Overview                                                                               

The female genital tract consists of the ovaries, uterus and fallopian tubes, the cervix, vagina and vulva.

Cancers may arise from any of the components of the female genital tract.  However, the most common sites are the ovary and uterus, with approximately 23,000 and 36,000 new cases diagnosed each year in the United States. 

While extremely common outside the United States, cervical cancer arises in less than 13,000 women each year in this country, primarily due to improved screening practices.  Cancers of the vulva and vagina are rare with approximately 3,400 and 2,100 cases diagnosed each year.

The presenting signs and symptoms vary between the different tumor sites.  Patients with uterine and cervical cancers typically present with vaginal bleeding, the later patients may complain of bleeding after intercourse (post-coital bleeding). Vulva cancer patients are typically older and present with a palpable mass in the labia.  Ovarian cancer is the most insidious in terms of symptoms with patients presenting with vague complaints of abdominal bloating and pain. 

Interested in learning more about specific gynecologic tumors? Check out the American Cancer Society website.

Role of Radiation Therapy                                                 

Radiotherapy is used in the treatment of a wide variety of gynecologic cancers. In women with cervical cancer, radiation may be used alone in early stage tumors (view paper), or combined with chemotherapy in locally advanced disease (view paper). In addition, radiation may be used prior to (preoperative radiotherapy) (view paper) or following (postoperative radiotherapy) (view paper) surgery in patients with high risk factors. 

While previously commonly delivered preoperatively in women with endometrial cancer, radiation therapy is now almost exclusively delivered following surgery in patients with high risk features, for example, lymph node involvement (view paper).  Radiation may also be used alone (definitive radiotherapy) in women unfit for definitive surgery due to advanced age and/or multiple medical problems (view paper).

Radiation is commonly delivered in patients with vaginal and vulvar cancers.  In vaginal cancer, radiation is often the sole treatment (view paper).  In patients with vulvar cancer, it is more commonly delivered following surgery (view paper) or, in patients with locally advanced tumors, prior to surgery to reduce the need for radical surgery (view paper).

Radiation Therapy Techniques                              

External Beam Radiation Therapy

Conventional 4-field “box” technique

More comprehensive treatment fields are used in select gynecology patients, for example pelvic plus inguinal (groin) irradiation in vaginal cancers patients due to the potential involvement of tumor to the groin lymph nodes.  Other patients may require irradiation of the para-aortic lymph nodes in the abdomen in conjunction with pelvic radiotherapy, a technique known as extended field irradiation. 

Although less commonly used today, select gynecology patients have been treated with fields encompassing the entire abdomen (whole abdominal irradiation). 

Brachytherapy

Many gynecology patients are treated with internal radiation therapy (brachytherapy). Brachytherapy is a method of delivering radiation to tumors by placing radioactive sources in close proximity to the tumor (“intracavitary” brachytherapy) or within the tumor itself (“interstitial brachytherapy). The more common approach is intracavitary brachytherapy.

Since the radiation source is placed close to the tumor, higher doses can be typically delivered than with external beam treatment.  Moreover, rapid dose falloff around the sources means that less radiation is delivered to surrounding normal tissues. Brachytherapy may be delivered alone or in conjunction with external beam irradiation.

Gynecologic brachytherapy is performed with either high-dose-rate (HDR) or low-dose-rate (LDR) techniques.  LDR approaches predominantly for much of the last century and have been used in a wide variety of tumor sites, notably cervical and uterine cancers.

Fletcher-Suit-Declos Applicator LDR Brachytherapy, Cervical Cancer

More recently, HDR have all but replaced LDR techniques.  Unlike LDR, HDR is an outpatient procedure avoiding the need for general anesthesia and a prolonged hospital stay at bedrest.  This is particularly appealing in the elderly and in patients with multiple medical problems.

HDR brachytherapy uses high activity Iridium-192 sources, allowing treatment to be delivered within minutes as opposed to days.  HDR is performed in a special HDR Suite within the Department of Radiation Oncology. Between treatments, the Iridium source is stored in a shielded device and is delivered under computer control.

