This document discusses carcinoma of the vagina, including vaginal intraepithelial neoplasia (VAIN). It covers the anatomy, epidemiology, risk factors, clinical presentation, evaluation, and treatment of vaginal cancer. Vaginal cancer is a rare malignancy that usually presents with irregular vaginal bleeding. Diagnosis involves biopsy of any suspicious lesions. Treatment depends on the stage and may involve surgery, radiation therapy, or chemotherapy. For early stage disease, brachytherapy alone can often control the cancer with local control rates of 67-100%.
This document discusses several clinical trials comparing different treatment approaches for esophageal cancer, including:
- Preoperative chemotherapy improved survival compared to surgery alone in some trials but not in others. High toxicity reduced benefits in some studies.
- Perioperative chemotherapy with fluorouracil and cisplatin significantly improved resection rates, survival, and disease-free survival compared to surgery alone.
- Chemoradiotherapy resulted in improved survival over radiotherapy alone or surgery alone in some trials for resectable esophageal cancer.
- Existing evidence did not clearly show preoperative radiotherapy alone improved survival over surgery alone for resectable esophageal cancer. Larger trials were needed.
This document summarizes several key studies on the use of concurrent chemo-radiation therapy for carcinoma of the cervix. Five randomized controlled trials from the 1980s-1990s showed significantly improved progression-free and overall survival when cisplatin-based chemo-radiation was used compared to radiation alone. Subsequent larger trials like GOG 120 and RTOG 9001 reinforced these findings. Long term follow up data continued to show survival benefits with acceptable toxicity rates for concurrent chemo-radiation, which is now the standard of care for locally advanced cervical cancer.
ROLE OF NEOADJUVANT CHEMORADIATION IN LOCALLY ADVANCED BREAST CANCERKanhu Charan
This retrospective study analyzed 187 breast cancer patients treated with neoadjuvant chemoradiation followed by mastectomy from 1970-1984. It found that the 10-year locoregional control, disease-free survival, and overall survival rates were 91%, 47%, and 55% respectively. Only pathological nodal involvement was an independent negative prognostic factor for disease-free and overall survival. The study demonstrates comparable long-term locoregional control with this approach compared to other trials, suggesting neoadjuvant chemoradiation followed by mastectomy can achieve good outcomes.
1) A landmark randomized clinical trial published in 1999 found that concurrent weekly cisplatin chemotherapy during pelvic radiation improved progression-free survival and overall survival rates for patients with bulky stage IB cervical cancer compared to radiation alone. The study demonstrated a 79% 5-year progression-free survival rate and 85% 5-year overall survival rate for patients receiving concurrent chemoradiation versus 74% and 63% respectively for radiation alone.
2) Another 1999 randomized clinical trial found that for high-risk cervical cancer patients, pelvic radiation with concurrent cisplatin and fluorouracil chemotherapy resulted in improved overall survival compared to pelvic and para-aortic radiation alone, establishing concurrent chemoradiation as the new standard
The document discusses triple negative breast cancer (TNBC) and early stage disease. It covers molecular subtypes of breast cancer, challenges in treating TNBC due to lack of targeted therapies, and evidence that neoadjuvant chemotherapy can improve outcomes for TNBC patients who achieve a pathological complete response. Ongoing research aims to better predict which patients will respond to neoadjuvant treatment and identify new targeted therapies for TNBC subtypes.
The document discusses the FAST Forward study, a phase III randomized trial comparing different fractionation schedules for adjuvant radiotherapy in breast cancer. The study involved 4096 patients randomized to receive either 40 Gy in 15 fractions, 27 Gy in 5 fractions, or 26 Gy in 5 fractions. At median follow-up of 71.5 months, there was no significant difference in ipsilateral breast tumor recurrence between groups. However, 27 Gy in 5 fractions was associated with significantly increased risk of moderate or marked late normal tissue effects compared to 40 Gy, based on clinical, patient-reported, and photographic assessments. Estimated α/β ratios were 3.7 Gy for tumor control and 1.7 Gy for normal tissue toxicity.
This document discusses management of prostate cancer through different treatment modalities including active surveillance, radical prostatectomy, radiation therapy, and hormonal therapy. It provides treatment recommendations based on cancer stage and risk level as well as 5-year outcomes. For low risk prostate cancer, active surveillance, radical prostatectomy, or radiation therapy are recommended depending on life expectancy. Radiation therapy techniques like 3D-CRT, IMRT, and brachytherapy are covered. Dose escalation studies showing improved outcomes with higher radiation doses are also summarized.
This document discusses several clinical trials comparing different treatment approaches for esophageal cancer, including:
- Preoperative chemotherapy improved survival compared to surgery alone in some trials but not in others. High toxicity reduced benefits in some studies.
- Perioperative chemotherapy with fluorouracil and cisplatin significantly improved resection rates, survival, and disease-free survival compared to surgery alone.
- Chemoradiotherapy resulted in improved survival over radiotherapy alone or surgery alone in some trials for resectable esophageal cancer.
- Existing evidence did not clearly show preoperative radiotherapy alone improved survival over surgery alone for resectable esophageal cancer. Larger trials were needed.
This document summarizes several key studies on the use of concurrent chemo-radiation therapy for carcinoma of the cervix. Five randomized controlled trials from the 1980s-1990s showed significantly improved progression-free and overall survival when cisplatin-based chemo-radiation was used compared to radiation alone. Subsequent larger trials like GOG 120 and RTOG 9001 reinforced these findings. Long term follow up data continued to show survival benefits with acceptable toxicity rates for concurrent chemo-radiation, which is now the standard of care for locally advanced cervical cancer.
ROLE OF NEOADJUVANT CHEMORADIATION IN LOCALLY ADVANCED BREAST CANCERKanhu Charan
This retrospective study analyzed 187 breast cancer patients treated with neoadjuvant chemoradiation followed by mastectomy from 1970-1984. It found that the 10-year locoregional control, disease-free survival, and overall survival rates were 91%, 47%, and 55% respectively. Only pathological nodal involvement was an independent negative prognostic factor for disease-free and overall survival. The study demonstrates comparable long-term locoregional control with this approach compared to other trials, suggesting neoadjuvant chemoradiation followed by mastectomy can achieve good outcomes.
1) A landmark randomized clinical trial published in 1999 found that concurrent weekly cisplatin chemotherapy during pelvic radiation improved progression-free survival and overall survival rates for patients with bulky stage IB cervical cancer compared to radiation alone. The study demonstrated a 79% 5-year progression-free survival rate and 85% 5-year overall survival rate for patients receiving concurrent chemoradiation versus 74% and 63% respectively for radiation alone.
2) Another 1999 randomized clinical trial found that for high-risk cervical cancer patients, pelvic radiation with concurrent cisplatin and fluorouracil chemotherapy resulted in improved overall survival compared to pelvic and para-aortic radiation alone, establishing concurrent chemoradiation as the new standard
The document discusses triple negative breast cancer (TNBC) and early stage disease. It covers molecular subtypes of breast cancer, challenges in treating TNBC due to lack of targeted therapies, and evidence that neoadjuvant chemotherapy can improve outcomes for TNBC patients who achieve a pathological complete response. Ongoing research aims to better predict which patients will respond to neoadjuvant treatment and identify new targeted therapies for TNBC subtypes.
The document discusses the FAST Forward study, a phase III randomized trial comparing different fractionation schedules for adjuvant radiotherapy in breast cancer. The study involved 4096 patients randomized to receive either 40 Gy in 15 fractions, 27 Gy in 5 fractions, or 26 Gy in 5 fractions. At median follow-up of 71.5 months, there was no significant difference in ipsilateral breast tumor recurrence between groups. However, 27 Gy in 5 fractions was associated with significantly increased risk of moderate or marked late normal tissue effects compared to 40 Gy, based on clinical, patient-reported, and photographic assessments. Estimated α/β ratios were 3.7 Gy for tumor control and 1.7 Gy for normal tissue toxicity.
