Table Of ContentMEDICAL RADIOLOGY
Diagnostic Imaging and Radiation Oncology
Editorial Board
Founding Editors L.W. Brady, M.W. Donner(t)
H.-P. Heilmann, F.H.W. Heuck
Current Editors
Diagnostic Imaging A.L. Baert, Leuven
F.H.W. Heuck, Stuttgart
J.E. Youker, Milwaukee
Radiation Oncology L.W. Brady, Philadelphia
H.-P. Heilmann, Hamburg
Springer
Berlin
Heidelberg
New York
Barcelona
Budapest
Hong Kong
London
Milan
Paris
Santa Clara
Singapore
Tokyo
Helmut W. Vahrson (Ed.)
Radiation Oncology
of Gynecological Cancers
With Contributions by
LA. Adamietz·J. Bahnsen·M.W. Beckmann·H.G. Bender·H.D. Bottcher
L.W. Brady·D. Carstens·G. Crombach·R.G. Dale·M.F. Dzeda·G. Emons
H.J. Frischbier·A. Gerbaulet·C. Haie-Meder·M. Herbolsheimer·R.D. Hunter
H. Jacobs· H. Junkermann· U. Karck· D. Kieback· P.G. Knapstein
R. Kreienberg· H. Kucera· H.-A. Ladner· S. Ladner· E. Lartigau· W.A. Longton
M. Maher·H. Marsiglia·B. Micaily·K. Morita·R.F. Mould·D. Niederacher
U. Nitz· D.M. Ostapovicz· C.A. Perez· R. pfab· A. Pfleiderer· G. Rauthe
K. Rotte· B. Schopohl·1. Schreer· K.-D. Schulz· V. Stelte· D. Timmerman
H.W. Vahrson·I.B. Vergote·D. von Fournier·W. Weikel
Foreword by
Luther W. Brady and Hans-Peter Heilmann
Springer
Professor Dr. HELMUT W. VA HRSON
Leiter der Abteilung fur Gynakologische Radiologie
und Strahlentherapie, Frauenklinik
Klinikum der Justus-Liebig-Universitat
Klinikstra6e 32, 35385 Gie6en, Germany
MEDICAL RADIOLOGY· Diagnostic Imaging and Radiation Oncology
Continuation of
Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
With 185 Figures in 245 Separate Illustrations and 199 Tables
ISSN 0942-5373
Library of Congress Cataloging-in-Publication Data.
Radiation oncology of gynecological cancers/H. W. Vahrson, ed.; with contributions by LA. Adamietz ... [et al.]; foreword
by Luther W. Brady and Hans-Peter Heilmann. p. cm. - (Medical radiology) Includes bibliographical references and
index.
TSBN-13: 978-3-642-64358-3 e-TSBN-13: 978-3-642-60334-1
DOT: 10.1007/978-3-642-60334-1
1. Generative organs, Female-Cancer-Radiotherapy. 2. Generative organs, Female-Cancer-Imaging. 3. Radioiso
tope brachytherapy. I. Vahrson, H.W. (Helmut). II. Adamietz, LA. III. Series. [DNLM: 1. Genital Neoplasms,
Female-radiotherapy. 2. Genital Neoplasms, Female-surgery. 3. Genital Neoplasms, Female-drug therapy. WP
145 R1285 1997] RC280.G5R326 1997 616.99'4650642-dc21 96-29741
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Foreword
The incidence, diagnosis, and treatment of gynecologic cancer have undergone
major changes during the past 20 years. In addition to significant changes in the
incidence of the diseases, there has been extensive application of new technologies in the
field.
- While the incidence of invasive cancers of the cervix has diminished sharply, there
has been a marked increase in the number of patients presenting with in situ carcinomas
of the cervix. This has resulted primarily from better education but also from the regular
use of Papanicolaou screening for early diagnosis. This trend has been associated
with a major shift from late stage disease to early stage disease, which has led to
more effective utilization of surgical techniques in primary management, with less
emphasis on radiation therapy techniques. Almost invariably, in situ cancers of the
cervix can be cured by surgical management, and high cure rates can be achieved by
surgical techniques in early invasive cancers of the cervix. Therefore, more patients
are receiving definitive surgical management rather than definitive radiation therapy
management.
- Because of its tendency to present at an early stage, cancer of the endometrium is now
more commonly managed by surgical techniques. Postoperative radiation therapy is
used when there is persistent residual disease following surgery, a more advanced disease
stage than indicated by preliminary study, transection or spillage of tumor during the
operative procedure, or positive cytology at the time of the original surgery.
- More precise programs for management of carcinoma of the vulva have been outlined,
with emphasis on surgical management for early stage invasive cancers and radiation
therapy with or without surgery for more advanced stage disease.
- Increasing emphasis is being placed on the use of chemotherapy techniques following
surgery in the management of patients with cancer of the ovary; by contrast, radiation
therapy is being relegated to the treatment of recurrent disease, more advanced disease
or special forms of metastatic disease.
- There have been advances in the workup to identify those patients with primary malig
nant disease of the vagina, and treatment techniques primarily involving radiation
therapy have been developed.
- It has been recognized that patients with carcinomas of the fallopian tube present unique
and complicated problems with regard to management.
- More appropriate techniques have been defined for the management of female patients
with carcinomas of the urethra, with emphasis on interstitial radiation therapy
techniques.
In spite of the more widespread utilization of surgical management with or without pre-/
postoperative radiation therapy, primary radiation therapy, and chemotherapy, local
regional recurrence remains a significant problem in gynecologic cancer, accounting for
50%-60% of failures of primary treatment regimens.
