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Gynecological oncology

Gynecological oncology. Prof. Roman Makarewicz Department of Oncology and Brachytherapy Collegium Medicum in Bydgoszcz. Cervical cancer.

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Gynecological oncology

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  1. Gynecologicaloncology Prof. Roman Makarewicz Department of Oncology and Brachytherapy Collegium Medicum in Bydgoszcz

  2. Cervicalcancer • Cancer of the cervix is the most common female genital cancer in developing countries every year about 500,000 women, acquire the disease and 75% are from frame developing countries. • About 300,000 women also die from the disease annually and of these 75% are from developing countries.

  3. Finland which has an advanced population based screening program has one of the lowest rates in the world.

  4. Riskfactors and anetilogy • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds. • Smoking Smoking for> 12 years increase the risk by 12.7 folds. • Male related risk factors: number of the partners previous sexual relationships is relevant . cervical cancer risk increased if partners has penile cancer (circumcision) Previous wife with cervical cancer. • Previous CIN • Poor uptake of screening program. • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids. • Immunosuppresion risk increased with immunosuppressed renal transplant patients and in HIV positive women

  5. Type of patient • Multiparous • Low socioeconomic class • Poor hygiene • Prostitutes • Low incidence in Muslims and Jews

  6. Symptoms

  7. Pathology type • Squamous cell carcinoma-90% • Adenocarcinoma-10%

  8. Types of growth • Exophytic: is like cauliflower filling up the vaginal vualt • Endophytic: it appears as hard mass with a good deal of induration • Ulcerative: an ulcer in the cervix

  9. Examination • Mainly vaginal examination using speculum nothing is found in early stage • Mass,ulcerating fungatingin the cervix • USG, NMR

  10. Pretreatment evaluation • Review history • General examination: • Anaemia • Lymphadenopathy-Supraclavicular LN • Renal area • Liver or any palpable mass • Oedema • Laboratory tests: • Chest X- ray • MRI • Ultrasound

  11. Staging Best to follow FIGO system • Examination under anaesthesia • Bimanual palpation • Cervical biopsy, uterine biopsy • MRI

  12. Stages of cancercervix • Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging • TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE

  13. Spread

  14. Differentialdiagnosis • Cervical ectropion • Cervical tuberculosis • Cervical syphilis, Schistosomiasis, and Choriocarcinoma are rare causes

  15. Treatment • Surgical • Radiotherapy • Radiotherapy & Surgery • Radiotherapy and Chemotherapy followed by Surgery • Palliative treatment

  16. The choice of treatment will depend on • Fitness of the patients • Age of the patients • Stage of disease • Type of lesion • Experience and the resources available

  17. Surgical procedure • The classic surgical procedure is the Wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient

  18. Werthemeim’s hystrectomy • Total abdominal hystrectomy including the parametrium • Pelvic lymphadenectomy • 3 cm vaginal cuff • The original operation conserved the ovaries,since squamous cell carcinoma does not spread directly to the ovaries • Oophorectomy should be performed in cases of adenocarcinoma as there is 5-10% of ovarian metastases

  19. Surgery offers several advantage • It allows presentation of the ovaries (radiotherapy will destroythem) • There is better chance of preserving sexual function • (vaginal stonosis occur in up 85% of irradiates • Psychological feeling of removing the disease from the body • More accute staging and prognosis

  20. Complications of surgery • Haemorrhage: primary or secondary • Injury to the bladder, ureters • Bladder dysfunction • Fistula • Lymphocele • Shortening of the vagina

  21. INDICATIONS OF P/O XRT FOLLOWING WERTHEIM’S HYSTERECTOMY (STAGE I, IIa): • Positive pelvic lymph nodes • Tumour close to resection margins and/or parametrial extension

  22. Radiotherapy • Stage IIb and III • Radical Radiotherapy • External irradiation (Teletherapy) • Intracavitary radiation (Brachytherapy) • In some cases of stage IIa or b radio and chemotherapy to be given then followed by simple hysterectomy

  23. Prognosis Depends on: • Age of the patient • Fitness of the patient • Stage of the disease • Type of the tumour • Adequacy of treatment

  24. THE OVERALL 5-YEARS SURVIVAL FOLLOWING THERAPY: • Stage I 80% • Stage II50-60% • Stage III30-40% • Stage IV4%

  25. Management of recurrentdisease • 1. Local recurrence: Radiation - if not used Pelvic exenturation • 2. Distant disease Chemotherapy

