Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 1 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 2 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 3 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) 4 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 5 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 6 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 7 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 8 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 9 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 10 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 11 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. 12 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 13 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. 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 14