The document discusses the role of radiotherapy in gynecological cancers. It provides details about Dr. Puneet Seth, a radiation oncologist with over 15 years of experience. It then discusses the various gynecological cancer types and how radiotherapy is used as an important treatment modality either alone or in combination with surgery and chemotherapy. The document outlines the radiotherapy techniques available for gynecological cancers including 3D conformal radiotherapy, IMRT, IGRT and brachytherapy. It highlights the improvements in radiotherapy over time that have led to better tumor control and reduced side effects.

1. ROLE OF RADIOTHERAPY IN
GYNECOLOGICAL CANCER
DR. PUNEET SETH
SR. CONSULTANT, MITTAL BHILAI HOSPITAL,
MIMS, BHILAI, DURG CG.

2. 8 MARCH 2021: INTERNATIONAL WOMEN’S DAY

3. ROLE OF RADIOTHERAPY IN GYNECOLOGICAL CANCER
DR. PUNEET SETH (RADIATION ONCOLOGIST) ( 15 years working Experience)
M.B.B.S GMC, Bhopal 1997-2002
M.D. Radiotherapy MGM MC, Indore 2004-07
Sr. Consultant, MIMS Raipur and Mittal Bhilai Hospital 2021
Ex- HOD, Alexis Multi-speciality Hospital, Nagpur 2017-2020
Ex- Consultant & HOD Apollo BSR Hospital, Bhilai 2011-16
Ass. Prof. G.R Medical College, Gwalior 2010
Junior Consultant, CBCC-Apollo Hospital, Ahmedabad 2009
Sr. Registrar, Apollo Hospital & A.I.I.M.S, New Delhi 2007-08

4. WELCOME TO BHILAI OBSTETRICS &
GYNECOLOGICAL SOCIETY. 03 OCT 2021

5. UNIQUE linear accelerator- 6 MV
Services Available at Mittal Bhilai Hospital
RAPIDARC
IGRT, IMRT
3DCRT
2D
PALLIATIVE

6. UNIQUE Linear accelerator
Millennium M.L.C 120 Leaves Shape tumor precisely
RapidArc & dynamic IMRT.
Patient protection (Laser Guard)
IGRT couch carbon fiber table top (EPID) Fast Real time Image
Advanced Computerized Varian TPS Treatment Planning System :
CT based (Fuse with MRI & PET-CT) Version 16.1 latest 2021
Quick and painless!
UNIQUE RAPIDARC IGRT LINAC & HDR BRACHYTHERAPY
GammaMedplus iX 3/24 CHANNEL (Varian)

8. GYNECOLOGICAL CANCER: INTRODUCTION
The most common forms of this category of cancer are uterine cancer,
cervical cancer, and ovarian cancer.
The rarer gynaecological cancers include vulvar cancer, vaginal cancer, and
gestational trophoblastic tumour.
Due to their intimate nature, gynaecological cancers are a cause of great concern as women
either miss the first signs or are hesitant and therefore late in reporting them.
According to the data fetched from the National Cancer Institute, All India
Institute of Medical Sciences (NCI-AIIMS), every 8 minutes, one woman in
India dies of cervical cancer. Alarmingly, India has witnessed 1 lakh new
cases of cervical cancer every year since 2016. This is unfortunate as most of
the gynaecological cancers are preventable with the help of awareness about
precautions, knowledge of symptoms and timely diagnosis.

9. GYNECOLOGICAL CA IN ELDER WOMEN
• Older women at increased risk of gynecologic tumors
•Serious impact on physical and mental wellbeing
• Adverse treatment side effects
• Disease-related symptoms
• Psychological problems
• Coexisting chronic conditions
• Improvements treatment &survival Improving QOL

15. In past decades the role of RT in the treatment of
gynaecological cancer change based on:
Developments in other
oncology modality
Onco-surgery,
Chemotherapy,
Immunotherapy
Target therapy
Incorporation of Advance imaging
(PET-CT, MRI)
New pathological
features
Implementation of new
3D conformal RT
technique 3DCRT
IMRT, IGRT, Adaptive RT
Image based Brachytherapy (IGABT)

16. CANCER IN WOMEN: BASIC TREATMENT MODALITIES
Cancer site Surgery Radiotherapy Chemotherapy
Breast ++++ ++ +++
Cervix ++ ++++ ++
Body uterus ++++ ++
Ovary ++++ + +++
Vagina + ++++
Vulva +++ +

