Transcript Gynecological cancer

RATH 4412
 Incidence




Endometrial (uterine corpus) 43,470 new cases
Ovarian 21,880 new cases
Cervical 12,200 new cases of invasive cancer
Other 2,300
 Death
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rates- 2010
rates- 2010
Ovarian, ranks 5th among cancer deaths for
women- 13,850
Endometrial- 7,950
Cervical- 4,210
Other- 780
 Approximately
83,750 new cases per year of
gynecological tumors (2010)
 Clear
cell vaginal
 Cervical cancer
 Uterine cancer
 Ovarian cancer
 Vulvar/vaginal
19
48
58
60
65+
 Cervical
cancer is more prevalent among
young women

Multiple partners
 Early
sexual activity
 Oral contraceptives
 Family- mother, sister
 Lower socioeconomic status-won’t seek
medical attention
 Multiple births- 3 or more

Younger than 17 years for first baby
 Multiple

pelvic infections
Chlamydia infections

bacteria that can infect the sex organs.
 Genital
warts
 Unprotected sex, HPV passed during sex
 Diethylstilbestrol (DES)
 Smoking
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Smoking- women who smoke are twice as likely
to get cervical cancer
Tobacco smoke produces chemicals that may
damage DNA in cervical cells
 Immunosuppression

HIV
 Diet
 Cervical
cancer is caused by the HPV virus
 Spreads through sex
 Cause infection
 If infection is not treated can lead to cancer
 No treatment for HPV- does not have
symptoms, cannot be treated
 The cell changes that HPV causes in the
cervix can be treated
 Endometrial
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cancer has increased due to:
Aging population
High calorie/high fat diets
Diabetes
hypertension
Estrogen use 60’s and 70’s
Most patients are 50 years of age and older
Linked to women taking tamoxifen
 Vaginal
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

and vulvar cancers are rare
Occur in older women
Vulvar cancer is 3x more common than vaginal
cancer
Vulvar cancer is associated with
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Diabetes
STD’s
Poor hygiene
Abnormal changes in the vaginal lining
Loss of hormone stimulation
Use of DES by pregnant mother
 Ovarian
cancer
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Ages 50-70- develop after menopause
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Late or few pregnancies
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Late menopause
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Lack of oral contraceptive use or the use of
fertility drugs longer than 1 year
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Family history
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Personal history of breast, colon, endometrial
cancer
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Diet high in fat and red meat
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Obesity
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Industrialized nation
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Estrogen replacement after menopause
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BRCA1 or BRCA2 gene mutation
 Women
with a family history of ovarian
cancer:

Lifetime risk increases from 1% to 40%
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Must have annual rectovaginal pelvic exam
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CA 125 serum determination
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Transvaginal ultrasound
 Most
endometrial cancers are of the
glandular cells found in the lining of the
uterus
 Most
endometrial cancers develop over
several years
 Is
the most common gynecological cancer in
female reproductive organs
 SIGNS
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Unusual bleeding, spotting, or other abnormal
discharge
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AND SYMPTOMS
Vaginal bleeding is the most common symptom
Approx 1/3 of post menopausal bleeding is cancer
related
Pelvic pain and/or mass and weight loss
 EARLY
DETECTION
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No specific screening tests
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Regular pelvic exams
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If at high risk for hereditary nonpolyposis colon
cancer, a yearly endometrial biopsy should be
done beginning at age 35
 Endometrial
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D
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biopsy
A tissue sample is obtained by using a thin
flexible tube and suction
Placed into the uterus through the cervix
Has approximately a 94% sensitivity rate
and C (dilation and curettage)
Done when the biopsy is inconclusive
Cervix is dilated
Tissue is scraped from inside the uterus
 Ultrasound
 PATHOLOGY
 Adenocarcinoma
of the endometrial lining is
the most common type
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Grade 1- most cancer cells look like normal
tissue
Grade 2- in between
Grade 3- more than half of the cells are unlike
the normal cells
Progesterone receptors

