beyond the cervix to nearby
areas, but it is still inside the pelvic area.
o Stage IIA: The cancer has spread beyond the cervix to the upper part of
the vagina. It is not in the lower third of the vagina.
o Stage IIB: The cancer has spread to the tissue next to the cervix, called
the parametrial tissue.
 Stage III: The cancer has spread to the lower part of the vagina or the pelvic
wall. The cancer may be blocking the ureters (tubes that carry urine from the
kidneys to the bladder).
o Stage IIIA: The cancer has spread to the lower third of the vagina but
not to the pelvic wall.
o Stage IIIB: The cancer extends to the pelvic wall and/or blocks urine
flow to the bladder. Note: In the alternate staging system by the American
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Joint Committee on Cancer, stage IIIB is defined by the fact that the
cancer has spread to lymph nodes in the pelvis.
Stage IV: This is the most advanced stage of cervical cancer. The cancer has
spread to nearby organs or other parts of the body.
o Stage IVA: The cancer has spread to the bladder or rectum, which are
organs close to the cervix.
o Stage IVB: The cancer has spread to distant organs beyond the pelvic
area, such as the lungs.
5-year survival rates by stage:
Stage
5-year survival
IA
Above 95%
IB1
Around 90%
IB2
Around 80%-85%
IIA/B
Around 75%-78%
IIIA/B
Around 47%-50%
IV
Around 20%-30%
Treatment:
 Radiation is the best treatment for cervical cancer.
 Surgery is reserved for medically operable patents in earlier stages
 Surgery is often used for younger women whereas radiation is used for
women who have a higher risk for surgical complications
 For early stage 0 and for stage IA1 invasive cancer, the usual treatment is a
total abdominal hysterectomy with a small amount of vaginal tissue known as
the vaginal cuff.
 For stage IA2 TAH or a more aggressive modified radical hysterectomy is
usually performed
 In the medically inoperable patient, 60 to 70 Gy may be delivered with the
use of a tandem and ovoid implant
 Postoperative irradiation is usually given for patients with pelvic nodes
positive for tumor, disease more advanced than originally staged, margins
positive for tumor and if disease is an incidental finding in a less than
definitive surgical procedure.
 Fields: four field allows exclusion of the anterior bladder and posterior
rectum or high energy AP/PA technique
 Borders:
o Inferior: at the bottom of the obturator foramen, unless the vagina is
involved in which case the lower extent of the border is at least 4 cm
below the lower extent of the disease
o Superior: usually at the top or bottom of L5
o Lateral: 1.5 to 2 cm lateral to the pelvic sidewall in the AP/PA plane
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Anterior: at or anterior to the pubic symphysis with a block designed
to include the external iliac nodes
 Posterior: includes S3
Anal markers, rectal barium, vaginal markers, and bladder contrast can be
used to help delineate critical structures during the simulation process
Prone with a belly board or full bladder allows the exclusion the small bowel
Intrauterine tandem and vaginal colpostats implants used.
o Prescription point A: 2 cm superior to the cervical os and 2 cm lateral to
the endocervical canal
o Point B 3 cm lateral to point A
The goal is to deliver 50 to 60 Gy to microscopic disease, 60 to 70 Gy to
small macroscopic disease, and 70 to 90 to large macroscopic disease while
limiting the volume and dose to the bladder, colorectal tissues, and small
intestine.
Radiation Tolerance
 The uterus and cervix tolerate extremely high doses of radiation and allow
the effectiveness of brachytherapy to the uterus
 Low dose rate brachytherapy, in combination with fractionated external
radiation therapy, can be delivered locally to the canal without necrosis when
the total dose does not exceed 200 Gy
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ENDOMETRIUM
Epidemiology and Etiology
 Incidence: 48% Most common
 Second most deadly: 25%
 Ratio of death to new cases: 17% - higher cure rate: early symptoms of
postmenopausal bleeding usually results in a physical evaluation at an
earlier stage
 Prevalence increase due to aging, high calorie and high fat diets and the use
of unopposed estrogen in the 60s and 70s
 Overweight by 50 pounds have a nine-fold increase in risk
 More than 75% of patients are women older than 50
 Incidence peaks at about 58 years
 Diabetes and hypertension are both linked with an increase in prevalence
 A higher risk also results from an increase in estrogen or the estrogen to
progesterone ratio, as occurs with nulliparity, infertility secondary to
anovulation (with a deficit in progesterone) dysfunctional bleeding during
menopause (secondary to estrogen over-stimulation) or prolonged hormone
replacement therapy- treatment duration dependant.