HDR Brachytherapy is the preferred Brachytherapy approach performed at UCSD and is used in a wide variety of gynecologic tumors including cervical cancer and endometrial (uterine) cancers.

Interesting in learning more about brachytherapy? Click here for an overview of brachytherapy.

Intensity Modulated Radiation Therapy (IMRT)                                     

Over the years, external beam radiation therapy treatment planning has progressed from 2-dimensional (2D) to 3-dimensional (3D) conformal RT (3DCRT) techniques.  3DCRT has allowed treatment to be individualized to the patient’s anatomy.

In recent years, a sophisticated form of 3DCRT is being increasingly used in patients with gynecologic tumors known as intensity modulated radiation therapy (IMRT).  Unlike conventional approaches, IMRT using highly modulated beams designed using sophisticated computerized optimization planning. When cast into the patient, these modulated beams better conform the radiation dose to the shape of the tumor in 3D, further reducing the volume of normal surrounding tissues receiving high doses.

IMRT Plan in a patient with endometrial cancer

In a recent survey of practicing radiation oncologists in the United States performed by Dr. Mundt and colleagues, gynecology cancers were found to be the 4th most common sites treated by IMRT in the United States.  Moreover, it was the most rapidly growing IMRT site behind prostate, head and neck cancers and prostate cancer.

Dr. Arno Mundt, the Chairman of the Department of Radiation Oncology, pioneered the use of IMRT in gynecologic cancers.  In a series of reports, he demonstrated the superiority of IMRT planning over conventional techniques (view paper), and subsequently, low rates of toxicity in gynecology patients treated with IMRT (view paper 1 and paper 2). 

Gynecology patients treated at UCSD routinely undergo treatment with IMRT to help reduce the risk of acute and chronic radiation toxicities.

Ask your physician whether IMRT is right for you.

UCSD Gynecologic Cancer Team                          

The UCSD Gynecologic Cancer Team is comprised of dedicated professional with considerable experience in the treatment of women with gynecologic tumors. 

Catheryn Yashar M.D. is the Chief of the Gynecologic Cancer Service in the UCSD Department of Radiation Oncology.

Catheryn Yashar, M.D. Chief, Breast Cancer Service Department of Radiation Oncology

Initially trained in the fields of Obstetrics & Gynecology and Gynecologic Oncology, Dr. Yashar has many years of experience caring for women with gynecologic cancers.  She has considerable expertise in a wide variety of radiotherapy techniques used in the treatment of these patients, including HDR brachytherapy and IMRT.

Working with Dr. Yashar in the Department of Radiation Oncology is Arno J. Mundt, M.D., Departmental Chair, and Radiation Nurse, Fiona Nasseradin, R.N.

Arno J. Mundt, M.D. Chair, Department of Radiation Oncology

Fiona Nasseraddin, R.N. Radiation Nurse Department of Radiation Oncology

The treatment of gynecologic cancer patients is a team approach. Dr. Yashar works together with UCSD gynecologic oncologists Steve Plaxe, M.D., Cheryl Saenz, M.D. and Brad Silverman, M.D.  All patients consulted at UCSD are presented and discussed at a multi-disciplinary Gynecologic Oncology Conference.

Steve Plaxe, M.D. Chief, Division of Gynecologic Oncology

Cheryl Saenz, M.D. Gynecologic Oncologist

Brad Silverman, M.D. Gynecologic Oncologist

Gynecologic Oncology Publications by UCSD Radiation Oncology Faculty      

Listed below are Gynecologic Cancer Articles published by members of the UCSD Department of Radiation Oncology.  For a full list of published articles by UCSD Radiation Oncology faculty see Research section

Mell LK, Kochanski JD, Roeske JC, Haslam JJ, Mehta N, Yamada SD, Hurteau JA, Collins YC, Lengyel E, Mundt AJ. Dosimetric predictors of acute hematologic toxicity in cervical cancer patients treated with concurrent cisplatin and intensity-modulated pelvic radiotherapy. Int J Radiat Oncol Biol Phys 2006;66:1356

