1 / 77

Gynaecology Oncology

Gynaecology Oncology. Ram Athavale Consultant Gynaecological Oncology University Hospitals Coventry & Warwickshire NHS Trust. Aims. A framework for main gynaecological cancers To provide a foundation for further study. Gynaecological malignancies. Gynaecological malignancies.

Download Presentation

Gynaecology Oncology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Gynaecology Oncology Ram Athavale Consultant Gynaecological Oncology University Hospitals Coventry & Warwickshire NHS Trust

  2. Aims • A framework for main gynaecological cancers • To provide a foundation for further study

  3. Gynaecological malignancies National Cancer Regfistrations UK 2004

  4. Gynaecological malignancies • 5-yr survival better in the USA compared to the UK • Differences in registriesadvanced stage?Post code lottery - practice variations - under investment • Lack of specialised servicessome managed by general gynaecologists • No specific referral pattern

  5. Calman Hine report • A policy framework for commissioning cancer services : A report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales (1995) • Uniform high standard of care • Needs of patients and carers purchasers, planners and professionals • Improving Outcomes for Gynaecological Cancers 1999 (IOG guidelines) • Hub - Cancer Centre Spoke - Cancer Units

  6. Cancer Unit • Diagnostic roleRapid assessment units2 week wait referral clinicsColposcopy • MDT • Manage certain cancers/ suspected cancerCervix up to FIGO IA Uterus IA/IB, grade 1 or 2Ovary- risk of malignancy index< 200Vulva- diagnostic excision of tumours less than 2 cms • Refer all other cases to the Cancer Centre

  7. Cancer targets • Patient seen within 14 days of referral (2 week wait rule) • Specific criteria for referral of suspected cancer • 31 day target- max 31 days from decision to treat to 1st treatment • 62 day target max 62 days from urgent GP referral to 1st treatment

  8. Cancer Centre • Manage all referred cases from unitsFunction as units for the drainage population • MDT • Chemotherapy, radiotherapy • Research • Training programmes • Role overlap based on service organisation

  9. Treatment of cancer • Surgery • Chemotherapy • Radiotherapy • Palliative care • Supportive therapy • Multidisciplinary approach critical

  10. Qs

  11. Cervical cancer

  12. Histology • Low grade disease • HPV changes • CIN I • High grade disease • CIN II • CIN III • Invasive cancer • CGIN

  13. Cervical Cancer • Incidence 8.7/100,000 in England & Wales • Associated with • Young age at first intercourse • Number of sexual partners • HPV 16,18,33 • Smoking • Immunosuppresion

  14. Pathology • Peaks 35-44 and 75-85 • Squamous (70%) • Adenocarcinoma (12%) • Adenosquamous (12%) • Direct spread - anatomical

  15. Clinical features at presentation • Abnormal bleeding • PCB,IMB,PMB • Abnormal smears • Advanced disease relatedoffensive PV dischargeneuropathic painrenal failureDVT

  16. FIGO Staging • I – Confined to cervixIA Micro – invasive (<5mm from basement epithelium from which it originates)IA1 up to 3 mm deep and 7 mm wideIA2 3-5 mm deep and 7 mm wide • IB – macroinvasive tumourIB1 < 4 cms, IB2 > 4 cms • II – Beyond cervixIIA Upper 2/3 of vagina IIB Parametrium not reaching side wall

  17. FIGO stage cervical cancer • III – involves lower third vagina or side wall IIIA lower 1/3 vaginaIIIB Pelvic side wall • IV – Beyond true pelvisIVA Mucosa of bladder or rectumIVB Distant spread

  18. Clinical Staging +/- investigations • Visible tumour • PV/PR to check spread to parametrial/rectovaginal space • EUA, cystoscopy • +/- Sigmoidoscopy,proctoscopy • MRI • CXR • FBC,U&E,LFT • PET?