This document discusses management of prostate cancer through different treatment modalities including active surveillance, radical prostatectomy, radiation therapy, and hormonal therapy. It provides treatment recommendations based on cancer stage and risk level as well as 5-year outcomes. For low risk prostate cancer, active surveillance, radical prostatectomy, or radiation therapy are recommended depending on life expectancy. Radiation therapy techniques like 3D-CRT, IMRT, and brachytherapy are covered. Dose escalation studies showing improved outcomes with higher radiation doses are also summarized.
This document summarizes key landmark clinical trials in breast cancer. It discusses trials related to prevention using tamoxifen and raloxifene, radiation therapy trials for DCIS and early stage breast cancer, breast-conserving therapy including accelerated whole-breast irradiation, neoadjuvant chemotherapy trials, and HER2 targeted neoadjuvant therapy trials. The trials demonstrated the effectiveness of tamoxifen and radiation therapy in breast cancer prevention and treatment, and showed that hypofractionated radiation regimens and partial breast irradiation are not inferior to standard radiation protocols. Neoadjuvant chemotherapy was found to increase breast-conserving surgery rates and pathologic complete response rates. Dual HER2 blockade neoadjuvant regim
Landmark chemotherapy trials in advanced ovarian cancer established platinum-based combinations as the standard of care. GOG 47 (1986) showed cisplatin improves response rates and progression-free survival compared to cyclophosphamide alone. GOG 111 (1996) found the combination of paclitaxel and cisplatin improved progression-free and overall survival over cyclophosphamide and cisplatin. Subsequent trials determined carboplatin as an effective alternative to cisplatin, with fewer side effects.
This document summarizes several landmark clinical trials in breast cancer treatment. It describes trials that tested chemoprevention drugs like tamoxifen to reduce breast cancer risk. It also summarizes radiation therapy trials comparing lumpectomy alone to lumpectomy with radiation. Further, it summarizes trials comparing breast-conserving surgery and radiation to mastectomy. The document finds that radiation after lumpectomy and mastectomy radiation for node-positive patients improve outcomes.
This document discusses the management of metastatic renal cancer. It notes that approximately 1/3 of newly diagnosed renal cancers are metastatic and 20-40% of localized cancers eventually metastasize. Metastatic renal cancer is usually fatal with 5-year survival rates under 5%. The document outlines treatment approaches including local therapies like cytoreductive nephrectomy and metastasectomy as well as systemic therapies like immunotherapy, targeted therapy and chemotherapy. It provides details on specific immunotherapy agents, targeted therapies including several tyrosine kinase inhibitors, and recommendations on treatment sequencing.
This document discusses prostate cancer and its treatment with radiation therapy. It provides details on:
1) The anatomy of the prostate gland and the cell types that compose normal prostate epithelium.
2) A case presentation of a 72-year-old male with high-risk prostate cancer.
3) Guidelines for risk stratification and treatment recommendations including neoadjuvant androgen deprivation therapy followed by radiation therapy with concurrent and adjuvant androgen deprivation therapy.
This document summarizes the treatment landscape for ovarian cancer. It discusses standard first-line treatment options including platinum-based chemotherapy with carboplatin and paclitaxel, as well as the importance of adequate surgery to remove as much of the tumor as possible. It also reviews several phase 3 clinical trials investigating the addition of angiogenesis inhibitors like bevacizumab to chemotherapy regimens. Trials like ICON7 and GOG 218 found improved progression-free survival when bevacizumab was added to first-line treatment. For recurrent disease, bevacizumab was also found to improve outcomes when added to chemotherapy in platinum-sensitive patients based on studies like OCEANS and GOG-213. Residual
Bladder-Sparing Trimodality Therapy for Muscle-Invasive Bladder CancerBJUI
This document summarizes bladder-sparing trimodality therapy for muscle-invasive bladder cancer. It discusses the evolution of bladder-sparing approaches including maximal transurethral resection of bladder tumor (TURBT), radiation therapy, and chemotherapy. Long-term outcomes from studies at Massachusetts General Hospital show 5-year overall survival of 52% and disease-specific survival of 64% with 29% of patients requiring cystectomy. Factors associated with improved outcomes include lower clinical stage, complete TURBT, and complete response to induction therapy.
This document discusses several landmark trials comparing different treatment approaches for esophageal cancer. The CALGB 9781 trial compared trimodality therapy (chemotherapy, radiation therapy, and surgery) to surgery alone and found improved overall survival and progression-free survival with trimodality therapy. Median overall survival was 4.48 years with trimodality therapy versus 1.79 years with surgery alone. The trial was closed early due to poor accrual, resulting in a small sample size.
This document outlines the EMBRACE II study protocol for evaluating image-guided intensity modulated external beam radiochemotherapy and MRI-based adaptive brachytherapy in locally advanced cervical cancer. The study aims to improve local control and reduce treatment-related morbidity through dose escalation to targets and dose reduction to organs at risk using advanced radiotherapy techniques including IMRT, IGRT, adaptive brachytherapy based on weekly MRI, and chemotherapy. Primary endpoints include local control and late morbidity. Secondary endpoints include disease-free survival, overall survival, patterns of failure, and quality of life. The study involves multiple centers and aims to accrue 500 patients over 5 years to validate hypotheses regarding dose-volume relationships and identify prognostic markers
1. Carcinoma of the cervix is a major cause of cancer deaths in women in India, with HPV infection being the primary risk factor.
2. It typically presents with vaginal bleeding and spreads locally and via lymph nodes to distant sites like lungs and bones.
3. Diagnosis involves cervical smears, biopsies and imaging while FIGO staging classifies the extent of disease.
4. Treatment depends on stage but commonly includes surgery, radiation therapy and chemotherapy with the goal of maximizing cure rates while minimizing treatment related morbidity.
Omission of RT in elderly breast cancer patientsBharti Devnani
This journal club presentation summarized the PRIME II randomized controlled trial which evaluated the efficacy of postoperative whole-breast radiotherapy for women aged 65 years or older with early-stage, hormone receptor-positive breast cancer treated with breast-conserving surgery and adjuvant endocrine therapy. The results showed that radiotherapy achieved a significant but relatively small reduction in local breast recurrence at 5 years compared to no radiotherapy. However, the 5-year rate of recurrence was low enough that omission of radiotherapy could be considered for select low-risk patients based on tumor characteristics and patient preferences. Treatment decisions require individualization based on prognostic factors and risk-benefit assessment.
Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomized, open-label, phase 3 trial
The RAPIDO trial tested a new experimental treatment for locally advanced rectal cancer that involved short-course radiotherapy followed by chemotherapy before surgery, compared to the standard treatment of long-course chemoradiotherapy followed by surgery and then chemotherapy. The results showed that the experimental treatment led to a lower rate of disease-related treatment failures and distant metastases, along with a doubled rate of pathologic complete responses, without increasing toxicities or compromising survival rates. This provides evidence that the experimental approach may be a new standard of care for high-risk locally advanced rectal cancer.
This document discusses radiotherapy planning for vulvar cancer. It begins with an introduction that notes vulvar cancer is rare but usually presents as early stage squamous cell carcinoma in elderly women. It then covers anatomy, lymphatic spread, investigations, staging, indications for radiotherapy, patient positioning and immobilization, target volumes, field arrangements, doses, and toxicities. The target volumes include the vulvar tumor bed, inguinal lymph nodes, and sometimes pelvic lymph nodes. Doses depend on whether radiotherapy is adjuvant or definitive and if there is gross disease or positive margins. Toxicities are a concern especially for organs at risk like the bowels and bladder.
This document discusses the management of early breast cancer. It covers workup including imaging and biopsy to determine tumor characteristics. Treatment options include breast conservation therapy with lumpectomy and radiotherapy or mastectomy with or without radiotherapy, depending on tumor size and other factors. It also discusses surgical management of the axilla including sentinel lymph node biopsy or axillary lymph node dissection. The role of chemotherapy, hormonal therapy and radiotherapy based on tumor biomarkers is summarized.