Positive cells for this receptor are slow growing and
spread more slowly
 Cystoscopy
 CT
scan
 MRI
 Chest x-ray
 IVP
 CA 125 blood test
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CA 125 is a substance released into the
bloodstream by many endometrial and ovarian
cancers
Very high CA 125 levels suggest that the cancer
has probably spread beyond the uterus
 STAGING
 FIGO
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system
I-IV, the lower the number, the less the cancer
has spread, page 816, Washington
Most endometrial cancers are stage I
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Poor prognosis
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Higher grade
Increased depth of invasion into the myometrial
muscle
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Lymph node involvement
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Cancer cells in the peritoneal fluid or
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Cancer cells on serosal surfaces
 SPREAD
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Lymphatic spread initially to the internal and
external iliac pelvic nodes
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If pelvic nodes are involved, there is about a 60%
chance that there will be periaortic node
involvement
 TREATMENT
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Surgery and/or
Radiation Therapy
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Can be given pre- or post-op
Can be treated with photon or brachytherapy
Doses depend on treatment or combinations of
treatment
Radiation therapy alone is usually used for inoperable
patients and stages III and IV
Depends on the stage, grade and medical
condition of the patient
 PROGNOSIS
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Depends on the stage and grade
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Patients treated with radiation therapy and
surgery have an overall survival rate of 81.6%
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A five year disease free all stages 88%%
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For all stage I, grade I (early stage) patients, 95%
5 year survival rate
 Ovarian
cancer is the most deadly of all the
gynecologic cancers
 It
has few symptoms until it is widely spread
 The
number of new cases of ovarian cancer
have been going down since 1991
3
in 4 women will survive at least 1 year
after diagnosis
 Almost
half of women with ovarian cancer
will reach 5 year survival
 When
younger than 65 years of age, better
survival
 DETECTION
AND DIAGNOSIS
 By the time ovarian cancer may be
suspected, it may have already spread
beyond the ovaries
 Seek a doctor if any of these signs are
unusual or have symptoms daily for a few
weeks
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Specific Signs
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Bloating
Pelvic/abdominal pain
Trouble eating
Early satiety
Urination frequency/urgency
 Pelvic
Ultrasound
 Abdominopelvic CT scan
 MRI
 Chest x-ray
 Laparoscopy with biopsy
 CA 125
 Renal and liver function blood work
 PATHOLOGY
AND STAGING
 The AJCC/TNM system is used
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Describes the cancer in terms of extent of the
tumor, spread to nearby lymph nodes, and to
other organs
90% are epithelial (surface of ovary)
7% stromal
3% ovarian germ cell- includes dysgerminomas
which are treated like seminomas
Page 817, Washington
 TREATMENT
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Surgical evaluation and debulking of the tumor
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Postoperative therapy may include:
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Single agent or combination chemotherapy and/or
Whole abdominal and pelvic radiation therapy
Radiation therapy might include external beam or
Brachytherapy
 PROGNOSIS
5
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year survival rates
Well differentiated stages IA and IB, 90%-100%
Microscopic residual disease, stage II, treated
with radiation therapy, 74%
Residual disease less than 2 cm, 58%
Residual disease greater than 2 cm, 39%
 Cervical
cancer is a slowly progressive
disease
 Noninvasive
carcinoma in situ occurs approx
10 years earlier before becoming invasive
 Dysplasia
 Cervical
cervix
cancer begins in the lining of the
 According
to the ACS there will be about
12,2000 new cases of invasive cervical cancer
in the US in 2010
 Non-invasive
cervical cancer is about 4 times
as common as the invasive type
 When
found and treated early, there is a high
cure rate
 SIGNS
AND SYMPTOMS
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Any unusual discharge from the vagina
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Blood spots or light bleeding other than a normal
period
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Bleeding or pain during sex- common
DETECTION AND DIAGNOSIS
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Pap test- finds changes in the cells of the cervix
caused by HPVs
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The death rate declined 74% from 1955-1992 due
to pap test
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Pelvic exam
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HPV cannot be cured or treated, but the cell
changes that it causes can be treated
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Biopsy of any suspicious lesions
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Colposcopy- use a colposcope to look at the
cervix. Can destroy or remove pre-cancerous
lesions
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Cystoscopy- looks at spread to the bladder
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Proctoscopy- looks at spread to the rectum
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Chest x-ray
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CT

MRI
 PATHOLOGY
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AND STAGING
There are two main types of cancer:
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Squamous cell carcinoma, 80-90%
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Adenocarcinoma, 10-20%
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Features of both types, mixed carcinoma
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Small cell and clear cell make up a small percentage
and have a higher metastatic potential
FIGO Staging, page 785, Washington
 TREATMENT
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Early stage 0 (carcinoma in situ) and stage Ia1,
invasive cancer
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Stage Ia2
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Total abdominal hysterectomy with a small amount of
vaginal tissue (vaginal cuff)
TAH or an aggressive modified radical hysterectomy
Medically inoperable patient
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Tandem and ovoid implant delivering 60-70 Gy

Surgery is often used for younger women
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Radiation is usually used for women who have a
higher risk for surgical complications

Radiation is used with a combination of external
beam therapy and implants
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External beam doses increases with advanced
disease
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Implant doses may stay the same or decrease
depending on critical organ doses
 Kinds
of surgery
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Cryosurgery- used for pre-invasive cancer
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Laser surgery- used for pre-invasive cancer
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Cone biopsy- cone shaped piece of tissue is
removed from the cervix
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Simple hysterectomy- removal of uterus either
through the abdomen or vagina.
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Radical hysterectomy and pelvic lymph node
dissection- removal of the uterus, tissues next to
the uterus, upper part of the vagina, and pelvic
lymph nodes
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Pelvic exenteration- radical hysterectomy and
pelvic node dissection including removal of the
bladder, vagina, rectum and part of the colon
 Five
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year survival
Early invasive cancer, 92%
All stages combined, 71%
Cervical Cancer and Pregnancy
Very early stage cancer
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Later stage cancer- decide whether or not to
continue pregnancy
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Safe to continue the pregnancy to term
Several weeks after delivery, a hysterectomy is
recommended
If pregnancy is continued, the baby should be
delivered by cesarean section as soon as it is able to
survive outside of the womb
Advanced cancer
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Immediate treatment is the safest option
All of these options should be discussed with the
patient’s doctor
 Usually
presents with a subcutaneous lump or
mass
 Advanced
 Most
disease- exophytic mass
common location- labia majora
 Patient
has had a long history of irritation
 PATHOLOGY
AND STAGING
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Squamous cell carcinoma, 90%
Adenocarcinomas, 10%
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Staging- stage I-IVa
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 TREATMENT
 Surgery-
radical vulvectomy with a groin
node dissection
 More
conservative approach using wide local
excision with external irradiation of the
primary and inguinal nodes
 Five
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year survival
Overall five year survival rate, 70%
Disease free with surgery
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Stage I
Stage II
Stage III
Stage IV
100%
86%
59%
25%
The five year survival goes down with nodal
involvement
 SIDE
EFFECTS OF GYNECOLOGIC TREATMENT
 acute effects
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Fatigue
Diarrhea
Dermatitis
dysuria
bleeding
nausea
Subacute effects
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Menopause
Vaginal dryness
Chronic cystitis
proctosigmoiditis
enteritis
obstruction