Aydogan B, Wang S, Smith B, Mundt AJ, et al. A dosimetric analysis of intensity-modulated radiation therapy (IMRT) as an alternative to adjuvant high-dose-rate (HDR) brachytherapy in early endometrial cancer patients. Int J Radiat Oncol Biol Phys 2006;65:266

Kochanski JD, Mell LK, Roeske JC, Mundt AJ. Intensity modulated radiation therapy in gynecologic malignancies: current status and future directions. Clin Adv Hem Oncol 2006:4:379-386

Salama JK, Mundt AJ, et al. Preliminary outcome and toxicity report of extended field intensity modulated radiation therapy for gynecologic malignancies. Int J Radiat Oncol Biol Phys 2006;65:1170-6

Xia D, Roeske JC, Yu L, Pelizzari CA, Mundt AJ, et al. A hybrid approach to reducing computed tomography metal artifacts in intracavitary brachytherapy. Brachytherapy 2005;4:18

Saxena A, Yashar CM, et al.  Cellular response to chemotherapy and radiation in cervical cancer. Am J Obstet Gynecol 2005;192: 1399

Burke T, Muggia F, Mundt AJ. Uterine Cancer. In: Devita V, Hellman S, Rosenberg (eds). Principles and Practice of Oncology.  Williams and Wilkins, Baltimore, 2005

Fleming GF, Montag AC, Mundt AJ, et al.  Uterine Malignancies.  In: Chang AE, Ganz PA, Hayes DF et al. (Editors). Oncology: An Evidence-Based Approach. Blackwell Publishing Ltd, Oxford, 2005

Yashar CM, Spanos WJ, Taylor DD, Gercel-Taylor C. Potentiation of the radiation effect with genistein in cervical cancer cells. Gyn Onc 2005;99:199

Haslam JJ, Lujan AE, Mundt AJ, et al.  Setup errors in patients treated with intensity modulated whole pelvic radiation therapy for gynecological malignancies. Med Dosim 2005;30:36

Schroder M, Mell LK, Hurteau JA, Collins YC, Rotmensch J, Waggoner SE, Yamada SD, Small W, Mundt AJ. Clitoral therapy device for treatment of sexual dysfunction in irradiated cervical cancer patients. Int J Radiat Oncol Biol Phys 2005;61:1078

Roeske JC, Lujan A, Reba RC, Penney BC, Yamada SD, Mundt AJ. Incorporation of SPECT bone marrow imaging in intensity modulated whole pelvic radiation therapy treatment planning for gynecologic malignancies. Radiother Oncol 2005;77:11

Mundt AJ, et al.  Phase I trial of concomitant vinorelbine, cisplatin and pelvic irradiation in cervical carcinoma and other advanced pelvic malignancies. Gynecol Oncol 2004;92:801

Salama JK, Roeske JC, Mehta N, Mundt AJ. Intensity modulated radiotherapy therapy in gynecologic malignancies. Curr Treat Options Oncol 2004;5:97

Citron J, Mundt AJ. Pathologic stage I-II endometrial cancer in the elderly: radiotherapy indications and outcome. Int J Radiat Oncol Biol Phys 2004;59:1432

Rowinsky E, Mundt AJ. 21st Century Innovative Therapies. In: Hoskins WJ, Perez CA, Young RC (eds). Principles and Practice of Gynecologic Oncology. J.B. Lippincott, Philadelphia, 2004

Mell LK, Meyer JJ, Tretiakova M, Kramtsov A, Gong C, Yamada SD, Montag AG, Mundt AJ. Prognostic significance of E-cadherin protein expression in pathologic stage I-III endometrial cancer. Clin Cancer Res 2004;10:5546

Murphy K, Rotmensch J, Yamada SD, Mundt AJ. Patterns of failure and outcome of clear cell carcinoma of the uterus: implications for adjuvant radiation therapy. Int J Radiat Oncol Biol Phys 2003;55:1272

