L.W. Brady, M.W. Donner(t) H.-P. Heilmann, F.H.W. Heuck

Transcription

1 MEDICAL RADIOLOGY Diagnostic Imaging and Radiation Oncology Editorial Board Founding Editors Current Editors Diagnostic Imaging Radiation Oncology L.W. Brady, M.W. Donner(t) H.-P. Heilmann, F.H.W. Heuck A.L. Baert, Leuven F.H.W. Heuck, Stuttgart J.E. Youker, Milwaukee L.W. Brady, Philadelphia H.-P. Heilmann, Hamburg

2 Springer Berlin Heidelberg New York Barcelona Budapest Hong Kong London Milan Paris Santa Clara Singapore Tokyo

3 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

4 Professor Dr. HELMUT W. V AHRSON Leiter der Abteilung fur Gynakologische Radiologie und Strahlentherapie, Frauenklinik Klinikum der Justus-Liebig-Universitat Klinikstra6e 32, 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 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: e-tsbn-13: DOT: / Generative organs, Female-Cancer-Radiotherapy. 2. Generative organs, Female-Cancer-Imaging. 3. Radioisotope 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 R ] RC280.G5R ' dc This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer-Verlag Berlin Heidelberg 1997 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The pubishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: de'blik, Berlin Typesetting: Best-set Typesetter Ltd., Hong Kong SPIN: / Printed on acid-free paper

5 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 malignant 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, localregional recurrence remains a significant problem in gynecologic cancer, accounting for 50%-60% of failures of primary treatment regimens.

6 VI Foreword This volume, edited by Professor HELMUT W. V AHRSON, 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 July 1997 LUTHER W. BRADY HANS-PETER HEILMANN

7 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 introduced, 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 radiation 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 threedimensional 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 techniques. 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 longterm 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 components 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 surgeons 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 ( ), 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).

8 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

9 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 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 Special Report 5 Cancer of the Vulva J. BAHNSEN and H.J. FRISCH BIER 6 Special Malignancies of the Vulva J. BAHNSEN and H.J. FRISCHBIER Cancer of the Vagina C.A. PEREZ Cancer of the Female Urethra B. MICAILY and M.F. DZEDA Cancer of the Cervix K. MORITA Cancer of the Endometrium M. HERBOLSHEIMER and K. ROTTE Malignancies of the Ovaries H.W. V AHRSON, U. NITz, and H.G. BENDER Cancer of the Fallopian Tube D.M. OSTAPOVICZ and L.W. BRADY 397

10 x 13 Genital Soft Tissue Sarcomas H.-A. LADNER and U. KARCK Contents Gestational Trophoblastic Disease H.-A. LADNER and S. LADNER Management of Reactions and Complications Following Radiation Therapy G. RAUTHE Palliative Radiation Therapy in Female Genital Cancers D. CARSTENS Radiation Treatment of Benign Gynecologic Diseases R. PFAB Subject Index List of Contributors