**2. Selection criteria for radiation**

Staging of the malignant disease is the most important factor in determining therapy and while planning contraindications to radiation to be looked for and histopathological examination report is mandatory.

*Contraindications for radiation*: (1) Severe acute sepsis or febrile illness, (2) severe cancer cachexia, (3) myocardial infarction and (4) unequivocal histopathological report. Though there are no absolute contraindications, radiation is not the preferred therapy for radio‐insensitive tumours like fibrosarcoma, leiomyosarcoma and melanoma.

*Carcinoma cervix*: The most common histopathological type is squamous cell carcinoma. The incidence of adenocarcinoma is on the rise contributing to as much as 25% [4]. In spite of the availability of screening tests in the modern era, as high as 85% are still presenting in late stage. Adherence to therapy is poor as it was reported that only 38.8% complete radiother‐ apy [5]. Pre‐therapy staging is based on clinical examination and imaging findings. Recently, imaging techniques are playing a great role in planning therapy even though traditionally staging is done by clinical examination.

*Role of imaging in staging*:


Survival rates are shown in **Table 2**.

gynaecological malignancies who receive radiation is of great importance as adherence to treat‐ ment is one of the factors that influences survival rates. The most important part is the selection and categorization of women for radiation. The aim of this chapter is to appraise the readers about the burden of the gynaecological malignancies in a tertiary‐care set up, counselling and selection

Cancer is the first and foremost cause of death in developing countries and the second most common cause in developed countries. Genital tract malignancies are the most common can‐ cers in women and the most common site affected is cervix followed by ovary and Uterine corpus [1]. The incidence of carcinoma cervix is 9 per 100,000 in developed countries as against 17.8 per 100,000 in developing countries. The mortality attributed to carcinoma cervix is 3.2 per 100,000 in developed regions when compared to 9.8 per 100,000 women in developing regions [2]. The cancer registry of our hospital recorded carcinoma cervix to be occurring in 70%, ovar‐ ian cancer in 20%, endometrial cancer in 9% and other cancers in 1% of cases in women. In India, every year 122,844 women were reported to be diagnosed with carcinoma cervix and 67,477 died of the disease and at present the trend of this malignancy is decreasing in incidence

[3]. The incidence of carcinoma cervix has declined by 75% in developed countries [1].

Staging of the malignant disease is the most important factor in determining therapy and while planning contraindications to radiation to be looked for and histopathological examination

*Contraindications for radiation*: (1) Severe acute sepsis or febrile illness, (2) severe cancer cachexia, (3) myocardial infarction and (4) unequivocal histopathological report. Though there are no absolute contraindications, radiation is not the preferred therapy for radio‐insensitive

*Carcinoma cervix*: The most common histopathological type is squamous cell carcinoma. The incidence of adenocarcinoma is on the rise contributing to as much as 25% [4]. In spite of the availability of screening tests in the modern era, as high as 85% are still presenting in late stage. Adherence to therapy is poor as it was reported that only 38.8% complete radiother‐ apy [5]. Pre‐therapy staging is based on clinical examination and imaging findings. Recently, imaging techniques are playing a great role in planning therapy even though traditionally

• The accuracy of CT in staging carcinoma cervix is 63–88%. The sensitivity and specificity of

• MRI distinguishes early from advanced disease, thereby stratifying patients for surgery

CT in detecting pelvic lymph node involvement is shown in (**Table 1**)

criteria for radiation, methods of radiation and the side effects and the outcome.

**1.1. Burden of gynaecological malignancies in tertiary care set up**

**2. Selection criteria for radiation**

staging is done by clinical examination.

*Role of imaging in staging*:

and chemoradiation.

tumours like fibrosarcoma, leiomyosarcoma and melanoma.

report is mandatory.

64 Radiotherapy


**Table 1.** Sensitivity and specificity of CT.

*Radiotherapy is advocated in the following situations*:


#### **2.1. Carcinoma endometrium/Uterine Corpus**

Carcinoma endometrium is the most common cancer of the uterus and its incidence is increasing. The median age is 63 years and more than 90% belong to 50 years of age or more and 25% occur before pre‐menopause. More than 75% are diagnosed in Stage I as the most common symptom is abnormal or postmenopausal bleeding. Survival rates are more than 75%. Adenocarcinoma is the most common type with good prognosis, but it is relatively radioresistant.


