Radiation Oncology

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Radiation Therapy for Gynecologic Tumors

Radiation plays an important role in the management of multiple gynecologic  malignancies including cancer of the cervix, endometrium, vulva and occasionally ovaries. Gynecologic tumors frequently require a multidisciplinary approach for optimal management including surgery, radiation, and chemotherapy.

Endometrial Cancer is the most common gynecologic cancer in American women. Thirty-five thousand women will be diagnosed this year. Fortunately, the large majority of patients will be cured because we have very effective treatment for this disease. Another reason for the high cure rate is that it is often diagnosed early. However, even when it is found in a more advanced stage, there is still a good chance of achieving a cure

The most common problem that leads to the diagnosis is postmenopausal bleeding. If there is not an obvious cause for abnormal bleeding, a gynecologist often does a D and C in order to examine the tissue that lines the uterus, or the endometrial lining. If a diagnosis of cancer is made, it is then staged.

In stage I, the cancer is limited to the upper part of the uterus

In stage II, the cancer involves both the upper portion as well as the cervix, or the lower portion of the uterus that opens into the vagina.

In stages III and IV, the cancer has spread beyond the uterus.

The stage is the main factor in recommending the type of treatment that is best for each patient . The depth of tumor penetration into the uterus and how it looks under the microscope are also important.

In stage I and II, the primary approach to treatment is hysterectomy and removal of the tubes and ovaries. Depending on several factors, radiation is often beneficial and improves the chance of cure. Radiation, when indicated, is usually given in a series of daily external beam treatments to the pelvis. The most advanced form of external beam treatment is 3D conformal therapy. The daily external beam treatments are usually followed by additional treatments to the vagina using a radioactive source inside a tampon like instrument (seen below).

This form of treatment is referred to as brachytherapy and delivers a high dose to the upper portions of the vagina without giving a significant dose to the surrounding tissues. This is often done in a brief series of out patient visits.

In more advanced cases, the treatment is highly individualized and may consist of radiation alone or a combination of surgery and radiation.

More recently, hormonal treatments as well as chemotherapy have also been used effectively especially when the disease has spread or when the woman is not a candidate for the standard types of treatments.

Cervix cancer is generally a slow growing tumor that develops over a long period of time. It can often be diagnosed at an early stage through the increased awareness and use Pap smears which scrapes cells from the cervix which are then examined under the microscope.

The primary management of early stage disease which is confined to the cervix is usually a hysterectomy performed by a gynecologic surgeon. External beam radiation is sometimes added if high risk features are identified at the time of surgery.

In patients with larger tumors or if there is evidence of disease extension beyond the cervix, combination radiation therapy is usually recommended. Radiation therapy involves a combination of external beam treatments to the pelvis followed by a brachytherapy boost to the cervix.

An apparatus (left) is inserted into the vagina for the purpose of delivering a high dose of radiation to the cervix while sparing the surrounding tissues. The device inserted into the vagina is termed a tandem and ovoid and depending upon the type of boost may be inserted in the operating room or as an outpatient.

One of the most exciting new developments in the treatment of cervical carcinoma is recent demonstration of improved outcomes with the addition of low-dose chemotherapy to standard radiation. A recent publication in the New England Journal of Medicine reported the results of several large trials which showed improved survival in patients who received weekly chemotherapy along with radiation. It is believed that not only does chemotherapy help control disease throughout the body, but also improves the cancer killing ability of radiation therapy locally.

Ovarian Cancer is primarily treated with a combination of surgery (hysterectomy) followed by chemotherapy. While radiation does not play a major role in this disease it is sometimes used for palliation of painful symptoms of metastatic disease.