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Gynaecological tumours. Prof.Dr.Póka Róbert. Female genital cancer incidence (N/100.000 population/year) in 2008 Eurostat, 2010. EUR HU Breast 88,4 78,7 Cervix 12,8 19,5 Endometrium 16,7 17,7 Ovary 13,7 13,7.

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gynaecological tumours

Gynaecological tumours

Prof.Dr.Póka Róbert

female genital cancer incidence n 100 000 population year in 2008 eurostat 2010

Female genital cancer incidence(N/100.000 population/year) in 2008Eurostat, 2010

EUR HU

Breast 88,4 78,7

Cervix 12,8 19,5

Endometrium 16,7 17,7

Ovary 13,7 13,7

female genital cancer mortality n 100 000population year in 2008 eurostat 2010

Female genital cancer mortality (N/100.000population/year) in 2008Eurostat, 2010

EUR HU

Breast 24,3 22,6

Cervix 5,2 5,7

Endometrium 3,8 3,6

Ovary 7,9 8,3

slide5

Cervical cancer treatment dilemmas

  • Early stg disease - Op, advanced - Rad
  • Rad limited by normal tissue tolerance
  • Clinically early might be biologically advanced
  • In early stg Op and Rad results are similar
indications and types of surgical treatment
Indications and types of surgical treatment
  • Preserve fertility
  • Classical Wertheim-Meigs operation
  • Neoadjuvant chemo followed by radical surgery
  • Surgery for recurrent disease
trachelectomy s necessity

Trachelectomy’s necessity

Changing morbidity

Changing demography

Changing technology

prerequisites of trachelectomy

Prerequisites of trachelectomy

Ca.cx.ut. Std. Ia1,Ia2,Ib1

Parametrial spread excluded by CT, MR

Fitness for surgery

Fertility preservation is desired

trachelectomy cases i

Trachelectomy cases I.

ID Age Stg Th Follow-up grav.

31 Ib1 (12*3mm) VTR 2x delivery (SC)

28 Ia1 (7*2mm) VTR+LND 1x deliver (SC)

25 Ia2 (7*3mm) VTR+LND 1x deliver (SC)

34 Ib1 (12*7) VTR+LND 1x deliver (SC)

36 Ia2 (5*3) VTR(R1)TAH+LND

TR: trachelectomy

LND: lymphadenectomy

trachelectomy cases ii

Trachelectomy cases II.

ID Age Stg Th Follow-up

6. 34 Ia1 (3*1mm) VTR 61mths NED

36 Ib1 (12*8mm) VTR+LND N1! 41mths NED

34 Ib1adeno ATR(R1N1)WM 23mths DOD

30 Ia1adeno ATR+LND 39mths NED

34 Ib1 ATR(N1)WM 25mths DOD

30 Ib1 ATR+LND 17mthsNED

TR: trachelectomy

LND: LSC lymphadenectomy

aims of neoadjuvant chemoterapy
Aims of neoadjuvant chemoterapy
  • Prevent spread
  • Down-staging
  • Tumour-demarcation
modes of administration
Modes of administration
  • Monotherapy or combined chemotherapy
  • Cyclical
  • Systemic or regional
mechanism of action
Mechanism of action
  • Alkilating Cytoxan,Ifosfamid
  • Antimitotic Vincristin, Taxol
  • Antimetabolites Methotrexat, Fluorouracil
  • Antibiotics Bleomycin, Mitomycin, Adriamycin, Peplomycin
  • Anticytosceletal Taxanes
  • Other Cisplatin, Carboplatin
side effects
Side-effects
  • Immediate endothel necrosis
  • Early nausea, vomiting, emesis, myelodepression
  • Late alopecia,myelodepression,mucositis, fibrosis pulmonum, neuritis, diarrhoea,insuff.hepatorenalis, cardiomyopathy
protocol
Protocol
  • BIP Bleomycin 30mg/12hrs 1.day

CDDP 50mg/m2

2.day

Ifosfamid 3 g/m2 3.day

Mesna 1g/m2 3*

3-weekly

neoadjuvant bip chemoterapy at ud mhsc
Neoadjuvant BIP chemoterapyat UD MHSC
  • Ib2-IIb N=23 (out of 100 WM)
  • Mean age 50 yrs (33-66)
  • Adenoca = 2, Planocell = 21
  • pTy0N0M0=7
  • pTy1-3N1M0=6
female genital cancer incidence n 100000 yr in 2008 eurostat 2010

Female genital cancerIncidence (n/100000/yr) in 2008Eurostat, 2010

EUR HU

Breast 88,4 78,7

Cervix 12,8 19,5

Corpus 16,7 17,7

Ovary 13,7 13,7

female genital cancer mortality n 100000 yr in 2008 eurostat 2010

Female genital cancerMortality (n/100000/yr) in 2008Eurostat, 2010

EUR HU

Breast 24,3 22,6

Cervix 5,2 5,7

Corpus 3,8 3,6

Ovary 7,9 8,3

gynecologic tumors staging in general

Gynecologic tumorsStaging in general

I localized to organ of origin

II spread to adjacent tissues

III regional lymphatic spread

IV distant metastasis

corpus cancer origin
Corpus cancer - Origin
  • Endometrial cancer
  • Endometrial stroma sarcoma
  • Myometrial sarcoma
gynecologic tumors staging in general1