Bladder preservation for CA Urinary BladderAnil Gupta
This document summarizes the case of a 74-year-old male patient with urinary bladder cancer who underwent bladder preservation treatment. He initially presented with hematuria and imaging found two bladder lesions, one of which was muscle-invasive. He received neoadjuvant chemotherapy followed by radical radiotherapy to the bladder, achieving a good response. Over 2.5 years of follow-up, he has remained with no evidence of disease and an intact, functional bladder. The document then discusses bladder cancer treatment approaches and evidence for bladder preservation with chemoradiotherapy as an alternative to radical cystectomy for select patients.
This document discusses bladder preservation as an alternative to radical cystectomy for muscle-invasive bladder cancer (MIBC). It outlines the trimodality approach of maximal transurethral resection of bladder tumor (TURBT) followed by concurrent chemoradiation. Studies have shown 5-year bladder intact survival rates ranging from 36-66% with this approach. Complete response to induction chemoradiation may allow bladder preservation. Radical cystectomy is associated with significant morbidity while bladder preservation maintains quality of life. Long-term outcomes depend on patient selection and a multidisciplinary approach can maximize organ preservation while achieving high cure rates.
This document provides an overview of vaginal cancer, including:
- The main types are squamous cell carcinoma, melanoma, and sarcoma. Squamous cell carcinoma makes up 80-90% of cases.
- Risk factors include HPV infection, low socioeconomic status, history of genital warts or abnormal Pap smears.
- Vaginal intraepithelial neoplasia (VAIN) is considered a precursor lesion that can progress to invasive cancer.
- Treatment depends on the cancer type and stage. It typically involves radiation therapy alone or combined with surgery and/or chemotherapy. The goal is organ preservation when possible.
This document discusses carcinoma of the cervix, including:
- It affects over 1,25,000 women in India annually. Risk factors include early sexual activity, multiple partners, HPV infection, and low socioeconomic status.
- It is usually squamous cell carcinoma and presents as abnormal bleeding or discharge. Staging involves clinical exams and imaging. Late stages can spread to lymph nodes, lungs, liver and bone.
- Treatment depends on stage but includes surgery, radiation, or chemo-radiation. Surgery is used for early stages while radiation is common for other stages. Five year survival rates range from 85% for stage I to 15% for stage IV.
This document summarizes key landmark clinical trials in breast cancer. It discusses trials related to prevention using tamoxifen and raloxifene, radiation therapy trials for DCIS and early stage breast cancer, breast-conserving therapy including accelerated whole-breast irradiation, neoadjuvant chemotherapy trials, and HER2 targeted neoadjuvant therapy trials. The trials demonstrated the effectiveness of tamoxifen and radiation therapy in breast cancer prevention and treatment, and showed that hypofractionated radiation regimens and partial breast irradiation are not inferior to standard radiation protocols. Neoadjuvant chemotherapy was found to increase breast-conserving surgery rates and pathologic complete response rates. Dual HER2 blockade neoadjuvant regim
Landmark chemotherapy trials in advanced ovarian cancer established platinum-based combinations as the standard of care. GOG 47 (1986) showed cisplatin improves response rates and progression-free survival compared to cyclophosphamide alone. GOG 111 (1996) found the combination of paclitaxel and cisplatin improved progression-free and overall survival over cyclophosphamide and cisplatin. Subsequent trials determined carboplatin as an effective alternative to cisplatin, with fewer side effects.
This document summarizes several landmark clinical trials in breast cancer treatment. It describes trials that tested chemoprevention drugs like tamoxifen to reduce breast cancer risk. It also summarizes radiation therapy trials comparing lumpectomy alone to lumpectomy with radiation. Further, it summarizes trials comparing breast-conserving surgery and radiation to mastectomy. The document finds that radiation after lumpectomy and mastectomy radiation for node-positive patients improve outcomes.
This document discusses the management of metastatic renal cancer. It notes that approximately 1/3 of newly diagnosed renal cancers are metastatic and 20-40% of localized cancers eventually metastasize. Metastatic renal cancer is usually fatal with 5-year survival rates under 5%. The document outlines treatment approaches including local therapies like cytoreductive nephrectomy and metastasectomy as well as systemic therapies like immunotherapy, targeted therapy and chemotherapy. It provides details on specific immunotherapy agents, targeted therapies including several tyrosine kinase inhibitors, and recommendations on treatment sequencing.
This document discusses prostate cancer and its treatment with radiation therapy. It provides details on:
1) The anatomy of the prostate gland and the cell types that compose normal prostate epithelium.
2) A case presentation of a 72-year-old male with high-risk prostate cancer.
3) Guidelines for risk stratification and treatment recommendations including neoadjuvant androgen deprivation therapy followed by radiation therapy with concurrent and adjuvant androgen deprivation therapy.
This document summarizes the treatment landscape for ovarian cancer. It discusses standard first-line treatment options including platinum-based chemotherapy with carboplatin and paclitaxel, as well as the importance of adequate surgery to remove as much of the tumor as possible. It also reviews several phase 3 clinical trials investigating the addition of angiogenesis inhibitors like bevacizumab to chemotherapy regimens. Trials like ICON7 and GOG 218 found improved progression-free survival when bevacizumab was added to first-line treatment. For recurrent disease, bevacizumab was also found to improve outcomes when added to chemotherapy in platinum-sensitive patients based on studies like OCEANS and GOG-213. Residual
Bladder-Sparing Trimodality Therapy for Muscle-Invasive Bladder CancerBJUI
This document summarizes bladder-sparing trimodality therapy for muscle-invasive bladder cancer. It discusses the evolution of bladder-sparing approaches including maximal transurethral resection of bladder tumor (TURBT), radiation therapy, and chemotherapy. Long-term outcomes from studies at Massachusetts General Hospital show 5-year overall survival of 52% and disease-specific survival of 64% with 29% of patients requiring cystectomy. Factors associated with improved outcomes include lower clinical stage, complete TURBT, and complete response to induction therapy.
This document discusses several landmark trials comparing different treatment approaches for esophageal cancer. The CALGB 9781 trial compared trimodality therapy (chemotherapy, radiation therapy, and surgery) to surgery alone and found improved overall survival and progression-free survival with trimodality therapy. Median overall survival was 4.48 years with trimodality therapy versus 1.79 years with surgery alone. The trial was closed early due to poor accrual, resulting in a small sample size.
This document outlines the EMBRACE II study protocol for evaluating image-guided intensity modulated external beam radiochemotherapy and MRI-based adaptive brachytherapy in locally advanced cervical cancer. The study aims to improve local control and reduce treatment-related morbidity through dose escalation to targets and dose reduction to organs at risk using advanced radiotherapy techniques including IMRT, IGRT, adaptive brachytherapy based on weekly MRI, and chemotherapy. Primary endpoints include local control and late morbidity. Secondary endpoints include disease-free survival, overall survival, patterns of failure, and quality of life. The study involves multiple centers and aims to accrue 500 patients over 5 years to validate hypotheses regarding dose-volume relationships and identify prognostic markers
1. Carcinoma of the cervix is a major cause of cancer deaths in women in India, with HPV infection being the primary risk factor.
2. It typically presents with vaginal bleeding and spreads locally and via lymph nodes to distant sites like lungs and bones.
3. Diagnosis involves cervical smears, biopsies and imaging while FIGO staging classifies the extent of disease.
4. Treatment depends on stage but commonly includes surgery, radiation therapy and chemotherapy with the goal of maximizing cure rates while minimizing treatment related morbidity.
Omission of RT in elderly breast cancer patientsBharti Devnani
This journal club presentation summarized the PRIME II randomized controlled trial which evaluated the efficacy of postoperative whole-breast radiotherapy for women aged 65 years or older with early-stage, hormone receptor-positive breast cancer treated with breast-conserving surgery and adjuvant endocrine therapy. The results showed that radiotherapy achieved a significant but relatively small reduction in local breast recurrence at 5 years compared to no radiotherapy. However, the 5-year rate of recurrence was low enough that omission of radiotherapy could be considered for select low-risk patients based on tumor characteristics and patient preferences. Treatment decisions require individualization based on prognostic factors and risk-benefit assessment.
Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomized, open-label, phase 3 trial
The RAPIDO trial tested a new experimental treatment for locally advanced rectal cancer that involved short-course radiotherapy followed by chemotherapy before surgery, compared to the standard treatment of long-course chemoradiotherapy followed by surgery and then chemotherapy. The results showed that the experimental treatment led to a lower rate of disease-related treatment failures and distant metastases, along with a doubled rate of pathologic complete responses, without increasing toxicities or compromising survival rates. This provides evidence that the experimental approach may be a new standard of care for high-risk locally advanced rectal cancer.
This document discusses radiotherapy planning for vulvar cancer. It begins with an introduction that notes vulvar cancer is rare but usually presents as early stage squamous cell carcinoma in elderly women. It then covers anatomy, lymphatic spread, investigations, staging, indications for radiotherapy, patient positioning and immobilization, target volumes, field arrangements, doses, and toxicities. The target volumes include the vulvar tumor bed, inguinal lymph nodes, and sometimes pelvic lymph nodes. Doses depend on whether radiotherapy is adjuvant or definitive and if there is gross disease or positive margins. Toxicities are a concern especially for organs at risk like the bowels and bladder.
This document discusses the management of early breast cancer. It covers workup including imaging and biopsy to determine tumor characteristics. Treatment options include breast conservation therapy with lumpectomy and radiotherapy or mastectomy with or without radiotherapy, depending on tumor size and other factors. It also discusses surgical management of the axilla including sentinel lymph node biopsy or axillary lymph node dissection. The role of chemotherapy, hormonal therapy and radiotherapy based on tumor biomarkers is summarized.
Bladder preservation for CA Urinary BladderAnil Gupta
This document summarizes the case of a 74-year-old male patient with urinary bladder cancer who underwent bladder preservation treatment. He initially presented with hematuria and imaging found two bladder lesions, one of which was muscle-invasive. He received neoadjuvant chemotherapy followed by radical radiotherapy to the bladder, achieving a good response. Over 2.5 years of follow-up, he has remained with no evidence of disease and an intact, functional bladder. The document then discusses bladder cancer treatment approaches and evidence for bladder preservation with chemoradiotherapy as an alternative to radical cystectomy for select patients.
This document discusses bladder preservation as an alternative to radical cystectomy for muscle-invasive bladder cancer (MIBC). It outlines the trimodality approach of maximal transurethral resection of bladder tumor (TURBT) followed by concurrent chemoradiation. Studies have shown 5-year bladder intact survival rates ranging from 36-66% with this approach. Complete response to induction chemoradiation may allow bladder preservation. Radical cystectomy is associated with significant morbidity while bladder preservation maintains quality of life. Long-term outcomes depend on patient selection and a multidisciplinary approach can maximize organ preservation while achieving high cure rates.
This document provides an overview of vaginal cancer, including:
- The main types are squamous cell carcinoma, melanoma, and sarcoma. Squamous cell carcinoma makes up 80-90% of cases.
- Risk factors include HPV infection, low socioeconomic status, history of genital warts or abnormal Pap smears.
- Vaginal intraepithelial neoplasia (VAIN) is considered a precursor lesion that can progress to invasive cancer.
- Treatment depends on the cancer type and stage. It typically involves radiation therapy alone or combined with surgery and/or chemotherapy. The goal is organ preservation when possible.
This document discusses carcinoma of the cervix, including:
- It affects over 1,25,000 women in India annually. Risk factors include early sexual activity, multiple partners, HPV infection, and low socioeconomic status.
- It is usually squamous cell carcinoma and presents as abnormal bleeding or discharge. Staging involves clinical exams and imaging. Late stages can spread to lymph nodes, lungs, liver and bone.
- Treatment depends on stage but includes surgery, radiation, or chemo-radiation. Surgery is used for early stages while radiation is common for other stages. Five year survival rates range from 85% for stage I to 15% for stage IV.
1. Carcinoma of the cervix is a common cancer in India, with over 125,000 new cases reported annually. Risk factors include early sexual activity, multiple partners, HPV infection, and low socioeconomic status.
2. Staging of cervical cancer involves clinical examination and investigations to determine if the cancer is localized only to the cervix or has spread further. Treatment depends on the stage, with surgery an option for early stages and radiotherapy preferred for more advanced cases.
3. Radiotherapy techniques include brachytherapy, which places radioactive sources near the tumor, and external beam radiotherapy. Combined chemo-radiation is now commonly used. Treatment aims to control the tumor while limiting damage to nearby
1. Carcinoma of the cervix is a common cancer in India, with over 125,000 new cases reported annually. Risk factors include early sexual activity, multiple partners, HPV infection, and low socioeconomic status.
2. Staging of cervical cancer involves clinical examination and investigations to determine if the cancer is localized only to the cervix or has spread further. Treatment depends on the stage, with surgery an option for early stages and radiotherapy preferred for more advanced cases.
3. Combined chemo-radiation using cisplatin has improved survival rates compared to radiotherapy alone. However, both radiotherapy and surgery carry risks of complications due to damage to surrounding organs. Five-year survival rates range from 85
1. Cervical cancer is the second most common cancer in women in Pakistan and is caused by HPV infection.
2. Diagnosis is usually made after abnormal bleeding or screening identifies pre-cancerous lesions. Staging involves examination under anesthesia and imaging of the pelvis and chest.
3. Treatment depends on stage but commonly includes radical hysterectomy for stage 1B and radiotherapy with or without chemotherapy for stages 2-4. Surgery and radiotherapy aim to remove the tumor while minimizing harm to surrounding organs.
This document discusses vulvar cancer, including its incidence, types, anatomy, etiology, clinical features, diagnosis, staging, treatment, prognosis, and complications. Some key points include:
- Vulvar cancer accounts for 0.6% of all malignancies and 4% of genital malignancies, with squamous cell carcinoma making up 90% of cases.
- Lymph node status is the single most important prognostic marker, with 5-year survival rates of 90% for node-negative patients and 50% for node-positive patients.
- Risk factors include HPV, VIN, smoking, immunosuppression, and history of other cancers.
- Diagnosis involves biopsy of any suspicious vulvar lesions.
This document discusses vulvar cancer, including its incidence, types, anatomy, etiology, clinical features, diagnosis, staging, treatment, prognosis, and complications. Some key points include:
- Vulvar cancer accounts for 0.6% of all malignancies and 4% of genital malignancies, with squamous cell carcinoma making up 90% of cases.
- Lymph node status is the single most important prognostic marker, with 5-year survival rates of 90% for node-negative patients and 50% for node-positive patients.
- Risk factors include HPV, VIN, smoking, immunosuppression, and history of other cancers.
- Diagnosis involves biopsy of any suspicious vulvar lesions.
1. Surgical staging and treatment of vulvar cancer depends on tumor size and extent of disease. Early stage disease is treated with local excision while more advanced stages require radical vulvectomy and lymph node dissection.
2. Lymph node involvement is the most important prognostic factor, with 5-year survival rates ranging from 83-100% for node-negative disease to 38-61% for node-positive disease.
3. Adjuvant radiation therapy may be recommended for high-risk pathologic features like large tumor size, positive margins, or lymphovascular space invasion. Radiation to lymph node regions reduces groin recurrence rates.
Here are brief answers to your questions:
- A Pap smear involves gently scraping cells from the cervix and vagina and examining them under a microscope to check for abnormal cells.
- Liquid-based cytology (LBC) uses a brush to collect cells which are then placed in a vial of preservative fluid, rather than smeared onto a slide. This allows for automated processing and may provide a more representative sample than conventional smears.
- Oncogenic ("high-risk") HPV strains associated with cervical cancer include types 16, 18, 31, 33 and 45. These are more likely to cause abnormal cell changes and progression to cancer if persistent.
- Metaplasia is a reversible
Seminoma testis is a relatively rare but common germ cell tumor in young men. It typically presents as a painless testicular swelling. Staging involves tumor markers, imaging and pathology. Stage I seminoma can be managed with surveillance, adjuvant chemotherapy or radiotherapy. Carboplatin is as effective as radiotherapy for stage I. For stage II, radiotherapy to retroperitoneum is standard but chemotherapy is also effective. Seminoma is highly curable with long term survival over 90% even with advanced stages. Careful follow up is needed long term.
