Radiotherapy plays an important role in the treatment of many gynecological cancers. It has evolved from early uses of X-rays and radium to modern techniques like 3D conformal radiation therapy, intensity modulated radiation therapy, and image-guided radiation therapy. Carcinoma of the cervix is the most common gynecological cancer globally and radiotherapy with brachytherapy is the standard of care for locally advanced disease. Other cancers like endometrial, vaginal, and vulvar carcinomas may also be treated with external beam radiotherapy and brachytherapy. While surgery remains primary for ovarian cancer, radiotherapy has limited roles in salvage situations.

1. RADIOTHERAPY IN
GYNAECOLOGY
Lt Col Sankalp Singh
Gd Spl Radiotherapy

2. SEQUENCE OF
PRESENTATION
Historical aspect
Radiation Physics & Radiobiology
Therapeutic modalities
Role in Gynaecology
Common Cancers
Acute & Late effects

3. HISTORICAL ASPECT
WILHELM ROENTGEN
Discovered X-rays in
1895
MARIE CURIE
Discovered natural
Radioactivity in 1898
EMIL GRUBBE
First used X-rays for
treatment of a cancer patient

4. HISTORICAL ASPECT
•Lupus Freund used X-ray therapy to treat a hairy nevus of a 5 year old girl
child in Nov 1896
•In 1901, the Curies lent a small radium tube to Henri Danlos for studying its
effects on skin
•Radiumtherapy or Curietherapy introduced by Danlos for treatment of skin
ailments like lupus
•Alexander Graham Bell proposed the use of radioactivity for cancer
treatment in 1903
•Abbe reported the first case of Ca cervix treated by this method in 1904 in
the United States
•Radiotherapy institutes were set up in Paris, Stockholm & Manchester in
early 20th century

5. HISTORICAL ASPECT
•Teletherapy (X-rays) was delivered by superficial low energy X-rays
•Radiumtherapy (BT) used sealed radioactive sources like 226Ra or
222Rn within metal containers or Glass capsules with a variety of
applicators & needles
•Single massive dose treatments aimed at eradication of tumours
were used initially
•Variety of experimental & non-scientific uses of radiotherapy
became popular
•Harmful side effects of treatment soon became apparent
•Various dosimetry systems were evolved to understand &
implement dose-response effects

6. SCIENCE OF RADIOTHERAPY:
IONIZING RADIATION Ionizing radiation is radiation
that carries enough energy to
free electrons from atoms or
molecules, thereby ionizing
them.

7. SCIENCE OF RADIOTHERAPY:
MECHANISM OF ACTION
DNA within the cell
nucleus is the primary
target for radiation
effects.
SS
B
DS
B

8. SCIENCE OF RADIOTHERAPY :
MECHANISM OF EFFECT
IONIZING
RADIATIO
N
LETHAL
DAMAGE
SUB
LETHAL
DAMAGE
CELL
DEATH
REPAIR
MUTATIONS
GENOMIC
INSTABILITY
MIS
REPAIR
NO EFFECT
CARCINOGENE
SIS

9. SCIENCE OF RADIATION : THE 4
RS OF RADIOBIOLOGY

10. SCIENCE OF RADIATION : WHY
FRACTIONATED THERAPY
Protects important normal tissues
Provides better tumor kill through Re-oxygenation & Reassortment
Repair and Repopulation favour normal tissue over tumor

11. SCIENCE OF RADIATION :
THERAPEUTIC RATIO
TR = Tumour Control Probablilty (TCP)
Normal Tissue Complication Probability (NTCP)
Therapeutic window:
Maximum probability
of Complication Free
Tumour Control

12. SCIENCE OF RADIATION :
MODIFIERS
Concurrent Chemotherapy
Hemoglobin levels
Hyperbaric Oxygen and Oxygen mimetics
Radioprotectors
Physical charactereristics of beam -

13. THERAPEURIC MODALITIES :
TELETHERAPY
Teletherapy or external beam radiotherapy is the delivery of therapeutic
radiation from outside the body.
Main types of equipment in use :
Telecobalt with 2D planning
Linear Accelerator with 3DCRT
IMRT
IGRT
SRS/SBRT
Protons & Heavy Ions

14. THERAPEURIC MODALITIES :
TELETHERAPY

15. THERAPEUTIC MODALITIES :
TREATMENT PLANNING
Treatment planning flow

16. THERAPEUTIC MODALITIES :
IMMOBILISATION

17. THERAPEUTIC MODALITIES :
SIMULATION

18. THERAPEURIC MODALITIES :
TELECOBALT & 2D

19. THERAPEURIC MODALITIES :
LINAC & 3DCRT

20. THERAPEURIC MODALITIES :
IMRT & IGRT

21. THERAPEUTIC MODALITIES :
IMRT & IGRT

22. EVOLUTION OF EBRT
THERAPEUTIC MODALITIES

23. RADIOTHERAPY : ROLE IN
GYNAECOLOGY

24. CARCINOMA CERVIX
 Most common cancer of Indian women
 Causes nearly 2,80,000 deaths every year globally
 Early detection and primary prevention key to control
 Role of surgery limited to early stage disease (FIGO stages IA, IB1, IIA1)
 >85% patients present in locally advanced stages (IIB & beyond)
 Radiotherapy (EBRT +BT) standard of care in these cases