Anatomy
 Uterus: hollow muscular structure that extends at a right angle from the
vagina to overlie the bladder
 3 layers: endometrium, myometrium and parametrium
 Parametrium: refers to the area immediately lateral to the uterine body
Radiation Tolerance
 The uterus and cervix tolerate extremely high doses of radiation and allow
the effectiveness of brachytherapy to the uterus
 Low dose rate brachytherapy, in combination with fractionated external
radiation therapy, can be delivered locally to the canal without necrosis when
the total dose does not exceed 200 Gy
Clinical presentation
 Increased risk in women who take the drug tamoxifen
 75% experience vaginal bleeding and about 30% have foul smelling vaginal
discharge
 Approximately one third of postmenopausal bleeding is cancer related
 Most are early stage
Lymphatic spread
 Spread occurs initially to the internal and external iliac pelvic nodes
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Prognostic features
 Poor prognostic factors include higher grade, increased depth of invasion
into the myometrial muscle, lymph node involvement, and cancer cells in the
peritoneal fluid
Clinical workup
 Aspiration curettage the gold standard of cancer screening
 History, physical examination, chest radiographs, blood counts and
chemistries, and a urinalysis, an ultrasound, pelvic CT, or MRI to assess
uterine invasion and lymph node involvement
Pathology
 Adenocarcinoma of the endometrial lining is the most common
 Papillary serous adenocarcinoma is an extremely malignant form that tends
to spread rapidly and has poor outcome
Treatment
 Treatment can involve surgery and or radiation therapy depending on the
stage, grade, medical condition
 Preoperative therapy for high grade and stages
 Postoperative therapy mostly
 Low surface doses of 60 to 70 G yor high doses for 5-7 Gy to a .5 cm depth
 Minimal nodal doses of 45 to 50 Gy with implants to bring mucosa dose to 80
Gy or more
 Irradiation alone for medically inoperable
 Fields similar to cervical fields
 The endometrial cavity can be taken to 75-90 Gy with brachytherapy, but the
bladder and rectum must be kept to about 60-65 Gy and the small bowel must
be kept at or below 50 Gy.
 Heyman capsule, or intrauterine tandem, colpostats used
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OVARIES
Epidemiology and Etiology
 Incidence: 29%
 Most deadly: 53%
 Ratio of death to new cases: 59% - due to the relatively nonspecific early
symptoms with a consequent diagnosis of later stage disease and less
effective treatment
 Fourth leading cause of cancer deaths in women following lung, breast and
colon
 Primarily in women between the ages of 50 and 70
Risk Factors:
 Older age
 Late or few pregnancies
 Late menopause
 Lack of oral contraceptive use
 Family history of ovarian cancer
 Personal history of breast, colon, or endometrial cancer
 Diets high in meat and or animal fat
 Living in industrialized nations
Anatomy
 Fallopian tubes: hollow structures designed to transmit the ova from the
ovaries located adjacent to them
Clinical presentation
 Ovarian cancer is the most deadly of the gynecologic cancers because it has
few symptoms until widely disseminated
 Disease is most common in women 50 to 70 yrs old
 It is considered early if confined to ovaries
 Progression occurs to the pelvis, abdominal cavity and nodes
 CA125 is often elevated in the serum of epithelial ovarian cancer and useful
prognostic indicator of successful chemotherapy treatment
 Subclinical mets are noted during surgery to the peritoneal fluid, periaortic
nodes, and diaphragm
 About 80% of patients have abdominal cavity involvement at the time of
presentation
 Spread occurs through the lymphatics and peritoneal fluid
Symptoms
 The most common presenting symptoms are abdominal and or pelvic pain,
abdominal distention, or nonspecific gastrointestinal symptoms such as
nausea, constipation, and heartburn due to the presence of tumor or fluid in
abdominal cavity
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Clinical workup
 History, physical examination, liver and renal function blood work, chest
radiographs, pelvic ultrasound, abdominopelvic CT or MRI scans, and serum
CA 125
 Barium enema, endoscopy and upper gastrointestinal series
 Cytological evaluation of the peritoneal fluid, intraoperative evaluation of
adnexal masses
Pathology
 About 90% of ovarian cancers are epithelial
Treatment
 The initial treatment involves surgical evaluation and debulking
 Postoperative therapy may include single agent or combination
chemotherapy and or complete abdominal and pelvic radiation therapy
Radiation Tolerance
 The ovary is the most radiosensitive gynecologic structure
 The dose response is age dependent
 A dose of 4 to 5 Gy produces the permanent cessation of menses in about 65
% of women younger than 40, 90% of those aged 40 to 44 and 100% aged 50
or older.