Uterine cancer is one of the most common female reproductive cancers. It occurs in the endometrial lining of the uterus. The main risk factors are prolonged, unopposed estrogen exposure from conditions like obesity, diabetes, nulliparity, or prolonged estrogen therapy without progesterone. Endometrial hyperplasia, which is often estrogen-dependent, can progress to cancer if left untreated. Uterine cancers are surgically staged and treated depending on the stage, with surgery being the main treatment for early stage disease and chemoradiation often added for more advanced stages. Prognosis depends on stage, grade, and histological subtype.
Cervical cancer is the second most common cancer in women globally. It is caused by persistent infection with human papillomavirus (HPV), with types 16 and 18 causing over 70% of cases. Screening through cervical smears has significantly reduced cervical cancer rates in developed nations. Treatment depends on the stage of cancer, ranging from conization for early stage IA1 to chemoradiation for later stages. Prognosis is best for early stage disease, with 5-year survival rates over 90% for stage IA tumors.
This document provides an overview of endometrial carcinoma, including its epidemiology, risk and protective factors, classification, clinical presentation, diagnosis, staging, treatment, prognosis, and prevention. Endometrial carcinoma is the most common gynecological cancer and occurs most often in postmenopausal women. Risk factors include older age, early menarche, late menopause, nulliparity, obesity, and unopposed estrogen exposure. Treatment involves surgery, with additional chemotherapy, radiation, or hormonal therapy depending on the stage and grade of cancer. Prognosis depends on histologic grade and stage, with 5-year survival rates ranging from 83% for stage I to 27% for stage IV disease.
This document discusses cancer of the vulva, including its incidence, risk factors, types, diagnosis, staging, prognosis, and management. Some key points:
- Vulvar cancer accounts for 1-4% of gynecological cancers and predominantly affects postmenopausal women. Risk factors include HPV infection, smoking, and history of other gynecological cancers.
- Squamous cell carcinoma makes up 90% of cases. Diagnosis requires biopsy of any suspicious lesions. Staging is based on tumor size and spread to lymph nodes or distant sites.
- Prognosis depends on lymph node involvement, with 5-year survival rates over 90% for stage I but under 50% if nodes are
The document provides information on cervical cancer including:
1. Statistics on global cancer incidence and mortality with cervical cancer among the most common cancers.
2. Risk factors for cervical cancer including human papillomavirus infection, young age of first intercourse, multiple sexual partners, and smoking.
3. Screening guidelines recommend co-testing with cytology and HPV testing every 5 years for women aged 30-65 or cytology alone every 3 years.
This document provides an overview of substernal goiters, which are enlarged thyroid glands that extend below the sternum. It defines substernal goiters and classifies them based on the percentage of the mass in the neck or chest. The document discusses the pathogenesis, clinical presentation, investigations including imaging studies, and management including thyroid suppression, radioiodine therapy, and surgical approaches. Surgery remains the primary treatment and can involve cervical, partial sternotomy, thoracotomy, or combined approaches depending on the extent of the mediastinal extension. Postoperative monitoring and potential complications are also outlined.
The document discusses salivary gland tumors, focusing on anatomy, epidemiology, pathology, staging, and treatment of tumors in the parotid, submandibular, and sublingual glands. It provides details on the borders and drainage patterns of the major salivary glands. The most common tumor of the parotid gland is pleomorphic adenoma, which is usually benign. Adenoid cystic carcinoma is an important malignant tumor that commonly spreads along nerves. Post-operative radiation is recommended for certain high risk features to improve local control.
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4. Epidemiology
• Rare malignancy
• 1-2% of all gynecological malignancies
• Diagnosis of exclusion
• Peak incidence- 6th and 7th decade
• Mean age- 65.7± 14.3 years
6. Vaginal intraepithelial neoplasia
• Incidence- 0.2-0.3 cases per 1 lac population
• Peak incidence 40-60 years
• VAIN-1 and 2- common in younger age group than VAIN-3
Risk factors-
• Low sociocultural level
• H/O genital warts
• Prior history of hysterectomy
at any age
• H/O CIN
• Immunosuppression
• Smoking
• Exposure to DES
• H/O STDs or HPV infection
• Prior pelvic irradiation
(controversial)
7. Natural history of VAIN
Risk of invasive carcinoma increases with VAIN:-
• 4.5% had VAIN-1, progressed to stage I cancer in 5 years
• 4.5% had VAIN- 3, progressed to stage I cancer in 4 years
• Overall spontaneous regression rate- 78%, of which 78%
occurring in VAIN-1 and 2
Clinical presentation :-
Usually asymptomatic
Detected after cytologic evaluation in routine surveillance
Surveillance cytology recommended post hysterectomy
8. VAIN pathology
• Definition- squamous cell atypia without evidence of invasion
• Classified according to depth of invasion-
Superficial 1/3rd –VAIN-1
Superficial 2/3rd – VAIN-2
> 2/3rd – VAIN-3
CIS- encompasses full epithelial thickness - included in VAIN-3
• Most lesions are epidermoid;
• Superior 1/3rd vagina- most commonly involved
• Exhibit full thickness alterations with atypical mitoses
• Mostly multifocal
• Associated with HPV infection (92.6-100% cases)
HPV 16 or 18 – 9%, 7% and 67% of VAIN- 1, 2 and 3 respectively
9. VAIN- treatment options
• No consensus guideline available
• Treatment approaches are-
• Local excision
• Partial or total vaginectomy (52-100% success rate)
• Laser vaporization (48-100% success rate)
• Electrocoagulation
• Topical 5-FU (75-100% success rate)
• Radiotherapy (83-100% success rate)
Most patients with VAIN-1 close surveillance
10. Surgical and ablative therapies
• Surgical approaches include:-
Local excision
Partial vaginectomy- vaginal vault
- post hysterectomy recesses
Total vaginectomy- rarely done (for highly extensive disease)
• Mostly performed via transvaginal approach
• Local therapy-
Cold knife approach
Electrosurgical loop excision
Laser
Ultrasonic surgical aspiration
CO2 laser
13. Radiation therapy
•Control rate- 80-100%
•Techniques- LDR/ MDR/ HDR
•Reserved for patients –
Relapse after more conservative treatment
•Drawbacks-
Under-treatment of occult invasive disease
Risk of 2nd malignancy- no data available
Long term morbidity
16. Risk factors
• HPV infection (80% with in situ disease and 60% with invasive disease)
• H/O CIN (10-50% cases develop disease after approx.14 years)
• Vulvar intraepithelial neoplasia
• Immunosuppression
• Early onset of intercourse
• Increased number of lifetime sexual partners
• Smoking
• Low socioeconomic status