**Table 2.** Staging grouping of carcinoma cervix.

#### *HPE grading*:

Gx = Grade cannot be assessed

Grade 1 = Tumour cells are well‐differentiated

Grade2 = Tumour cells are moderately differentiated

Grade 3 = Tumour cells are poorly differentiated

The histopathological types are as follows:


#### 9. Mucinous tumours

#### 10.Undifferentiated.

*HPE grading*:

66 Radiotherapy

Gx = Grade cannot be assessed

**Table 2.** Staging grouping of carcinoma cervix.

5. Papillary serous carcinoma 6. Clear cell adenocarcinoma

8. Uterine sarcomas

Grade 1 = Tumour cells are well‐differentiated

Grade 3 = Tumour cells are poorly differentiated

2. Adenocarcinoma with squamous differentiation 3. Adenoacanthoma (benign squamous component)

7. Carcinosarcoma/malignant mixed mullerian tumour

The histopathological types are as follows:

Grade2 = Tumour cells are moderately differentiated

Stage IV

1. Endometroid adenocarcinoma (secretory, ciliated, papillary)

**S. no. Stage (FIGO) TNM (AJCC) Survival rates (5‐year** 

1 Stage I A1 **(T1a1, N0, M0 93%**

3 Stage I B **(T1b, N0, M0) 80%**

9 Stage 2 B **(T2b, N0, M0) 58%** Stage III **(T3, N0, M0)** 10 Stage III A **(T3a, N0, M0 35%**

12 Stage IV A **(T4, N0, M0) 16%** 13 Stage IV B **(any T, any N, M1) 15%**

11 Stage III B **T3b, N0, M0; OR T1‐T3,** 

2 Stage I A1 **(T1a2, N0, M0)**

4 Stage B 1 **(T1b1, N0, M0)** 5 Stagve I B2 **(T1b2, N0, M0)**

6 Stage II A **(T2a, N0, M0)** 7 Stage II A1 **(T2a1, N0, M0)** 8 Stage II A2 **(T2a2, N0, M0)**

Stage 0 93%

**Stage II (T2, N0, M0) 63%**

**N1, M0) Hydronephrosis**

**observed rates)**

**32%**

4. Adenosquamous carcinoma (malignant squamous component)

Staging of endometrial carcinoma with survival rates is shown in **Table 3**. Radiotherapy is also indicated in Stage I as per risk stratification.


*Note*: T = denotes extent of the tumour; N = designates whether cancer has spread to the lymph nodes; M = denotes distant metastasis.

Nx = Spread to nearby lymph nodes cannot be assessed; N0 = no spread to nearby lymph nodes; N1 = spread to pelvic lymph nodes; N2 = spread to para‐aortic lymph nodes.

Lymph node involvement: Stage I A‐5%, Stage I B‐10%; Stage I C‐15%; Stage II‐20% and Stage III‐55%.

**Distant spread**: M0 = there is no spread to distant lymph nodes, organs and tissues; M1 = spread to distant lymph nodes, upper abdomen, omentum, other organs, liver, lung.

**Table 3.** TNM classification and FIGO staging [8].

*Stage I low risk* includes Stage I A grade 1 and 2 endometroid adenocarcinoma without or with minimal myometrial invasion.

*Stage I intermediate-risk group* includes Stage I with grade 1 or 2 adenocarcinoma with >50% myometrial invasion or grade 3 adenocarcinoma with superficial invasion and with extensive lymphovascular involvement

*High-risk endometrial cancer* includes Stage II with deep cervical stromal involvement and Stage III and IV disease.

#### **2.2. Picture of USG and gross specimen of endometrial carcinoma (Figure 1)**

*Vulval and vaginal cancer*:

A. Vulval carcinoma: Most common after 65 years of age but recently the incidence of carci‐ noma vulva in the age group between 40 and 49 years is reported to have been doubled. Its incidence is 1.3/100,000 women. Pathological types: Squamous cell carcinoma—90%; others include malignant melanoma, Paget's disease, Bartholin gland tumours, adenocarci‐ noma and basal cell carcinoma. Local recurrence is common when there is lymphovascular involvement, when the growth is of infiltrative type and when prominent fibromyxoid tumour is present at the edge of resected margins [9]. Gross picture of carcinoma vulva is shown in **Figure 2**.

