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Gynecologic malignancies (Uterine Cervix (Classification (Stage IA disease…
Gynecologic malignancies
- incidence: breast > colon > lung > uterus > cervix > ovary
- mortality: breast > lung > colon > pancreas > ovary > stomach > cervix > CNS > uterus
Uterine Cervix
- 4th most common cancer in women,
- 7th overall (9th cause of death)
- 85% occurs in developing countries
- the most common cancer in women in Eastern and Middle Africa.
- Mean age of diagnosis 52 years
- Squamous cell carcinoma 85%-90%
Risk factors
low socioeconomic group
first intercourse in early age
multiple partners
large number of pregnancies
sexually transmitted diseases
-
Screening
- exfoliative cytology (Pap smear)
initial smear 18y /any age sexually active or 21y or 25y up to 60-65y
every 3 years
can find early cell changes and treat them before they become cancer.
- HPV test every 5 years
-
Symptoms
- CIN and early invasive cancer:
usually asymptomatic and detected only with screening
- postcoital bleeding
- irregular menses or postmenopausal bleeding yellowish, bloody, foul-smelling vaginal discharge
- pelvic or back pains
- urinary symptoms
Diagnosis
Clinical examination (supraclavicular areas)
Speculum examination
Bimanual rectovaginal examination
Chest X-ray
CT scan of abdomen and pelvis
Lab tests: complete blood count, blood chemistry
Classification
-
Stage IA disease
- Stage IA1 = <3mm depth of invasion and <7mm wide
- Stage IA2 = 3-5mm depth of invasion and <7mm wide
- Treatment = LLETZ
Stage IB disease
- Stage IB = any tumour which is visible
- Stage IB1 = <4cm
- Stage IB2 = >4cm
- Confined to cervix
- Treatment: Surgical for 1B1, Chemoradiotherapy for IB2
Stage II disease
- Stage II = invades beyond uterus, but not to pelvic sidewall or lower 1/3 of vagina
- Stage IIA – spread into the top of the vagina
- IIA1 = <4cm
- IIA2 = >4cm
- Stage IIB – spread into parametrium
Stage III disease
- Tumour extends to pelvic sidewall and/or involves lower 1/3 of vagina and/or causes hydronephrosis
- Stage IIIA – Cancer has spread to lower 1/3 of vagina, but not to pelvic sidewall
- Stage III B disease
- Spread to pelvic sidewall and / or hydronephrosisa
Stage IV
- Carcinoma has extended beyond true pelvis or has involved mucosa of bladder or rectum
- Stage IVA – spread of growth to adjacent organ
- Stage IVB – spread to distant organs
Treatment
Early stages – surgery or radiotherapy
IIB-IIIB – radiotherapy (+chemotherapy)
IVB – palliative treatment
Surgery
- IA:
hysterectomy
conization in selected groups
- IB - IIA
radical hysterectomy+pelvic lymph node dissection (Wertheim-Meigs operation)
- IIB – IVB
surgery not recommended!!
Radiation Therapy
- IIB – IIIB:
external beam irradiation 50 Gy
brachytherapy ~ LDR 2x17-20 Gy, HDR 4x7Gy
-
-
Endometrial carcinoma
Epidemiology
- most common female reproductive cancer
- 6% of all cancers, 2% of cancer deaths in women
- mostly postmenopausal
- mean age 63 years
Risk factors
- Early menarche (age <12), late menopause (age >52)
- Infertility or nulliparity
- Obesity
- Treatment with tamoxifen for breast cancer
- Estrogen replacement therapy (ERT)
- Diet high in fat
- Diabetes
- Age greater than 40
- Caucasian women
- Family history of endometrial cancer or hereditary nonpolyposis colon cancer (HNPCC)
- Personal history of breast or ovarian cancer
-
Diagnosis
- No standard screening
- endometrial biopsy and curretage
- chest x-ray
- Pelvic examination
- Pap smear (detect cancer spread to cervix)
- Dilation and curettage
- Transvaginal ultrasound
-
Classification
FIGO
IA Tumor invades up to or less than 1⁄2 of myometrium
IB Tumor invades to more than 1⁄2 of myometrium
IIA Endocervical glandular involvment
IIB Cervical stromal invasion
IIIA Tumor invades serosa and/or adnexa and/or cancer cells in ascites or peritonal washing
IIIB Vaginal involvment
IIIC Regional lymph nodes metastases
IVA Tumor invades bladder mucosa and/or bowel mucosa
IVB Distant metastasis
Treatment
Surgery
- total hysterectomy and bilateral salpingooophorectomy +/- pelvic lymphadenectomy
-
-
-
Metastatic disease
- chemotherapy
- hormone therapy (progesterone, tamoxifen)