• H/O genital warts
• Vaginal discharge/ irritation
• H/O abnormal cytology
• H/O prior irradiation- controversial
Prior hysterectomy
Use of vaginal pessary
Vaginal trauma
Alcoholism
17. Clinical presentation
• Irregular vaginal bleed (65% cases)- primary symptom
• Vaginal discharge (10-15% cases)- 2nd most common
symptom
• Presence of a mass
• Pain
• Urinary symptoms (Frequency/ Dysuria/ Hematuria)
• GI complaints (Tenesmus/ Constipation/ Malaena)
18. Clinical presentation Contd…
• Nodular/ ulcerated/ indurated/ exophytic/ endophytic lesion
• Well/ moderate/ poorly differentiated
• Keratinizing/ non-keratinizing/ basaloid/ warty/ verrucous
• Most common site- upper 1/3rd of vagina (50-83% cases)
• Middle and lower third equally involved or lower third > middle
third
• Posterior vaginal wall involvement ≥ anterior wall
• Verrucous carcinoma-
Histological variant
Well circumscribed, soft, cauliflower like mass
Well differentiated
Papillary growth pattern
Acanthotic epithelium
Less aggressive behavior
Rarely metastasizes
19. Clinical presentation
• Spreads along vaginal wall involves cervix/ vulva,
• Spreads radially
1. Into the lumen exophytic mass
2. Through the vaginal wall invades surrounding structures
• Anterior wall lesion vesicovaginal septum/ urethra
• Posterior wall lesion rectovaginal septum rectal mucosa
• Lateral extension parametrium and paracolpol tissue
Urogenital diaphragm, levator ani muscle or pelvic fascia
Pelvic side wall
20. Lymphatic spread
• Risk of nodal involvement-
Increases with stage
20% have clinically positive inguinal nodes at the time of diagnosis
Nodal failure- most common form of local recurrence
•Stage I- 0-14%
•Stage II- 21-32%
•Stage III- 78%
•Stage IV- 83%
21. Distant spread/ hematogenous spread
• Most common site- lung > liver and bone
• Stage wise incidence-
•Stage I- 16%
•Stage II- 31%
•Stage IIB- 46%
•Stage III- 62%
•Stage IV- 50%
22. Initial evaluation
• Complete history and thorough physical examination
• CBC, LFT and KFT
• EUA for complete assessment of tumor extent and vaginal walls
• Bimanual examination
• Biopsy of suspected lesion
• Colposcopy with acetic acid followed by lugol’s iodine- may be done
• Biopsy from cervix- to rule out cervical primary
23. Initial evaluation Contd…
Imaging
Chest x-ray
Cystoscopy and proctosigmoidoscopy- if indicated
CT scan- for local disease, lymphadenopathy and renal
parenchyma
CEMRI (superior to CT)
- Delineation of primary
- LN assessment
- 80% sensitive, 88% specific
USG guided FNAC of suspicious LNs
Whole body PET CT scan- 67% sensitive, 95% specific
26. Prognostic factors
• Stage at the time of presentation- most important factor
• 5 year survival rate (NCDB and Shah et al)
• Lymph node involvement
• Size of initial lesion
5 year survival rate- (SEER database study and Tran et al)
•Stage 0- 96%
•Stage I- 73%
•Stage II- 58%
•Stage III and IV- 36%
•Size ≥ 4 cm- 65%
•Size < 4cm- 84%
27. Prognostic factors Contd…
• Tumor involving ≥ 2/3rd of vagina
• Tumor with circumferential growth
• Location of the lesion-
5 year survival rate- 60% -upper 1/3rd of vagina
- 37.5%- middle 1/3rd of vagina
- 37%- lower 1/3rd of vagina
Lesions of posterior vaginal wall- 10 year recurrence rate- 32% (vs.19% in
anterior wall)
• Histologic grade
• Age
• HPV- favorable in stage III onwards
30. Surgery
• Indications-
Early stage lesions
Previously irradiated patients
• WLE-
Carcinoma in situ
Small, superficially invasive, well demarcated lesions
• Radical hysterectomy, upper vaginectomy and bilateral pelvic
lymphadenectomy-
Extensive lesion in proximal vaginal canal if positive margin,
then adjuvant radiation
31. Surgery Contd…
Lesions extending to inferior vagina
Total vaginectomy with radical hysterectomy, pelvic lymphadenectomy ±
vulvovaginectomy and inguinofemoral lymphadenectomy
Vagina is in close proximity with rectum and urethra
Early involvement of these structures
Pelvic exenteration in 40-50% cases to obtain negative margins
•Anterior exenteration
For invasive anterior wall lesions
Removes-
1. Vagina
2. Urethra
3. Bladder
•Posterior exenteration
For invasive posterior wall lesions
Removes-
1. Vagina
2. Rectum
•Complete exenteration-
For deeply invasive,
circumferential lesions
•Radiotherapy is the treatment of choice
32. Surgery Contd…
• Select stage I disease-
Surgery may have excellent result
5 year survival rate- 56-100%
• Neoadjuvant chemotherapy followed by surgery-
Benedetti et al [5] -
1. 11 patients with stage II SCC vagina
2. 3 cycles of NACT (Paclitaxel+ Cisplatin)
3. 91% had pCR or CR, out of which 27% had CR
4. 100% had clear margin post surgery
5. 1 patient had positive LN
6. Median follow up time- 75 months
34. Stage I
• Stage I lesions- 0.5-1 cm in thickness
• Individualised management based on-
Size
Depth
Location
• May be treated with brachytherapy alone
• Local control rate- 67-100%
• Perez et al –
Stage I patients, treated with brachytherapy alone
Dose- 60-70 Gy, prescribed 5 mm beyond the plane of implant or
vaginal mucosa
Vaginal surface dose- 80-120 Gy
88% pelvic tumor control
Frank et al & Dancuart et al
Result- Pelvic relapse rate of
18% at 10 years in patients
treated with brachytherapy
alone
35. • Entire length of the vagina is treated to a mucosal dose of 60 to 65 Gy
• Additional mucosal dose of 20 to 30 Gy delivered to the area of tumor involvement
• LDR brachytherapy-
Treatment can be delivered in two applications
1st to treat the entire vaginal wall
2nd application to cover the tumor volume
Delivered with a shielded vaginal cylinder to treat the tumor with a 2-cm margin
• HDR brachytherapy-
To treat superficial lesions
Vaginal mucosa - dose of 21 to 25 Gy, prescribed to a depth of 5 mm, in weekly #s of
5 to 7 Gy each
Additional 21 to 25 Gy delivered to the tumor , prescribed to a depth of 5 mm, via
shielded vaginal cylinder, with weekly #s of 5 to 7 Gy
Total dose - 42 to 50 Gy
36. When the lesion is thicker than 5 mm!
• Combination of intracavitary and interstitial brachytherapy
• Vaginal cylinder delivers 45 Gy (LDR) or 21 to 25 Gy (HDR) to a
depth of 5 mm into the vaginal mucosa
• Subsequent therapy - via interstitial implant, to deliver an additional
dose of 25 to 35 Gy (LDR) to the tumor volume
For more extensive stage I lesions, with
greater infiltration or poor differentiation
Combination of EBRT and brachytherapy is used
37. Stage II - Radiotherapy
Primary treatment
• EBRT + Brachytherapy
36% pelvic tumor control with brachytherapy alone
67% with EBRT + brachytherapy
• Dose- 45-50.4 Gy, 1.8 Gy/ #, with parametrial boost if-
Extensive primary infiltration
High suspicion of nodal disease
For lesions involving distal vaginal canal-
Inguinal LN are included in whole pelvic field
• Tumor volume should receive 75-80 Gy combining EBRT +
brachytherapy dosages
39. • Minimum tumor dose- 75-80 Gy
• If extensive tumor infiltration
• Involvement of rectovaginal septum/ bladder
• Overall cure rate-
Stage III- 30-50%
Stage IV- worse prognosis
• 5 year actuarial survival rate-
Stage III- 25-58% and local failure rate- 30-75%
Stage IV- 0-40%
Shrinking field
technique/
IMRT is used
