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This is the homepage for the Gyne sitegroup.
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Introduction to Gynecological Malignancies
Gynecological malignancies are predominantly a disease of the old age. They represent a challenge in terms of etiology, prevention, treatment and rehabilitation. The anatomy and physiology of the female pelvis serves the purpose of procreation and excretion. To prevent diseases resulting from the natural activities of the pelvis and to ensure the optimum functioning of the same, post treatment, is our collective endeavor.
Anatomy and Physiology
The below links give a comprehensive overview of the anatomy.
OVARY-http://education.yahoo.com/reference/gray/subjects/subject/266
UTERUS-http://education.yahoo.com/reference/gray/subjects/subject/268
VAGINA-http://education.yahoo.com/reference/gray/subjects/subject/269
The External Genital Organs-http://education.yahoo.com/reference/gray/subjects/subject/270
The Lymphatics-http://education.yahoo.com/reference/gray/subjects/subject/180
CT scan
http://www.med.wayne.edu/diagRadiology/anatomy_Modules/Pelvis/Pelvis.html
Link collection 2
Approach to Gynecological Malignancies
Individual diseases
CERVIX
UTERUS Endometrium
VAGINA
VULVA
OVARY
Current issues
List of pages dealing with Gynecological Cancers in Isocentre
Cervix Cochrane Metaanalysis on Chemoradiation 2010
This is a notification on an important publication FoldUnfold Table of Contents The article Summary of methods: Main results Of interest What does this mean for practice? The article The...
Cervix
FoldUnfold Table of Contents Introduction Risk Factors Pathology Staging Screening Management Introduction The following links provide general information about cervical cancer....
Welcome to the Gynecology Sitegroup
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Hi Chendil,
A really difficult question to answer specifically because all the data about treating microscopic disease in squamous cell cancers is mainly empirical. If the patient had no nodes at presentation then anything between 40 -54 Gy can be sufficient for pelvic control. However if there was a node that was missed then 40 would be a palliative dose essentially.
As far as the ICMR guidelines are concerned I dont see any real evidence backing them up. Unfortunately the same goes for TMH and surprise NCCN also (there is no mention of the level of recommendation in all three of them) - NCCN does mention a dose of 45 as minimum though.
In PGI we used to give 46 Gy in 23# without MLS. In early stage carcinoma cervix who were treated with simultaneous brachytherapy and EBRT a dose of 40 Gy was given with a MLS along with brachy so that the total point A dose was in the region of 80 Gy LDR eq. We ensured patients were node negative and had no significant parametrial extension with and MRI before starting treatment though. I have not analysed the dataset but I dont recall seeing isolated pelvic nodal failures in these patients. So 40 can be considered sufficient for pelvic nodal microscopic disease in these patients. However these were really early patients with stage I disease < 4 cm (usually 2 -3 cm was the norm). I suspect from this though that the dose response curve for microscopic disease should be flattening out after 45 Gy.
The main issue with IIB would be control of the parametrial disease with 40 Gy if patient had no positive nodes in the pelvis. Depending on the parametrial extension of the disease you would have to think if the initial gross disease would receive a sufficiently high tumoricidal dose with brachytherapy
On an unrealted note this experience from Ghent does suggest that going beyond 51 Gy EQD2 doesnt seem to improve the control in elective neck nodes.
http://www.redjournal.org/article/S0360-3016(09)03420-8/abstract
Hi,
There is no right answer here. I agree with Santam, the standard in most places for Stage IIb would be 45 -50 Gy. The main reason being the control of parametrial disease and pelvic LN's. If your case is low volume IIb and if the assumption is that the possibility of pelvic lymph nodes metastasis is <15-20% then you may be fine. But if it is a large volume IIb and you think the probability of LN is higher (>20%) then you need more dose.
In India we did 40Gy/20#'s (MLB after 20Gy) + 7Gy x5# HDR. but if we had large volume disease then they got 50Gy/25#'s (MLB after 40Gy) + 7Gyx3#'s HDR. OTT < 8 weeks. We did excellent quality brachytherapy though. If you have doubts about the geometry that you may be able to achieve then go with 50Gy. In real life we face this situation where the tumor is small but the vagina is narrow or conical in that case you will not be able to deliver 7Gyx5 so it makes sense to push dose externally. Many centres in India practice parametrial boost for IIIb but we never did.
In Canada we do 45Gy/25#'s + 7Gy x4#'s HDR. Some centres do 6 - 6.5 Gy x 5#'s HDR. If we see a positive LN on imaging then we do SIB and boost the node.
While discussing the case with your colleagues dont forget to keep the OTT <8 weeks.
A case of Carcinoma cervix IIB was treated by Box-field technique with C0-60 gamma rays to a total dose of 40Gy in 20 fractions (5Fr/week) over 4 weeks, without any midline block along with concurrrent weekly cisplatin. The patient was referred to a private center for brachytherapy.
The Radiation Oncologist was not comfortable with the Whole Pelvic Dose of 40 Gy, his argument being that atleast 45 Gy is required to account for the microscopic Nodal disease.
Recently ICMR has published guidelines for Carcinoma Cervix. The Guidelines is available at icmr.nic.in/guide/cancer/CcMG.pdf ( On Closer scrutiny It Resembles the EBM Guidelines of TMH).
To Quote From The above Guidelines
Radiation therapy doses: Stage IIB: The radical radiation therapy including external radiation technique, portals and doses and intracavitary radiation delivered are similar as described above for Stage IB/IIA.
External Radiation: Using conventional fractionation, a dose of 40‐50 Gy in 20‐25 fractions
over a period of 4‐5 weeks is recommended. Use of two filed or four‐field beam
arrangement, corner shields and a special midline block (after 20 Gy), helps in reducing the
dose to rectum, bladder and small bowel during external radiation.
Considering against this back-drop and keeping in mind that various institutions follow their own in-house protocol,inviting further comments from the house.
I was always taught that the whole pelvis dose can be kept 'low' at 40Gy if it is early IB and then the brachytherapy dose would need to be a bit higher ~40Gy. I have this pairing of 45/35 and 40/40 in my head although it is years since I did a brachy treatment.
When doing the EBRT, I limit the bowel and bladder to 45 Gy pre-brachytherapy but find that I can put 50-55 into the tumour areas with IMRT