Uterine sarcoma
- Cancer of the uterine stromal layers
- 2-4% of uterine cancers
- Types:
Endometrial stromal sarcoma,
Leiomyosarcoma,
Carcinosarcoma (most common)
Risk Factors
- Race (2x more common in African Americans)
- Age (more common in 50s and 60s)
- Endometrial cancer risk factors:
Obesity, Estrogen replacement or tamoxifen therapy, Infertility, Diabetes, Early menarche or late menopause
Diagnosis
Pap smear, Biopsy, D & C, Hysteroscopy, Transvaginal ultrasound, CT scan
treatment
Radical
- Surgery:
+/- Radiation Therapy
+/- Chemotherapyf
Palliative
- Chemotherapy
- Hormone Therapy (in ER+)
Ovarian Cancer
Epidemiology
- Most lethal of gynecologic malignancies, >70% in advanced stage
- Increases with age
- Usually NOT due to a predisposing genetic factors
Only 5-10% are related to genetic mutations:
-BRCA1 & 2
-Increased risk in patients with:
hereditary nonpolyposis colon cancer (HNPCC) --> mismatch repair gene mutations
Gorlin syndrome (nevoid basal cell ca syndrome) --> PTCH tumor suppressor gene mutation
Peutz-Jeghers syndrome --> STK11 tumor suppressor gene mutation
Risk Factors
- Early menarche (< age 12), Late menopause (> age 52)
- Age (> 50)
- On hormonal replacement therapy (HRT) or fertility drugs
- Later age of first pregnancy (> age 30)
- Infertility
- Personal history of breast or colon cancer
- Family history of ovarian, breast or colon cancer
Symptoms
- Lower abdominal discomfort:
Bloated or fullness, Loss of appetite, Nausea, gas, indigestion
- Vaginal bleeding
- Weight loss
- Constipation or diarrhea
- Frequent urination (due to pressure from growing tumor on bladder)
- Unfortunately symptoms do NOT normally present until the cancer is at an advanced stage
-
Diagnosis
- Gynecological examination
- Ultrasound
- CT- CA-125:
May not be elevated in early disease
Not specific
Treatment
- Surgery:
hysterectomy, ovariectomy, omentectomy appendectomy, pelvic lymphadenectomy
+adjuvant chemotherapy (platin analogues + taxane)
- Advanced stages: Cytoreductive surgery+chemotherapy
-
Vaginal carcinoma
- rare
- Usually diagnosed in elderly women with abnormal bleeding
- cervical cancer has to be excluded
- symptoms: discharge, bleeding
-treatment:
early cases – surgery
advanced cases - radiotherapy
Types
- Squamous cell carcinoma: 60-80 years of age; 87% of all vaginal ca
- Adenocarcinoma: 12-30 years of age; 7% of all vaginal ca
- Clear cell adenocarcinoma (very rare)
is due to DES (diethylstilbestrol) exposure as fetus - given to pregnant women 1945-70 to prevent miscarriage.
- Malignant melanoma
- Leiomyosarcoma
- Rhabdomyosarcoma
Risk Factors
- Age (50% >60, most 50-70 yrs)
- Fetal DES exposure, vaginal adenosis
- Cervical cancer history
- History of cervical precancerous conditions
- HPV infection
- Vaginal irritation
- Uterine prolapse
- Smoking
Common Symptoms
- Bleeding or discharge not related to menstrual periods (especially postmenopausal bleeding)
- Difficult/painful urination
- Pain during intercourse
- Pain in the pelvic area
- Constipation
- Palpable mass
Diagnosis
- Pelvic examination of the vagina and other pelvic
- Colposcopy - abnormal tissue --> colposcopic biopsy
- Paptest/Smear
- Biopsy
Treatment
- Surgery:
Local excision to remove the cancer
Vaginectomy to remove the vagina
- Radiation therapy (EBRT or BT or both) as radical or adjuvant treztment
Vulvar carcinoma
- lesion(s) on surface of vulva or labia; most often on labia majora or minora
- rare disease --> 0.5% of all cancers in women
- 90% of vulvar cancers are squamous cell carcinomas
- melanoma 2nd most common --> found in labia minora or clitoris
- other types of vulvar cancer: Adenocarcinoma, Paget's disease, Sarcomas, Verrucous carcinoma, Basal cell carcinoma
Symptoms
- vulvar mass or ulcer
- long story of pruritus and vulvar dyscomfort
- in advanced cases – inguinal lymph node involvment
Common Symptoms
- Changes in color and appearance of vulva
- Severe burning, itching, or pain
- White, rough skin in the vulvar area
- Growing lesion
- Unusual pigmentation
- Non-healing ulcer
Treatment
- local excision
- vulvectomy
- radical vulvectomy
- +/- bilateral groin dissection
- +/-adjuvant external beam radiation therapy (EBRT)