Primary modality of therapy is surgical excision and groin lymph node dissection. Survival rates with staging are shown in **Table 4**.

#### *Selection criteria for radiation*:

#### *Primary radiotherapy is suggested in women*:


*Adjuvant radiotherapy* is advised to groin and pelvic nodes in the following situations

**Figure 1.** (**A**) USG (TVS) picture of endometrial carcinoma showing increased endometrial thickness and increased vascularity and (**B**) picture of same uterus (panel A) as gross specimen showing endometrial carcinoma in the cavity.

**Figure 2.** Cauliflower type of growth on the vulva.

*Stage I low risk* includes Stage I A grade 1 and 2 endometroid adenocarcinoma without or with

*Stage I intermediate-risk group* includes Stage I with grade 1 or 2 adenocarcinoma with >50% myometrial invasion or grade 3 adenocarcinoma with superficial invasion and with extensive

*High-risk endometrial cancer* includes Stage II with deep cervical stromal involvement and

A. Vulval carcinoma: Most common after 65 years of age but recently the incidence of carci‐ noma vulva in the age group between 40 and 49 years is reported to have been doubled. Its incidence is 1.3/100,000 women. Pathological types: Squamous cell carcinoma—90%; others include malignant melanoma, Paget's disease, Bartholin gland tumours, adenocarci‐ noma and basal cell carcinoma. Local recurrence is common when there is lymphovascular involvement, when the growth is of infiltrative type and when prominent fibromyxoid tumour is present at the edge of resected margins [9]. Gross picture of carcinoma vulva is

Primary modality of therapy is surgical excision and groin lymph node dissection. Survival

• When Ulcerated groin nodes. Radiotherapy is followed by surgery or surgery followed by radiotherapy. However, surgery following radiation is associated with high morbidity.

**Figure 1.** (**A**) USG (TVS) picture of endometrial carcinoma showing increased endometrial thickness and increased vascularity and (**B**) picture of same uterus (panel A) as gross specimen showing endometrial carcinoma in the cavity.

*Adjuvant radiotherapy* is advised to groin and pelvic nodes in the following situations

**2.2. Picture of USG and gross specimen of endometrial carcinoma (Figure 1)**

minimal myometrial invasion.

68 Radiotherapy

lymphovascular involvement

Stage III and IV disease.

*Vulval and vaginal cancer*:

shown in **Figure 2**.

*Selection criteria for radiation*:

rates with staging are shown in **Table 4**.

*Primary radiotherapy is suggested in women*:

• When optimal surgical therapy is not possible.


*Pre-operative radiotherapy* is advocated to preserve anal sphincter function when the tumour is close to the anal sphincter. Radiotherapy may also be combined with chemotherapy. Chemo‐ RT may increase the morbidity, especially skin toxicity.

Recurrence is very common in vulvar cancer and it varies from 15 to 33%. The sites of recur‐ rence can be vulva itself (69.5%), groin nodes (24.3%) and distant sites (18.5%).


adenocarcinoma 60% and malignant melanoma 30%.

**Table 4.** FIGO and AJCC stage grouping and survival; carcinoma vulva.

B Vaginal carcinoma: Vaginal cancer is rarely encountered and its incidence is reported to be 1 in 11,000 and ocxcurs in women more than 70 years of age and only 15% occur in women less than 40 years. Presenting symptoms are usually abnormal discharge, bleeding per vaginum, post‐coital bleeding and mass per vaginum. Symptoms during late stages include constipation, pelvic pain and difficulty in micturition. Confirmation of diagnosis is by speculum examination demonstrating a cervix free of disease and growth in the vagina. Biopsy determines the type of cancer. If the growth involves cervix and vagina, it is classi‐ fied under cervical cancer. If it involves vagina and vulva, it is classified as vulvar cancer. The most common pathological type is squamous cell carcinoma (70%); and others include adenocarcinoma (15%), melanoma (9%), sarcoma (4%) and miscellaneous [10].