Mundt AJ, Mell LK, Roeske JC. Preliminary analysis of chronic gastrointestinal toxicity in patients with gynecologic malignancies treated with intensity modulated whole pelvic radiation therapy. Int J Radiat Oncol Biol Phys 2003;56:1354

Mell LK, Mundt AJ. Concern with "Is there a survival benefit to adjuvant radiotherapy in high-risk surgical stage I endometrial cancer?" (Letter to the Editor). Gynecol Oncol 2003;90:499

Lujan AE, Mundt AJ, et al.  Intensity-modulated radiotherapy as a means of reducing dose to bone marrow in gynecologic patients receiving whole pelvic radiotherapy. Int J Radiat Oncol Biol Phys 2003;57:516.

Mehta N, Yamada SD, Rotmensch J, Mundt AJ. Outcome and pattern of failure in pathologic stage I-II papillary serous carcinoma of the endometrium: implications for adjuvant radiation therapy. Int J Radiat Oncol Biol Phys 2003;57:1004

Roeske JC, Bonta D, Lujan AE, Mell LK, Yamada SD, Rotmensch J, Mundt AJ. A dosimetric analysis of acute gastrointestinal toxicity in women receiving intensity-modulated whole-pelvic radiation therapy.  Radiother Oncol 2003;69:201

Roeske JC, Lund C, Pelizzari CA, Pan X, Mundt AJ. Reduction of computed tomography metal artifacts due to the Fletcher-Suit applicator in gynecology patients receiving intracavitary brachytherapy. Brachytherapy 2003;2:207

Mundt AJ, et al.  Intensity modulated whole pelvic radiation therapy in women with gynecologic malignancies. Int J Radiat Oncol Biol Phys 2002;2:1330

Mundt AJ, et al.  Intensity-modulated radiation therapy in gynecologic malignancies. Med Dosim 2002;27:131

Mundt AJ, et al.  Treatment of Recurrent Endometrial Cancer: Chemotherapy, Hormonal therapy, and Radiation Therapy. In: Gershenson, Gore, McGuire, Quinn, Thomas (eds). Gynecologic Cancer: Controversies in Management. Elsevier Science (USA), Philadephia, 2002

Brixey C, Roeske JC, Lujan AE, Mundt AJ. Impact of intensity modulated whole pelvic radiation therapy on acute hematologic toxicity in women with gynecologic malignancies. Int J Radiat Oncol Biol Phys 2002;54:1388

Mundt AJ, et al.. Can intensity modulated radiation therapy replace brachytherapy in the treatment of patients with cervical cancer? Point. Brachytherapy 2002;1:192

Mundt AJ. Commentary on “Postoperative pelvic radiotherapy improved locoregional control but not survival in stage I endometrial carcinoma” Creutzberg CL, van Putten WLJ, Koper PCM, et al. Lancet 2000;355:1404-1411. Evidence-based Obstet Gynecol 2001;3:46

Mundt AJ, et al.  Phase I trial of concomitant vinorelbine, paclitaxel and pelvic radiation therapy for cervical cancer and other advanced pelvic malignancies.  Gynecol Oncol 2001;82:333

Ashman JA, Connell PP, Rotmensch J, Waggoner S, Yamada SD, Mundt AJ.  Outcome and management of endometrial carcinoma patients with involvement of the uterine serosa. Gynecol Oncol 2001;82:338

Mundt AJ, et al.  Pelvic recurrence in high-risk pathologic stage I-IV endometrial carcinoma patients following adjuvant chemotherapy alone: implications for adjuvant radiation therapy. Int J Radiat Oncol Biol Phys 2001;50:1145

Mundt AJ, et al.  Surgery and postoperative radiation therapy in FIGO stage IIIC endometrial carcinoma. Int J Radiat Oncol Biol Phys 2001;50:1154

Mundt AJ, et al.  Initial clinical experience using intensity modulated whole pelvic radiation therapy for gynecologic malignancies. Gynecol Oncol 2001;82:456