Gynecologic tumorsStaging in general

I localized to organ of origin

II spread to adjacent tissues

III regional lymphatic spread

IV distant metastasis

histologic type distribution

Histologic type distribution

Endometrioid 82 %

Adenosquamous 6 %

Mucinous 1%

Papillary serous 4 %

Clear cell 2 %

Squamous 0,5 %

Other 4,5 %

pathogenesis
Pathogenesis
  • Estrogen-dependent proliferation
  • Lack of gestogen-suppression
  • Insulin-resistance
  • Tumorsuppressor-mutations (p53,p21)
  • Extragonadal aromatase-activity
characteristic associated disorders and medical history
Characteristic associated disorders and medical history
  • Hypertension
  • Diabetes mellitus
  • Obesity
  • PCO
  • Anovulatory cycles
  • Less pregnancies
  • Shorter lactation
diagnosis

Diagnosis

Histologic verification

prognostic factors in endometrial cancer
Prognostic factors in endometrial cancer
  • Age
  • Histologic type
  • Degree of differentiation
  • Depth of myometrial invasion
  • Cervical involvement
  • Adnexal involvement
  • Lymphatic spread
  • Distant metastasis
pathologic staging changes in 2010

Pathologic staging(changes in 2010)

Ia Localized to endometrium

Ib (Ia) Superficial myometrium-invasion

Ic (Ib) Deep myometrium-invasion

IIa (Ib) Spread to cervix mucosa

IIb (II) Cervical stromal involvement

IIIa Adnex/serosa involvement

IIIb Vaginal metastasis

IIIc (IIIc1/IIIc2) Pelv./paraaort. nodal metastasis

IVa Bladder/rectum invasion

IVb Distant metastasis

slide32

I

IA (FIGO 2010)

IB (FIGO 2010)

IB (FIGO 2010)

II (FIGO 2010)

IIIc2 (FIGO 2010)

IIIc1 (FIGO 2010)

treatment
Treatment
  • Surgery (TAH+BSO+lymphadenect)
  • Radiotherapy (adjuvant or primary)
  • Chemotherapy (adjuvant or primary)
  • Gestogen therapy (adjuvant)
five year survival

Five-year survival

Surgery 84%

Radiotherapy 45,3%

Radiosurgery 83,6%

Surgery+Radiotherapy 82,4%

Surgery+Chemotherapy 59,8%

Hormonal therapy 42,9%

prevention
Prevention
  • Combined oral contraceptives >10yrs
  • Bodyweight control
  • Oncological surveillance
  • Progestogenic opposition
endometrial cancer young cases

Endometrial cancer young cases

All cases 1368

Age <45 yrs 96

Age <45 yrs without hysterectomy 6

endometrial cancer cases at ud mhsc without hysterectomy

Endometrial cancer cases at UD MHSC without hysterectomy

ID Age Stg Th Grav Follow-up

27 IaG1 6*Cu P2 25yrs PD

43 IaG1 2*Cu 0 8yrs NED

29 IIG1 Cu+2*IC 0 24yrs ov.ca.III/b

25 IaG1 Cu+5*IC 0 4yrs PCOD

30 IaG1 Cu+MPA 0 2yrs NED

23 IaG1 Cu+MPA 0 1yr NED

ovarian cancer
Ovarian cancer
  • Epidemiology
  • Incidence, mortality
  • Staging
  • Diagnostic work-up
  • Debulking surgery (pathological staging)
  • Adjuvant chemotherapy
  • Neoadjuvant chemotherapy
vulval carcinoma epidemiology
Vulval carcinoma, Epidemiology
  • Disease of the elderly
  • 2-3% of all genital cencers
  • In Hungary 122 new cases in 1994, 205 in 2005
  • 90% squamous
figo stages
FIGO stages
  • Ia <2cm, <1mm invasion
  • Ib <2cm, >1mm invasion
  • II >2cm
  • III urethra/vagina/perineum/anus involvement, unilateral inguinal met
  • IVa rectal/bladder involvement, bilateral inguinal met
  • IVb distant met
tnm stages
TNM stages
  • FIGO T N M
  • Ia 1a 0 0
  • Ib 1b 0 0
  • II 2 0 0
  • III 1-3 0-1 0
  • IVa 1-3 2 0
  • IVa 4 0-2 0
  • IVb 1-4 0-2 1
macroscopic appearance
Macroscopic appearance
  • Superficial 5-15%
  • Exophytic 40%
  • Endophytic 45%
spread
Spread
  • Inguinal and femoral lymph nodes
  • Cloquet/Rosenmüller nodes
  • Parailiac nodes
evolution of surgical treatment
Evolution of surgical treatment
  • Parré-Jones
  • Inguinali radiotherapy
  • <1 mm invasion warrants no nodal disease
  • Sentinel nodes
  • Neville Hacker
progression free survival improved by lymphadenectomy
Progression free survival improved by lymphadenectomy

Vulvectomy+lymphadenectomy -

Vulvectomy

overall survival improved by lymphadenectomy
Overall survival improved by lymphadenectomy

Vulvectomy+lymphadenectomy -

Vulvectomy

summary of treatment for vulval cancer
Summary of treatment for vulval cancer
  • Survival of vulval cancer with no spread to urinary or GI tracts is improved by adding lymphadenectomy to wide excision of primary tumour.
  • Advanced or regional metastatic disease treated with radiotherapy
  • Disseminated tumours require chemotherapy
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