25. CA CERVIX - FIGO STAGING
IB
IA
IIB
IIIA
IVA
IVB
IIIB
IIA

26. CARCINOMA CERVIX
 Intent of treatment may be radical, adjuvant or palliative
 Treatment is a combination of external & internal irradiation
 Chemoradiation is preferred over RT alone (as long as it is tolerated)
 3DCRT is considered standard (though 2D used extensively all over the
world)
 IMRT advantageous over 3DCRT only in setting of post op RT or paraaortic
LN irradiation
 SBRT boost not found to be equivalent to brachytherapy boost

27. CARCINOMA
CERVIX:TELETHERAPY
 Treatment volume
 all gross disease
 possible areas of subclinical disease -
 uterus,
 cervix,
 parametria,
 uterosacral ligaments,
 sufficient vaginal margin from the gross
disease (at least 3 cm),
 lymph nodes
 presacral nodes
 Ext & Int iliac LNs
 Obturator nodes
 Common iliac LNs (if N+ on imaging)
 Treatment dose
 45 to 50 Gy
 in 25 to 28 fractions
 of 1.8Gy/fx
 5 days a week
 Concurrent
Chemotherapy
 Inj Cisplatin / Cisplatin +
5-Flurouracil
 40 mg/m2
 Weekly
 4 to 5 cycles
RADICAL OR DEFINITIVE TREATMENT

28. CARCINOMA
CERVIX:TELETHERAPY
 Indications post radical hysterectomy
 +ve LNs
 +ve margins
 +ve parametrium
 Minor criteria :
 Size of tumour
 Lympho-vascular space invasion (LVSI)
 Deep stromal invasion
ADJUVANT TREATMENT

29. CARCINOMA CERVIX
 INDICATIONS
 Metastatic disease
 Poor PS of patient
 Symptomatic disease
 Bleeding
 Fungation
 Pain
 Skeletal metastases
 CNS metastases
PALLIATIVE TREATMENT
DOSING SCHEDULES & VOLUMES
 Short, hypofractionated schedules
 Only symptomatic disease is targeted
 Never with chemotherapy
 Common schedules
 30 Gy/10 fx
 20 Gy/5 fx
 8 Gy/1 fx

30. CARCINOMA CERVIX : BRACHYTHERAPY
 Critical component of definitive RT – high dose boost to residual tumour after EBRT
 Usually follows EBRT to allow regression of tumour and hence better geometry of implant
 In highly selected IA2, BT alone maybe curative (non-surgical candidate)
 Applicators :
 Intact cervix – Uterine tandem + vaginal ovoids/ ring/ cylinder
 Difficult geometry – Uterine tandem + interstitial needles
 Post hysterectomy – Vaginal cylinder

31. CARCINOMA CERVIX : BRACHYTHERAPY

32. CARCINOMA CERVIX : BRACHYTHERAPY

33. CARCINOMA CERVIX : INTERSTITIAL BT

34. CARCINOMA CERVIX : INTERSTITIAL BT

35. CARCINOMA CERVIX : INTERSTITIAL BT

36. PREGNANCY AND CERVICAL CANCER
 Most frequently diagnosed type of cancer in pregnant women
 Most pregnant (75%) women with cervical cancer have stage I disease.
 Carcinoma in situ maybe observed till completion of pregnancy – conization has
been attempted
 Clinical dilemma with invasive disease - delay treatment until fetal maturity or
immediate treatment
 Ist trimester :
 Termination of pregnancy advised & treatment by RH + BPLND /
CCRT+ICRT
 If continuation preferred by patient , close monitoring with serial MRIs
2-3 monthly

37. CARCINOMA VAGINA

38. CARCINOMA VAGINA

39. CARCINOMA VAGINA : ICBT

40. CARCINOMA VULVA

41. CARCINOMA VULVA : EBRT

42. CARCINOMA VULVA : ISBT

43. CARCINOMA ENDOMETRIUM
 Most common gynecological cancer of Western countries
 Commonly effects post menopausal women
 Surgery is cornerstone of management with extensive
surgical staging followed by RT for adverse pathological
features
 Radical RT can be offered to medically inoperable women
 EBRT fields and doses similar to Carcinoma cervix
 BT by vaginal cylinder for postop cases and uterine
tandems for radical cases.

44. CARCINOMA ENDOMETRIUM

45. CARCINOMA ENDOMETRIUM

46. CARCINOMA ENDOMETRIUM

47. CARCINOMA ENDOMETRIUM

48. CARCINOMA ENDOMETRIUM
ICBT

49. CARCINOMA OVARY
 Primary management is surgery + chemotherapy
dependeing on stage
 Consolidative Whole Abdominal Radiotherapy of
historical/experimental value
 Focal RT for small areas of isolated pelvic recurrence in
heavily treated patient only indication at present
 Intra-Operative RT along with surgical salvage may have
possible benefit

50. CARCINOMA OVARY : IORT

51. THANK YOU