  26. Conclusions • Cancer of the cervix is still quite common, reduction in incidence depends on the quality of the screening program • The etiology appears to be multifactorial the prime oncogenic agent is probably [HPV-16,18] • Clinical presentation is with intermenstrual,postcoital, postmenospausal bleeding or following abnormal cytology • Tumour spreads locally to involve the uterus bladder, vagina, parametrium, ureters, rectum and bone

  27. Spread also to the internal and external iliac, obdurator and common iliac nodes then to para-aortic nodes • Distant metastasis spread to liver, lung and bone • Microinvasion squamous tumour carry a good prognosis allowing conservative treatment initially if required

  28. Early invasive squamous cell disease (stage Ib,IIa and in some cases of IIb) may be treated by either a Wertheime’s hysterectomy or radiotherapy as first line treatment • Advanced stage (IIb, III,IV) treated by radio or chemotherapy

  29. Glandular tumours (adenocarcinomas) are not detectable by screening are associated with skip lesions and require radical surgery

  30. Endometrialcancer • The exact cause is unknown • Estrogen • Estrogen replacement therapy • Tamoxifen • Women who have been treated with tamoxifen, a drug used to prevent and treat breast cancer may have a slighty increased risk of developing endometrial cancer

  31. Diagnosis • Hysteroscope/endoscope tube with vision is inserted into uterus through the cervix • Allows the doctor to view the inside of the uterus and collect endometrial tissue samples

  32. Signs and symptoms • Early symptoms • Vaginal bleeding or spotting in postmenopausal women • All bleeding without conection with periods between normal periods: extremely long, heavy or frequent episods of bleeding after sexual intercourses • Vaginal discharge • Late symptoms • Weight loss • Anemia • Lower abdominal pain

  33. Type of endometrialcancer • Type 1 • Caused by excess estrogen • Type 2 • Etiology unknown, but it doesn’t seem to be caused by too much estrogen

  34. Type 1 • Not very aggressive • Slow to spread to other tissues • Grades 1 or 2 • Occur most commonly in pre- and peri-menopausal women • History of estrogen exposure and endometrial hyperplasia • Carry a good prognosis

  35. Type 2 • Occur in older, post-menopausal women • More common in African-Americans • More likely to grow and spread outside of the uterus • Carry a poorer prognosis

  36. Endometrialadenocarcioma • 80% of uterine neoplasms • It arises from the glands of the endometrium • Essential is grade which says how aggressive cancer is • 40% Grade 1, 20% Grade 2, 40% Grade 3 • Example of type II cancer • The uterine papillary serous cancer (5% of cancers) • The uterine clear cell cancer (2% of cancers) • Both are aggressive and have high recurrence rate

  37. Treatment for endometrialcancer • Depends on: • The stage of the disease • Overallhealth of the patient • Primarytreatmentis the surgery • Radiationtherapy, hormonotherapy and chemotherapymay be used as anadjuvanttreatmentor in patients with metastaticorrecurrentdisease • Hysterectomy • Simple • Total including the cervix • Total with salpingo-ophorectomy • Total with salpingo-ophorectomy with nodalsampling • With pelviclymphadectomy • The proceduresaredoneusing a lowtransverseincisionor a verticalincision

  38. Chemotherapy • Treatmentthatusesdrugs to stop the growth of cancercells, either by killing the cellsor by stopping the cells from dividing • Treatmentusuallyinvolves a combination of twoorthreedrugsgivingintravenously • Whenchemotherapyisgiven • Adjuvanttretmentonceevery 21 days (6-8 cycles) • Metastaticdisease (to progression) • Whendrugsareused to treatendometrialcancer • Carboplatin • Cisplatin • Doxorubcin • Paclitaxel • Cyclophosphamide

  39. Radiationtherapy • The purpose is: • To get rid of any tumor cells that may be left in the body after surgery • Candidates: • Depends on: • Grade 2 and 3 • How deeply is invasion • Pathologic diagnosis • Methods: • Vaginal brachytherapy • External beam RT

  40. Hormonotherapy • Progestins as the main hormone treatment for endometrial cancer • Medroxyprogesterone acelate (Provere) • Megestrol acelate (Megace)

  41. There is no effective screening programme • Occasionally cervical smears contain endometrial cancer cells • Ultrasound thickness more than 5 mm in postmenopausal patients indicates a need for endometrial staging and one attention

  42. Ovariancancer - symptoms • Nonspecific • Persistent

  43. Symptoms • Bloating • Pelvic or abdominal pain • Difficulty eating or feeling full quickly • Urgency or urinary frequency • Most common is abdominal enlargement

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