19. CERVICAL CANCER: MC GYNECOLOGICAL CA
Cervical cancer It is the most common gynecologic malignancy.
It arises from lower part of uterus, is mainly linked to HPV infection.
 It can be prevented by vaccine against HPV (Nanovalent Gardasil).
In fact, cervical cancer cases have fallen from 28% to 14% in the last 10 years due to
several factors, including the introduction of a vaccine in India in 2008.
It can be detected early by regular Pap smears and HPV testing.
Treatment options for very early cervical cancer include Surgery.
For early stage bulky disease and locally advanced stages,
Radiation therapy along with chemotherapy followed by
brachytherapy is the mainstay of treatment.

20. KNOW YOUR SYMPTOMS! KEY FOR DIAGNOSIS
Abnormal vaginal bleeding or discharge – a common symptom for all
gynaecological cancers, except vulvar cancer.
 Pelvic pain or pressure; frequent need to urinate and/or constipation – common for
ovarian and uterine cancers.
Vaginal odour and bleeding after sexual intercourse – common for cervical cancer.
Feeling full too quickly or difficulty in eating, bloating, and abdominal or back pain –
common for ovarian cancer.
Itching, burning sensation, pain, or tenderness of the vulva, and changes in colour of
vulva or skin irritation, such as a rash, sores, or warts – happens in vulvar cancer.

21. Art of radiation oncology:
possibility to balance between the high probability to control
tumor with the low probability of causing a side effect

24. TYPE OF RADIOTHERAPY: INTENT
ADJUVANT (P.O)
Ca Endometrium
Ca Cervix I-IIA
CURATIVE
(RADICAL)
Ca Cx IB2-IV A
SALVAGE
(loco-regional
recurrence post surgery)
Margin + PM+
Multiple LN+
PALLIATION
Ca Ovary
Obstruction
Brain mets

25. Role of radiotherapy:
Better
local
tumor
control
Decreased
adverse
effects
Better
OS
QOL

26. Ca Endometrium
Majority of cases - stage I and II
• Stage III - in 5% to 10% of patients
• Stage IV - less than 5%
•Most common cell type endometrioid adenocarcinoma
(75%-80%)
•Clear cell, papillary serous and undifferentiated carcinoma
are tumors with the worse prognosis

32. UNSTAGED CA ENDOMETRIUM: IVRT/PELVIC RT

33. STAGED CA ENDOMETRIUM: IVRT/PELVIC RT

37. Survival Rates in Ca Cervix
Stage 5 year survival rate
I 85-95% ( Surg >= RT)
II 55-70% RT-CT
III 38-45% RT-CT
IV 10-15% RT/ Pall Surg

39. Management: Multidisciplinary CA CERVIX
Limited disease
IA/B1
IIA/B (<4cm)
Locally extended
disease
IB2, IIA/B (>4cm)
IIIA, IIIB, IVA, IV
Recurrence or
persistent disease
Surgery
Radiotherapy
Surgery
Radiotherapy
(postoperative or
definitive) +
Chemotherapy
Surgery
Radiotherapy (Paliative)
Chemotherapy

41. EBRT + BRACHYTHERAPY (ICBT-ICRT/CVC)

45. EXTERNAL BEAM RT : IGRT IMRT/ RAPIDARC

46. ICRT TANDEM & OVOID SET ASSEMBLY

47. 3D-CRT
2D RT

48. 3D CONFORMAL RT ADVANTAGES GYNEC CA:
•2 or 4 field (or more field) BOX FIELD 2D/3DCRT
•Avoidance of geographical miss IMRT/ IGRT
•More homogenous dose distribution RAPIDARC/VMAT
•Reduction of treated volume.
•OAR: limited sparing possible (rectum, bladder, partly
bowel)

49. ROLE OF IMRT INTENSITY MODULATED RADIOTHERAPY
Reduction of dose to normal structures - ‘conformal
avoidance’
–Less morbidity (less dose to bowel, bladder, bone marrow)
–Larger volumes with small doses (clinical effect)
Deliver multiple dose levels at one time
–simultaneous in-field boost SIB TECHNIQUE
–Boost after large field BOOST
Dose escalation –more dose in better defined target-
improved disease control

50. TUMOR REGRESSION AND MOTION DURING RT
Uncertainties due to:
-Tumor regression during RT
-Tumor-uterus movement
-Organ movement (bowel, sigmoid)