40. Role of chemotherapy and radiation
• No randomised controlled trials available comparing RT alone with
CTRT
• Cisplatin is used by extrapolating data of improved PFS and OS in
cervical carcinoma
• 5-FU and Mitomycin C- also used, but results were inferior
• Frank et al - retrospective series at MDACC
9 patients with stage II- IVA
RT alone and RT+ concurrent cisplatin chemotherapy
Median follow up time- 129 months
44% treated with CTRT were free of disease
42. External beam radiotherapy
• Radio opaque marker- used to delineate distal tumor margin
• CT simulation for contouring of vessels for LN localization
• Frog leg position- for inguinal LN treatment
• CECT preferred over NCCT for planning purpose
• Fusion of pelvic MRI or PET CT with planning CT, if available
43. 2 D treatment planning
• Opposed anterior and posterior fields (AP/PA)- most commonly used
• 4 field technique with small bowel blocks in lateral fields
• Avoid shielding of presacral, perirectal and anterior external iliac LNs
while shielding small bowel
• Target volume must cover-
Vagina
Common iliac nodes
External iliac nodes
Obturator nodes
44. 2 D treatment planning Contd…
• Borders-
Superior border- L5-S1 interspace (covering the retroperitoneal nodes)
- or 1-2 cm superior to inferior margin of SI joint
- If positive pelvic LN, then L4-5 interspace or higher
to include common iliac nodes
Inferior border- introitus or 4 cm distal to vaginal tumor
Lateral border- 1.5-2 cm lateral to pelvic brim
Lateral fields-
Anterior border- pubic symphysis
Posterior border- S2-3 interspace
•Mostly failures occur in vagina, paracolpos and parametria
•Regional nodes must be negative on imaging
45. How to minimize dose to femoral heads
while 2 D planning
• Electron boost to inguinal nodes
• Unequally weighted AP/ PA beams (2:1)
• Low and high energy photons
• Wide AP and narrow PA fields with boost to inguinal nodes
46. 3 D conformal radiotherapy
• GTV- gross disease+ palpable LN+ suspicious LN on imaging
• CTV-
GTV with 1-2 cm margin
Entire length of vagina
Paravaginal tissue up to pelvic side wall
Bilateral pelvic LNs
• Pelvic nodal CTV-
1-2 cm margin around blood vessel
Common iliac LN
External iliac LN
Internal iliac LN
For distal vaginal involvement- inguinal LN are included
Inferior border- ischial tuberosity or lesser trochanter
Obturator LN
Perirectal LN
Presacral LN
47. 3 D conformal radiotherapy
• PTV- CTV+ 1 cm
• Dose- 45-50.4 Gy/ 1.8 Gy per fraction ± Parametrial boost 50-65 Gy
• Elective nodal irradiation of inguinal nodes- 45-50 Gy
• Gross nodal disease- 60-65 Gy
• After EBRT, tumor of vaginal apex > 0.5 cm depth-
Interstitial brachytherapy/ EBRT boost
• Tumor < 0.5 cm depth-
Intracavitary brachytherapy
• Tumors of mid vagina or distal vagina-
Interstitial brachytherapy/ EBRT boost
• Anterior/ lateral tumors of mid vagina-
Interstitial brachytherapy
48. IMRT
• Must be done cautiously
Constant normal tissue changes
Rapid response with RT
Vaginal volume should be contoured with both bladder full and empty
Rectal filling must be taken care of
Dose constraints (RTOG trial 0921)
No > 30% of entire small and large bowel should receive > 40 Gy
D2cc- maximum 55Gy
At least 35% of bladder volume must receive ≤ 45 Gy with D2cc 90Gy
At least 60% of rectosigmoid junction must receive ≤ 40 Gy with D2cc 70-
75 Gy maximum
At least 15% of femoral head must receive ≤ 35Gy
Plans must be optimized to minimize volume of PTV receiving > 110% of
prescribed dose
49. Brachytherapy
• Indications-
Superficial disease ≤ 5 mm in thickness intracavitary
Thickness > 5mm interstitial brachytherapy
• Intracavitary brachytherapy as monotherapy-
VAIN
Highly selected stage I patients with minimally invasive disease
• Used after EBRT as boost with small lesions < 5 mm thick
• Cumulative dose- 70-75 Gy
50. LDR intracavitary brachytherapy
• Most commonly performed with vaginal cylinder of Cs-137
• 2-3 Cesium sources are placed along the central tandem
• Most appropriate when thickness ≤ 5 mm, due to rapid fall of dose
• Labia are sutured close, to secure the implant in place
51. HDR intracavitary brachytherapy
• Iridium-192 is used
• Dose- 3-8 Gy per session for 1-6 sessions
• Mock et al –
Largest series of HDR brachytherapy, at Vienna
86 patients with stage 0-II
Intracavitary HDR brachytherapy alone
Dose per fraction- 5-8 Gy, mean dose 7 Gy, 2-6 sessions (median-5)
5 year recurrence free survival- 100%, 77% and 50% for stage 0, I and II
52. Interstitial brachytherapy
• Indications-
1. Paravaginal extension
2. Lesion thickness > 5 mm
3. Distal vaginal extension
4. Vagina unable to accommodate standard intracavitary applicators
Dose-
With gross residual disease- 70-90 Gy, with 60 Gy prescribed to entire
vaginal surface
57. Epidemiology
• <1% of all cancers diagnosed in women
• 3-4% of all gynecologic malignancy
• Incidence increases with age
• Median age 68 years
• Constitutes 0.4% new cancer cases in USA
• Estimated number of cases in 2018 in USA- 6190 with
1200 (0.2%) deaths due to vulvar Ca
58. Cancer vulva- facts
• Vulvar cancer has two peaks in age incidence
• Younger vulvar cancer patients-
1.More commonly smoke
2.Higher incidence of HPV infection
3.Associated with vulvar intraepithelial neoplasia (VIN)
• In elderly patients
1.HPV infection is less likely
2.Concurrent VIN less common
3.Background of lichen sclerosus is common
• Only 4% of patients with lichen sclerosus will develop clinically
apparent neoplasia
60. Clinical features
•Vaginal pruritus- most common
•Vulvar lesion-
•Bleeding
•Pain
•Discharge
•Dysuria
•Rectal bleeding
•Enlarged groin lymph node
•Lower extremity edema
•Unifocal vulvar plaque
•Ulcer
•Mass
•Multifocal in 5% cases
61. Primary sites
•70% - labia majora and minora
•15% - clitoris
•5% perineum and fourchette
prepuce, Bartholin’s glands and urethra
•5% - too extensive at presentation to classify
63. Lymphatic spread
•Most commonly seen in-
•Superficial inguinofemoral LN→ deep inguinofemoral nodes
•Contralateral LN involvement is unusual for well lateralized
disease
•Lesions of the clitoris or urethra can spread directly to pelvic
lymph nodes
•High grade tumors
•Spray growth pattern
•Lymphatic space invasion
64. Factors affecting LN involvement
• Tumor thickness
• Histologic grade
• Capillary like space involvement
• Depth of invasion
• Location of tumor
• Extension to other sites (also worsens the prognosis)
• Tumor size
• Clinical stage
• Positive inguinal nodes
• Positive margin at primary site
• PNI
•When ≤1 mm, LN involvement is ≤5%
•When it is ≥5mm, LN involvement increases to 33.3%
- Rowley et al, Gynecol Oncol, 1988
•Depth of invasion of 1,2 and 3 mm corresponds to
4.3, 7.8 and 17% incidence of LN involvement
- Rowley et al, Gynecol Oncol, 1988
65. Distant metastases/ hematogenous
• Typically occurs late in the course of disease
• Rare without inguinofemoral LN involvement
• Portends a very poor outlook
• Most common site- lungs > liver > bones
*
*Hacker NF, Berek JS, Lagasse LD, et al. Management of regional lymph nodes
and their prognostic influence in vulvar cancer. Obstet Gynecol 1983; 61:408.
