**8. Treatment of recurrent carcinoma of cervix**

• *After previous surgery*

**6.2. Image‐guided radiation therapy (IGRT)**

**6.3. Stereotactic body radiotherapy (SBRT)**

toxicities in cervical cancer treatment.

**6.5. Image‐guided brachytherapy**

*Side effects of pelvic radiation:*

doses with SBRT as compared with brachytherapy.

recurrence with the use of image‐guided brachytherapy [19].

planned radiation field.

84 Radiotherapy

**6.4. Proton therapy**

The definition of IGRT, as given by the American College of Radiology and American Society of Radiation Oncology practice guidelines, is a procedure that refines the delivery of thera‐ peutic radiation by applying image‐based target relocalization to allow proper patient reposi‐ tioning for the purpose of ensuring accurate treatment and minimizing the volume of normal tissue exposed to ionizing radiation [18]. It is particularly useful in cases with a large mobile uterus as seen in young women and with a concern regarding the position of the uterus in the

SBRT delivers radiation with large fraction sizes using highly conformal treatment tech‐ niques. In isolated para‐aortic node cases, it has been considered for a nodal boost. It should not be used as replacement for brachytherapy due to the significant increase in normal tissue

The rationale for proton therapy lies in the improvement of therapeutic ratio by reducing the radiation dose to non‐targeted tissues, thereby reducing toxicity and facilitating dose escala‐ tion to achieve increased tumour control. Proton therapy can offer the best way of sparing the small bowel and rectum and can contribute to significant decrease in acute and chronic

Currently, image‐guided adaptive brachytherapy in gynaecological malignancies is based on CT and MRI. Ultrasonography (USG) as an imaging modality for guidance is also being explored. Advantages of USG include easier availability, cost‐effectiveness and small learning curve which makes it highly useful in developing countries. Limited availability and acces‐ sibility to CT and MRI prevented the early adoption of these promising techniques. Potter et al. reported the clinical outcome of 156 patients treated with image‐guided brachytherapy. Ninety‐seven percent of patients achieved complete remission with 3‐year overall local con‐ trol rates of 95%, 3‐year overall cancer‐specific survival rates of 74% and 3‐year overall sur‐ vival rates of 68%. They concluded that there is reduction in major morbidity and pelvic

Radiation‐induced side effects depend on the type of tissue, dosage and methods of deliv‐ ery of radiation, and the manifestations can be acute and chronic. Acute side effects usually occur during or within the first 3 months of completing radiation. These include fatigue, skin irritation or redness of the skin and loose bowel movements discomfort when urinating. Approximately 50% of patients with localized recurrences after surgery alone may be sal‐ vaged with radiation. EBRT (45–50 Gy) with concurrent chemotherapy followed by brachy‐ therapy is recommended. If the tumour is inaccessible for brachytherapy, dose escalation with IMRT with at least 65–70 Gy may be attempted.

#### • *After definitive irradiation*

Important factors to be considered for re‐irradiation are the time period between the two treatments, beam energy, volume and doses delivered in the initial treatment. EBRT for recur‐ rent tumour is given to limited volumes (40–45 Gy, 1.8 Gy/fraction).

#### **8.1. Treatment of recurrent carcinoma of endometrium**

Radiation therapy can be used to treat small vaginal recurrences in patients who have not received prior radiation. EBRT (45–50 Gy) and brachytherapy are often combined.

#### **8.2. Treatment of recurrent carcinoma of vagina**

Lesions that recur after limited surgical procedures can be treated using radiation or more extensive surgery. Most patients have received prior EBRT and, thus, have options limited to surgery.

#### **8.3. Treatment of recurrent carcinoma of vulva**

If there is clinical local recurrence confined to vulva or clinical nodal recurrence, no prior RT, then EBRT with concurrent chemotherapy can be delivered. Doses range from 50.4 Gy in 1.8 Gy/# for adjuvant therapy to 59.4–64.8 Gy in 1.8 Gy/# for unresectable disease. Large nodes may be boosted to a dose of 70 Gy.

### **9. Conclusion**

Radiation therapy in gynaecological malignancies involves multidisciplinary approach, care‐ ful planning and execution. Counselling is an essential part to increase compliance and to achieve high cure rates.

## **Author details**

Papa Dasari1,\*, Singhavajhala Vivekanandam2 and Kandepadu Srinagesh Abhishek Raghava2


2 Department of Radiotherapy, Regional Cancer Centre, JIPMER, Puducherry, India

#### **References**

[1] Ramesh N, Anjana A, Kusum N, Kiran A, Ashok A, Somdutt S. Overview of benign and malignant tumours of the genital tract. J Appl Pharm Sci. 2013;3:140–149.

[2] WHO ; International Agency for Research on cancer. American Cancer Society. Global Cancer. Facts and Figures. 2nd edition. Globacon; 2008.

• *After definitive irradiation*

surgery.

86 Radiotherapy

**9. Conclusion**

achieve high cure rates.

**Author details**

**References**

Important factors to be considered for re‐irradiation are the time period between the two treatments, beam energy, volume and doses delivered in the initial treatment. EBRT for recur‐

Radiation therapy can be used to treat small vaginal recurrences in patients who have not

Lesions that recur after limited surgical procedures can be treated using radiation or more extensive surgery. Most patients have received prior EBRT and, thus, have options limited to

If there is clinical local recurrence confined to vulva or clinical nodal recurrence, no prior RT, then EBRT with concurrent chemotherapy can be delivered. Doses range from 50.4 Gy in 1.8 Gy/# for adjuvant therapy to 59.4–64.8 Gy in 1.8 Gy/# for unresectable disease. Large nodes

Radiation therapy in gynaecological malignancies involves multidisciplinary approach, care‐ ful planning and execution. Counselling is an essential part to increase compliance and to

and Kandepadu Srinagesh Abhishek Raghava2

received prior radiation. EBRT (45–50 Gy) and brachytherapy are often combined.

rent tumour is given to limited volumes (40–45 Gy, 1.8 Gy/fraction).

**8.1. Treatment of recurrent carcinoma of endometrium**

**8.2. Treatment of recurrent carcinoma of vagina**

**8.3. Treatment of recurrent carcinoma of vulva**

Papa Dasari1,\*, Singhavajhala Vivekanandam2

\*Address all correspondence to: dasaripapa@gmail.com

1 Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India

2 Department of Radiotherapy, Regional Cancer Centre, JIPMER, Puducherry, India

malignant tumours of the genital tract. J Appl Pharm Sci. 2013;3:140–149.

[1] Ramesh N, Anjana A, Kusum N, Kiran A, Ashok A, Somdutt S. Overview of benign and

may be boosted to a dose of 70 Gy.


dosimetric and clinical outcomes with conventional radiotherapy. Gynecol Oncol. 2012;125(1):151–157.


**Chapter 5**