51. ADJUVANT RT: POST OP RADIOTHERAPY
Intermediate risk features: presence of 2 of 3 risk features
Large tumor size, LVI, deep stromal invasion
GOG 92 trial: 46% reduction in the risk of recurrence in the RT arm
vs. observation arm and adverse effect in 7% vs 2.1%
High risk: positive lymph node, margins or parametrium
Intergroup Trial SWOG, GOG and RTOG: OS 3-years-87% for
Stage Ia2,Ib,IIa with concurrent RT-CH (vs. 77% only RT group)

52. ROLE OF SURGERY IN CA CERVIX
• Stage Ia2  IIa disease
• Wertheim’s / Meig’s hysterectomy
(Extended hysterectomy with pelvic lymphadenectomy)
• Uterus including cervix
• Adnexae (Ovaries spared in the young)
• Wide resection of the parametrium
• Removal of vaginal cuff
• Dissection of peri-ureteral tissues
• Pelvic lymphadenectomy
•Stage IV a disease
• Exenteration

53. RADICAL HYSTERECTOMY & PELVIC LYMPHADENECTOMY

54. PELVIC LYMPHADENECTOMY & PARA-AORTIC LN

55. P.O.R.T ADJUVANT EBRT

58. HYST TYPE
T SIZE
T SITE
TYPE, GRADE
DOI STROMAL INV.
MARGIN
LVSI

64. Bimodal age distribution
•Risk factors:
HPV+, smoking, VIN, Paget’s
disease, lichen sclerosis
•Histology:
•Squamous cell carcinoma 85%
•Adenocarcinoma
•Melanoma
•basaloid

67.  Modern technology is improving the delivery of radiation to
escalate doses, reduce toxicity and improve outcome.
 Radiation is infrequently used in ovarian cancer but may
provide good palliation.
 Late RT toxicity and survivorship issues are now recognized
as important factors.
 Every year, ‘September’ is observed as Gynecologic
cancer awareness month.
 It is important for women to understand what are most
common Gynecologic Malignancies and how to prevent
them and detect them early, to save lives.

68. PREVENTABLE GYNEC CA: LESSON TO LEARN
Pap smear tests and getting vaccinated against human papillomavirus,
that causes cervical and vaginal cancer
HPV vaccines are recommended more for teenagers between 11 and
12 years of age as it helps build immunity better and faster.
In older girls, it will necessitate more shots. If HPV vaccine is
administered before age 15, a two-dose schedule is recommended while
those past their 15th birthday will need three shots.
Practicing safe sex using a condom, maintaining personal hygiene
and being aware of the warning signs are equally vital for timely
diagnosis.
Lifestyle modifications such as quitting tobacco and alcohol and
taking a plant-based diet with no extra sugar and salt also play an
important role in preventing cancer and improving fertility.

69. GYNEC CA AND FERTILITY
Treatment of gynaecological cancers can significantly impact the aspirations of
parenthood of the recovered cancer patients.
Surgery, chemotherapy, and radiotherapy – the mainstays of ovarian, cervical and
endometrial cancers – can impact the uterus and ovaries.
The treatment modalities of gynaecological cancers can affect the reproductive
organs of a woman anatomically or functionally.
Besides, cancer treatment is often a prolonged affair that weakens the sexual function
and psychological wellbeing of patients: mental conditions such as anxiety, depression
and impaired quality of life are relevant aspects of patient care that have a say on their
fertility too.
In fact, the fact that cancer treatment can result in loss of fertility potentially could
be severely distressing.

70. KEY POINTS OF ROLE OF RT IN GYNEC ONCOLOGY
Radiation therapy is used for the treatment of primary and metastatic gynecologic
carcinomas.
Photons are the primary modality of therapeutic irradiation used in gynecologic
carcinomas.
Radiation is measured in international system (SI) unit of centigray and Gray. A
typical dose for therapeutic irradiation for adjuvant therapy is 45 to 50 Gy and for
gross disease, as in cervical carcinoma, is 80 to 85 Gy.
Radiation is primarily generated from human-made sources, as in a linear accelerator
LINAC, called x-rays, or from naturally radioactive decay, termed gamma rays
(COBALT -60).
Brachytherapy, a crucial component to the safest and most effective treatment of
many gynecologic cancers, delivers radiation from sources that are placed within the
body. Dose of radiation at a given point is inversely proportional to the square of the
distance from the source of radiation (dose ∝ 1/Distance2).