VI Foreword
This volume, edited by Professor HELMUT W. VA HRSON, deals effectively with these
important issues in gynecologic cancer, and contributes significantly to the definition of
appropriate treatment programs for each of the major tumor sites.
Philadelphia/Hamburg LUTHER W. BRADY
July 1997 HANS-PETER HEILMANN
Preface
The management of patients with gynecological cancer has undergone far-reaching
changes. Today, radical surgery is being used more commonly in patients with cancer of the
cervix and endometrium, including older patients who were formerly treated with radiation
therapy; this has occurred because of better perioperative care, better anesthesia, and better
general medical management. More effective chemotherapeutic agents have been intro
duced, and some, particularly platinum compounds and taxol, have been associated with
long-term survival. Trials with combined radiation therapy and chemotherapy are being
conducted more actively in advanced stages of cervical cancer or are replacing sole radia
tion therapy or chemotherapy in ovarian cancer.
At the same time, radiation therapy techniques have become more sophisticated, with
three-dimensional reconstructed treatment planning and delivery being more commonly
utilized today than 5 years ago. This allows for more precise definition of the tumor extent
by computed technological techniques with contrast material, and the use of three
dimensional reconstruction of the treatment program with non-coplanar fields in order to
avoid complications from the inclusion of small bowel, bladder, or rectum. Manual radium
brachytherapy, used worldwide until recently, has been replaced by modern remotely
controlled afterloading techniques. On the other hand, source-dependent low-, medium-,
and high-dose-rate regimens are still under study, and it remains a matter of controversy as
to which is better. Biological considerations with regard to the reduction of the acute and
late complications of treatment have had a considerable influence on the move toward
multiple fractions with teletherapy and brachytherapy remote-controlled afterloading tech
niques. Quality of life has emerged as a major concern in any treatment program, the
emphasis being on achieving satisfactory quality of life without any reduction in the long
term survival or cure rates.
In Germany, formerly independent Departments of Gynecological Radiation Therapy
are now being merged into Departments of Radiation Oncology, and the diagnostic compo
nents of these departments merged into Departments of Diagnostic Radiology. In the near
future this development will have been completed. Therefore, the present volume clearly
represents a significant opportunity to preserve the experience and knowledge of experts on
gynecological radiation oncology. The approach adopted in this volume differs from that in
other books on the same subject, in that knowledge and recent developments in surgery and
chemotherapy, as well as radiation oncology, are presented. Leading gynecological sur
geons discuss the role for surgery in the management of patients with cancer of the cervix
and the vulva as an alternative to radiation therapy techniques. Therefore, the reader is
provided with information on the entire field of treatment for female genital cancers. The
individual chapters are all written by experts who have achieved international recognition
for their work.
The editor expresses his deep debt of gratitude to the late Professor RICHARD K. KEPP
(1912-1984), Director of the Universitats-Frauenklinik Giessen, and Professor W. DIETRICH
HOFMANN (born in 1925), of the same institution. Professor KEPP wrote Grundlagen der
Strahlentherapie and Gyniikologische Strahlentherapie (published in 1952 by G. Thieme,
Stuttgart), while Professor HOFMANN is the author of Klinik der Gyniikologischen
Strahlentherapie (published in 1963 by Urban & Schwarzenberg, Miinchen/Berlin).
VIII Preface
The editor expresses his sincere appreciation to the various authors for their cooperation
and to Mrs. BERGER and Mrs. SCHNEIDER, who transcribed the chapters and managed the
correspondence. The volume is dedicated to my wife, FRAUKE, who agreed to my frequent
absence, without which this volume could not have been accomplished.
I wish to express my thanks to Mr. RICK MILLS (Nottingham, UK), who reviewed and
thoroughly corrected all of the contributions to this volume, ensuring that they are all of a
high linguistic standard.
GieBen, July 1997 HELMUT W. V AHRSON
Contents
The Historical Roots of Modern Brachytherapy
for Cervical and Endometrial Cancer
R.F. MOULD ....................................................... .
Basics
2 Radiobiological Considerations in Gynaecological Radiotherapy
R.G. DALE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 Diagnostic Workup and Staging
H. JUNKERMANN and D. VON FOURNIER
with contributions from H.W. VAHRSON 25
4 Radiation Planning in Female Genital Cancers
H.D. BOTTCHER, LA. ADAMIETZ, and B. SCHOPOHL . . . . . . . . . . . . . . . . . . . . . . . 39
Special Report
5 Cancer of the Vulva
J. BAHNSEN and H.J. FRISCH BIER 69
6 Special Malignancies of the Vulva
J. BAHNSEN and H.J. FRISCHBIER 99
7 Cancer of the Vagina
C.A. PEREZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
8 Cancer of the Female Urethra
B. MICAILY and M.F. DZEDA 133
9 Cancer of the Cervix
K. MORITA ......................................................... 143
10 Cancer of the Endometrium
M. HERBOLSHEIMER and K. ROTTE 241
11 Malignancies of the Ovaries
H.W. VA HRSON, U. NITz, and H.G. BENDER 297
12 Cancer of the Fallopian Tube
D.M. OSTAPOVICZ and L.W. BRADY 397
x Contents
13 Genital Soft Tissue Sarcomas
H.-A. LADNER and U. KARCK 415
14 Gestational Trophoblastic Disease
H.-A. LADNER and S. LADNER ......................................... 429
15 Management of Reactions and Complications Following Radiation Therapy
G. RAUTHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
16 Palliative Radiation Therapy in Female Genital Cancers
D. CARSTENS ....................................................... 455
17 Radiation Treatment of Benign Gynecologic Diseases
R. PFAB •..•......••.......••.•..•..•.••..••••.••.•.........•..•.•. 467
Subject Index ...................................................... 473
List of Contributors ................................................. 483