  19. Treatment • Micro invasive up to IA1cone biopsy to preserve fertility option simple hysterectomy • IA2radical hysterectomy, lymph nodes limited parametrectomy • IB1 and IIA radical hysterectomy • IB2 , IIB and above- chemoradiotherapy

  20. Surgical treatment • Radical hysterectomy and pelvic node dissection • BSO in older women or adenocarcinoma • Complications • Haemorrhage • Infection • Damage to bladder/bowel • Atonic bladder • Fistulae • Laparoscopic RH • Coelio- Schauta Radical vaginal hysterectomy, laparoscopic nodes

  21. Chemoradiotherapy • Current gold standard for IB2, IIB or above (apart from some cases with stage 4 disease) • External beam (teletherapy) • Pelvic spread especially nodes • Para-aortic • Intracavity (brachytherapy)cervical tumour • Concurrent chemotherapy platinum agent

  22. Fertility preservation- Radical trachylectomy • IA2, small volume IB1excise cervix, limited parametriumlaparoscopic node dissectionFertility preservationLong term survival data unavailableExpertise not always available Pregnancy outcomes promising

  23. Palliative procedures • ExenterationAnterior or posterior or both • Radiotherapy • Tumour embolisation • Symptom control only

  24. Prognosis Average 5 year survival • Stage I – 80%, higher for IA disease(95%), role for prevention • Stage II – 61% • Stage III – 32% • Stage IV – 15%

  25. Follow up • Clinical examination • Reassurance • Symptom relief – side effects of treatment • HRT • Psychosexual • Early detection of recurrenceVault smears limited role after radical surgeryNot recommended after radiotherapy

  26. Qs

  27. Ovarian cancer

  28. Ovarian cancer • Killer disease • 60-75% stage 3 or 4 • Incidence increases with age, plateaus by 60 • Early imaging - More lesions identified • About 6% of all ovarian cysts are malignant

  29. Aetiology • Majority sporadic (90%) • Genetic origin (up to 10%)BRCA1 gene – 40-60 % riskBRCA2 – 10-30%Two or more 1st degree relatives affectedHNPCC • Increased risk in nullips, early menarche, late menopause, ovarian stimulation, abnormal ovarian development

  30. Pathology • 85% of all ovarian cancers are epithelial in origin • Sex cord stromal -6% • Germ cell 2-3% • Secondary tumours – 6% • Epithelial - Borderline or malignant

  31. Presentation • Asymptomatic • Pelvic mass (diff. diagnosis) • Pressure symptoms/abdominal distension/GI symptoms • Pain • Abnormal bleeding • Hormonal effects

  32. Screening & Diagnosis • Clinical examination • CA-125 & Transvaginal scan/Abd. Scan • Other tumour markers - CEA, CA 19-9 • CT/MRI abdomen & pelvis • FBC,U&E, LFT, CXR • Overlap between benign and malignant

  33. Benign or malignant? • Risk of malignancy index (RMI)RMI = U X M X CA-125(direct value)U= ultrasound score 1 or 3bilateral, solid area, septationascites, other depositseach criterion 1 point0-1 criterion = score 12-5 criteria = score 3M = menopausal statuspremenopausal= score 1postmenopausal=score 3

  34. RMI score • RMI < 200more likely benignmanaged at Cancer Units • RMI > 200more likely malignantmanaged at Cancer Centre

  35. FIGO Staging • Surgical/ pathological • I – Confined to ovarieswith or without malignant ascites • II – Confined to pelvisincludes spread to uterus/ tubespelvic tissues • III – Confined to peritoneal cavitysize of omental mets decides IIIA/B/C • IV – Distant metastasese.g. liver / lung mets, malignant pleural effusion

  36. Management • Cancer centre • Surgery – Laparotomy,peritoneal washings, TAH BSO, omentectomy lymph nodes, peritoneal and diaphragmatic biopsies • Aim for Complete /Optimal cytoreduction • Adjuvant chemotherapy • Platinum based – carboplatin • Taxane – paclitaxel • Second line agents - caelyx, topotecan • Neoadjuvant chemotherapy followed by surgeryCHORUS trial

  37. Follow up • 5 years • History, Pelvic exam • CA-125 in most cases • Prognosis for recurrent disease poor • Overall 5 year survival, all stages together 30-35% • Early stage disease 60- 85% depending upon histological type, role for screening

  38. UKCTOCS trialUK Collaborative trial for ovarian cancer screening

  39. UKCTOCS trial • No screening v/s USS or CA-125 or combined modalities • Examine role for early diagnosisMorbidity of surgerySurvival benefit in cancer cases • Results by 2012

  40. Qs

  41. Endometrial / Uterine cancer

  42. Endometrial cancer • Predominantly a disease of postmenopausal women • <5% risk under age 40 • Numbers increasing, probably obesity related?Diet influence

More Related