Phelan C, Montag A, Rotmensch J, Yamada SD, Waggoner SE, Mundt AJ. Outcome and management of pathologic stage I endometrial cancer patients with involvement of the lower uterine segment. Gynecol Oncol 2001;83:513

Wollschlaeger K, Connell, PP, Waggoner S, Rotmensch  J, Mundt AJ.  Acute problems during low-dose-rate intracavitary brachytherapy for cervical carcinoma. Gynecol Oncol 2000;76:67

Tran BN, Connell PP, Waggoner S, Rotmensch J, Mundt AJ.  Characteristics and outcome of endometrial carcinoma patients age 45 years and younger.  Am J Clin Oncol 2000;23:476

Mundt AJ, et al.  Do conventional pathologic features lose their prognostic significance following postoperative radiation therapy in pathologic stage 1-II endometrial carcinoma?  Int J Cancer 2000;90:224

Castro IN, Connell PP, Waggoner S, Rotmensch J, Mundt AJ.  Synchronous ovarian and endometrial malignancies.  Am J Clin Oncol 2000;23:521

Rotmensch J, Connell PP, Yamada D, Waggoner SE, Mundt AJ.  One versus two intracavitary brachytherapy applications in early stage cervical cancer patients undergoing definitive radiation therapy.  Gynecol Oncol 2000;78:32

Mundt AJ, et al.  Age as a prognostic factor for recurrence in patients with endometrial carcinoma.  Gynecol Oncol 2000;79:79

Roeske JC, Lujan A, Rotmensch J, Waggoner SE, Yamada D, Mundt AJ. Intensity modulated whole pelvic radiation therapy in patients with gynecological malignancies.  Int J Radiat Oncol Biol Phys 2000;48:1613

Connell PP, Rotmensch J, Waggoner S, Mundt AJ.  Significance of adnexal involvement in endometrial carcinoma. Gynecol Oncol 1999;74:74

Connell PP, Waggoner S, Rotmensch J, Mundt AJ.  Race and clinical outcome in endometrial carcinoma.  Obstet Gynecol 1999;94:713

Calvin D, Connell PP, Rotmensch J, Waggoner S, Mundt AJ.  Surgery and adjuvant radiation therapy in stage II endometrial carcinoma.  Am J Clin Oncol 1999;22:238

Mundt AJ, et al.  Phase I trial of concomitant chemoradiotherapy for cervical cancer and other advanced pelvic malignancies.  Gynecol Oncol 1999;72:45

Mundt AJ, et al.  Preoperative intracavitary brachytherapy in early stage cervical carcinoma,  Am J Clin Oncol 1999;22:737

Weiss M, Connell P, Rotmensch J, Waggoner S, Mundt AJ.  External pelvic radiation therapy in stage IC endometrial carcinoma, Obstet Gynecol 1999;93:599

Mitchell PA, Rotmensch J, Waggoner S, Mundt AJ.  Radiation therapy in elderly patients with cervical carcinoma.  Gynecol Oncol 1998;71:291

Mundt AJ, et al. Race and clinical outcome in patients with cervical carcinoma undergoing radiation therapy. Gynecol Oncol 1998;71:151

Roeske J, Mundt AJ. et al.  Late rectal sequelae following definitive radiation therapy for carcinoma of the uterine cervix: a dosimetric analysis.  Int  J Radiat  Oncol  Biol  Phys 1997;37:351

Shields LB, Gercel-Taylor C, Yashar CM, et al.   Induction of immune responses to ovarian tumor antigens by multiparity.  J Soc Gynecol Investig 1997;4:298

Yashar CM, et al.  Lymophokine-activated killer (LAK)-mediated lysis of sequentially isolated ovarian cancer cell lines.  Am J Reprod Immunol 1997;38:431

Pearl ML, Yashar CM, et al. Exponential regression of CA 125 during salvage treatment of ovarian cancer with taxol.  Gyn Onc 1994;53:339

Sharma S, Singhal S, Sandhu APS, et al. Local thermoradiotherapy in carcinoma cervix : Improved local control versus increased incidence of distant metastasis. Asia - Oceania J Obstet Gynaecol 1991;17:5