No. of positive LNs Risk of hematogenous spread
≤3 4%
>3 66%
66. Prognostic factors
• Lymph node metastasis
• Tumor size
• LVI
•Most important prognostic factor
•Presence of inguinal LN ≈ 50% reduction in long term survival
67. Initial evaluation
• Complete history and thorough physical examination
• CBC, LFT and KFT
• EUA, (cystoscopy and proctoscopy- if indicated)
• Imaging
May not be necessary in early lesions
CT scan- for lymphadenopathy
CEMRI
- Delineation of primary
- LN assessment
- 80% sensitive, 88% specific
USG guided FNAC of suspicious LNs
Whole body PET CT scan- 67% sensitive, 95% specific
71. Challenges in the management
•Patients - older & have comorbidities
•Tumor easily involve adjacent organs
• The treatment can have major psychosexual impact
on patients
73. Outline of management
Early invasive disease
• Surgery
• Radiation therapy
Advanced disease
• Multimodality approach
• CTRT as
Neoadjuvant or
Post operative adjuvant
74. Radiation therapy in early invasive disease
• Radiation to the tumor bed to prevent local recurrence
• Pathologic features associated with higher risk of LR
Lymphatic-vascular invasion (LVI)
Depth of invasion >5 mm
Margins <8 mm
Microscopically positive margins
• Patients with
Extracapsular extension (ECE) of tumor in the nodes
Residual disease in the inguinal areas
• Postoperative radiation should be given to-
Pelvis
Groins
Primary tumor bed area
75. GOG trial
• Patients underwent bilateral inguinal lymphadenectomy
• Inclusion criteria- positive groin nodes
• Arms- pelvic lymphadenectomy or radiation to the pelvis and bilateral groins
• Findings-
Radiation arm
Pelvic
lymphadenectomy
arm
Groin recurrence
rate
5.1% 23.6%
2 year survival
benefit
(p value= 0.03)
68% 54%
Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy versus pelvic node resection for
carcinoma of the vulva with positive groin nodes. Obstet Gynecol 1986;68:733–740
79. Wide local excision
• Also known as-
Radical local excision or radical wide excision or
modified radical vulvectomy
Disease should not involve-
Anus
Vagina
Urethra
Depth of excision- deep perineal fascia
2 cm clear margin (at least 1cm)
If clitoris is involved or abutted, cannot be preserved
80. Inguinofemoral lymph node dissection
• Must be done cautiously
• Complications-
Wound breakdown
Lower extremity lymphoedema
• Indications-
Tumor size >2 cm
Depth of invasion- >1mm
Midline or clitoral lesion
Palpable inguinal lymph nodes
81. • Small (<2cm), lateralized lesions may be treated by u/l groin
dissection
• For midline and clitoral lesions & for those >2cm b/l groins
should be assessed
• For patients undergoing primary surgery, palpable inguinal
nodes should be removed
• Assessment of groin nodes can be done via full superficial
inguinal dissection or sentinel lymph node procedure
82. Pelvic lymph node
Clinically or pathologically positive groin nodes
Increased risk of contralateral groin and pelvic LN involvement
• GOG trial[1]
Pelvic node dissection vs. pelvic node radiation
Similar result in terms of control
Result- RT to the pelvic node is preferred over surgery
Reason- women in need of treatment to pelvis, also require RT to
primary and/ or inguinal nodes
1. Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy versus pelvic node resection
for carcinoma of the vulva with positive groin nodes. Obstet Gynecol 1986;68:733–740.
85. Treatment volume
• Target volume- vulva+ both groins+ lower pelvic nodes
• Use of midline block should be avoided- may increase the chance for local
recurrence
• Factors associated with increase in chances of vulvoperineal recurrence are-
Close or positive margin (<8 mm)
Primary tumor size > 4 cm
LVSI
Deep invasion (> 9 mm)
Tumor thickness >1 cm
Infiltrative growth pattern/ spray pattern
> 25% keratin in the tumor
High mitotic rate >10/10 hpf
86. Treatment field
• Superior border- middle of SI joint to
cover external and internal iliac nodes
• If external and internal iliac nodes are
positive – superior border extended to
L3/4 interspace to cover common iliac
nodes
• Inferior border- should cover entire
vulva and most superficial, inferior
inguinal nodes
• Lateral border- 2 cm lateral to the widest
point of pelvic inlet Position- Frog leg
87. • To reduce dose to femoral head while using AP field-
Narrow posterior field covering only the pelvis and sparing femoral
heads
Inguinal dose is supplemented with electron field matched with pelvic
field
• Bolus- to ensure adequate dose to superficial portion of groins
• 2nd method- wide AP field with narrow PA field, with partial
transmission block placed in central portion of AP field
• 3rd method- AP/PA field to include primary and pelvic nodes
- Groin with separate anterior electron fields
88.
89.
90. IMRT technique
• GTV- gross tumor/ post op tumor bed
• CTV- 1 cm margin around GTV
- 1-2 cm margin around B/l external iliac, internal iliac and inguinofemoral LNs for
pelvic nodal CTV
• PTV- 1 cm margin around CTV
• Dose- 43-48 Gy in pre op setting, 45-50.4 Gy for post op cases and 59.4-64.8 Gy for
unresectable disease,1.8 Gy/ fraction
• Post operative RT should be started within 6-8 weeks
• Large nodes may be boosted to a total dose of 70 Gy
91. Preoperative radiotherapy with
concurrent chemotherapy
• Dose- 45-55 Gy
• Chemotherapy regimen- 5-FU, Cisplatin and Mitomycin-C
CTRT
CR
Inguinal LN
dissection is
must
93. Post operative radiotherapy
• Indications-
Limited surgery (for organ preservation)
Positive or close margin (<8 mm)
LVI
Depth of tumor invasion > 5mm
> 1 involved inguinal node
ECE
Gross residual nodal disease
• In positive or close margin, re-resection prior to RT can be done
• Field- same as earlier (AP/PA)
• Dose- 50 Gy (50-60 Gy if ECE present and 65-70 Gy for R2 resection)
94. Brachytherapy
• Radical ISBT-
Stage IA
• Boost ISBT (after EBRT)-
Stage IB, II and III
• Salvage ISBT-
Recurrent vulva (small size)
Indications
95. Brachytherapy Contd…
• Dose- 3-4 Gy times 4-6 sessions, 2 sessions per day,
prescribed at 3-4 mm from applicator surface, or
• 7-10 Gy, 3 sessions, once weekly, dose prescribed at 3-4 mm
at surface
96. Chemotherapy
• Chemotherapy alone is reserved for patients-
Advanced disease
Inoperable disease
Metastatic disease
Recurrent disease
• Evidence in support not available
• Associated with higher toxicity and poor response
• Biologic agents
EGFR inhibitors- (Erlotinib)
97. •Paclitaxel and Erlotinib- single agents showing
activity against advanced vulvar cancer in phase II
studies (only case reports are available)
•Combination chemotherapy regimens- Cisplatin and
5-FU
99. Toxicities (post surgery)
• Lymphoedema (69%*)
• Wound infection (20-40%) and hematoma
• Seroma
• Hemorrhage
• DVT
• Pulmonary embolism
• Osteitis pubis
• Femoral nerve injury- loss of sensory perception in anterior aspect of thigh
Chronic cellulitis of inguinal areas
Stenosis of introitus
Femoral hernia
Rectovaginal and rectoperineal fistula
100. Toxicities (post RT or CTRT)
• Mucocutaneous reaction in vulva, perineum or inguinal folds
• Acute hematologic toxicity- (common after chemotherapy)
• Telangiectasias
• Atrophy of skin and mucosa of vulva
• Dryness of mucosa of vagina and vulva
• Narrowing of vaginal introitus
• Avascular necrosis of femoral head (very rare)
Psychosexual morbidity
Mons pubis consist of prominent tissue located anteriorly to pubic symphysis
Labia majora are 2 elongated skin folds that course posteriorly from mons pubis and blend into perineal body….skin of majora is pigmented and contain hair follicles and sebaceous glands
Minora- small pair of skin folds located btw majora…skin of minora contain only sebaceous glands and no hair follicles
Clitoris is 2 to 3cm ant to urethral meatus and is supported externally by fusion of labia minora
There are numerous vestibular glands located in vulva
Bartholins gland also k/a greater vestibular gland are 2 small mucous secreting glands located in post aspect of majora
Skenes gland or paraurethral gland open in ant aspect of introitus
Perineal body is 3 to 4cm band os skin that separated vaginal introitus from anus and form post margin of vulva with fusion of labia minora
Inguinofemoral nodes are located in the triangle. There are superficial inguinal nodes that are located along saphenous vein.
3 to 5 deep nodes….the most superior of which is located under inguinal ligament and is k/a cloquet node.
From these inti external and common iliac nodes
Lymphatic drainage is specific to location of vulvar lesion…..Labial lesions, lesions of fouchette and perineum drain into superficial inguinal nodes and femoral nodes and then penetrate cribriform fascia and reach deep femoral nodes
Lymphatic from clitoris and perineal body enter u/l or b/l into superficial/deep femoral nodes and pelvic nodes
Keratinizing and basaloid squamous carcinoma, old age, vulvar dystrophy, HPV and VIN negative
BSC- othera nogenital ca
Confluent, compact or spray or finger like
Spray-trabecular appearance with small island of poorly diff tumor cellls
Gog trial in 1986
Excision of 2cm margins of grossly normal appearing tissue is recoomended when possible with the goal of obtaining atleast 1cm microscopic margins
For pts with advanced ds preop ctrt is used. After CTRT response of therapy is assessed at primary site and lymph nodes.