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Lymphatics:
 Includes the inguinal lymph nodes external and internal, pelvic nodes (the
internal iliac chain which originates approximately with the obturator node,
and external iliac chain) and periaortic nodes
 The deep inguinals drain into the external iliac chain, and the internal and
external iliac chains join and then drain into the periaortics
 Ovarian and upper endometrial lymphatics follow the ovarian blood supply to
terminate in periaortic lymph nodes at the level of the kidneys and follow the
round ligament to involve the inguinal lymphatics
 The primary drainage pattern of the cervix and additional drainage patterns of
the ovary and uterus are to the external iliac, obturator, and hypogastric
chains
 Upper vaginal drainage follows the cervical pathways
 Lower vaginal drainage may follow the vulvar drainage into the inguinal
nodes.
Critical Structures:
 Bladder: located anterior to the vagina and cervix and somewhat under the
uterus, expands forward and away from these structures when it is files
 The point tolerance is about 70 Gy, but whole bladder treatment results
in acute cystitis at doses as low as 30 Gy
 This results in acute bladder irritation with dysuria, frequency, and
urgency but usually resolves in a couple of weeks
 Chronic cystitis occasionally occurs 6 months after radiation with doses
above 50 to 60 Gy and contracture and or hemorrhagic cystitis occurs
with doses above 65 Gy
 Rectum: immediately posterior to the vagina and cervix, also has a point
tolerance of about 70 Gy
 Continues superiorly with the sigmoid colon, with a whole organ
tolerance of about 50 Gy
 Diarrhea, bleeding, urgency, and pain can occur acutely at 30 to 40 Gy
 Stricture, bleeding and perforation are late complications that occur with
doses above the tolerance level
 Small bowel is variable looped down in the pelvis and may overlie the uterus
and bladder
 The bowel has a lower tolerance at 45 Gy, can yield the same acute
toxicity as the large bowel (lower dose) and is more likely to obstruct as a
chronic complication
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Side effects:
 Acute side effects of pelvic
 Fatigue: can occur the first week of treatment and can be exacerbated or
complicated by anemia and depression
 Rest, reassurance, adequate nutrition and antidepressants
 Anemia should be corrected to at least maintain a hemoglobin level
above 10 g/dl.
 Diarrhea: usually occurs the second or third week of treatment and is
related to large and small bowel treatment
 Chemotherapy can worsen problem
 Low fiber diets, sucralfate (Carafate) as a small bowel coating agent,
dephenoxylate (Lomotil), and loperamide are useful
 Excluding as much bowel as possible using belly boards, the prone
position with a full bladder on smaller fields, custom shielding, and
serial field size reduction.
 Dermatitis: more common with low energy treatment, AP/PA fields,
perineal flash or bolus when indicated and concomitant chemo
 Domboro soaks, Aquaphore ointment and natural care gels can lessen
the severity and speed healing
 Dysurea: usually occurs during the third or fourth week of treatment and
can be lessened by treatment with a full bladder
 Pyridium and Urised can be used to anesthetize the bladder
 Rectal irritation can be treated with hemorrhoidal preparations, steroids,
topical anesthetic agents and sitz baths.

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Sub-acute effects can include
 Menopause: can be treated with cyclic hormonal therapy
 Vaginal dryness: can be treated with moisturizing agents such as Replens
or hormonal creams
 Shrinkage: can be prevented with vaginal dilators or regular sexual
activity
 Inflammation (chronic cystitis, proctosigmoiditis, enteritis): can be
treated with anti-inflammatory agents and pain medications
 Obstruction: treated surgically
Abdominal fields can also cause diarrhea, nausea, and upper gastrointestinal
bleeding.
Brachytherapy Review
 Vaginal cylinder: a canal filling cylinder into which an isotope can be placed
to ensure an even dose to the vaginal mucosa
 Intrauterine tandem: a small, hollow, curved cylinder that fits through the
cervical os into the uterus
 Vaginal colpostats: two golf club shaped, hollow tubes placed laterally to
the tandem into the vaginal fornices
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