Transcript Precancer diseases of the female sexual organs. Female cancer.

Precancer diseases of the
female sexual organs. Female
cancer.
O. Stelmakh
Precancer cervical lesions
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Cervical
intraepithelial
neoplasia (CIN)
Erythroplakia
atypia
Leukoplakia
atypia
Adenomatosis
with
with
Risk factors for cervical dysplasia
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Human papillomavirus is
a common virus that most
women will be infected
with at some time in their
life.
smoking
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multiple sexual partners
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pregnancy before the age
of 20
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suffering from conditions
that affect the immune
system, like HIV
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Layers of squamosus epithelium of
cervix
CIN Classification
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CIN I: Mild dysplasia;
abnormal cells can be found
in 1/3 of the lining of the
cervix
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CIN II: Moderate dysplasia;
abnormal cells can be found
in 2/3 of the lining of the
cervix
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CIN III: Severe dysplasia;
abnormal cells can be found
in more than 2/3 of the
lining of the cervix and up to
the full thickness of the
lining
Diagnosis of cervical dysplasia
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Speculum examination
PAP – smear
Processing of 3 %
acetic acid of a cervix
and revealing a white
spot
Colposcopy
Cervical biopsy
Endocervical curettage
HPV - testing
Dysplasia is initially detected through
a Pap smear
What is the thinnest and the more
effected place of the cervix???
The smear should be
taken from
squamocolumnar
junction – transition
zone !
Types of PAP smears
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I – normal
II a- inflammatory
process
II b – mild dysplasia
III a - moderate
dysplasia
III b – severe dysplasia
IV – carcinoma in situ
V – cancer
VI – smear is not
informative
Frequency of Pap Smears
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Begin no later than age 21.
If patient is sexually active <21.
Once initiated, screening
should be performed
annually
After 30, for women who
have had 3 consecutive,
normal Pap smears,
screening frequency may be
reduced to every 3 years.
Screening may stop after total
hysterectomy, >70 if the the patient is at
low risk, and has had three consecutive
normal Pap smears within the last 10
years.
Treatment for cervical dysplasia
CIN1 – 70 % spontaneous regression.
CIN 2/3 lesions are usually surgically removed by:
destruction (ablation) by carbon dioxide laser (photoablation) and
cryocautery and removal (resection) by electrosurgical excision
procedure (LEEP), cold knife conization.
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
CERVICAL CARCINOMA
Risk factors
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10 years from CIN III to cancer
Human Papillomavirus (HPV)
Infection - (16, 18, 31, 33, 35
and 6 more)
Family History of Cervical
Cancer
Age – 35-55
Sexual and Reproductive History
Socioeconomic Status
Smoking
HIV Infection
In Utero DES Exposure
Oral contraceptives
From initial infection to CIN III – 6
years
Types
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Squamous cell Carcinomas
 Cancer of flat epithelial cell
 80% to 90%
Adenocarcinomas
 Cancer from glandular
epithelium
 10% - 20%
Mixed carcinoma
 Features both types
Stages of Cervical Carcinoma
What are the symptoms of cervical
cancer?
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Abnormal bleeding
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Unusual vaginal discharge
Other symptoms
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Between periods
With intercourse
After menopause
Leg pain
Pelvic pain
Bleeding from the rectum or bladder
Some women have no symptoms
Diagnosis
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Complaints
Speculum examination.
The cytological examination
HPV screening involves a
Polymerase Chain Reaction
(PCR)
Bimanual vaginal
examination
Rectovaginal examination
Application of acetic acid
and Colposcopy
Biopsy.
What should I do if I have just been diagnosed
with cervical cancer?
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Discuss treatment options
 Conization
 Hysterectomy
 Radical trachelectomy
Surgical removal of the cervix and
upper vagina with the surrounding tissues.
uterine body remains
Radical hysterectomy
 Radiation with chemotherapy
Ask about clinical trials (Gynecologic Oncology Group)
Other considerations
 Preserve your fertility
 Preserve your ovaries
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Cervical cancer: What is the chance of
survival after treatment?
FIGO Stage
5-Year Survival
Stage I
81-96%
Stage II
65-87%
Stage III
35-50%
Stage IVA
15-20%
Vaccines
Who should get the vaccine?
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The FDA has recommended the
following groups of women get
vaccinated:
 Girls 11–12: Recommended
Age Group (can be started as
young as age 9).
 Women 13–26: the benefit of
the vaccine may be lower
depending on prior HPV
exposure.
The vaccine does not work to
eliminate current HPV infections
The vaccine only prevents certain
types of HPV infection
Endometrial cancer precursors
Endometrial hyperplasia an overgrowth of the
lining of the uterus, is a
precursor
to
the
development of cancer.
Abnormal
uterine
bleeding is usually the
first symptom
Risk Indicators for Endometrial Cancer and
Precursors
 Age
60 years
Obesity (with upper body fat pattern)a
 Estrogen-only replacement therapy
Previous breast cancer
 Tamoxifen therapy for breast cancer
Chronic liver disease
Infertility
 Low parity
 Chronic anovulation (Polycystic ovarian disease, estrogensecreting ovarian stroma or tumors)
WHO Classification and Diagnostic Criteria of Endometrial Hyperplasi
Simple Hyperplasia Without Cytologic Atypia
Increased number of glands relative to stroma
Dilated glands with irregular outlines
Crowded, clustered glands
Tall, columnar epithelium with nuclear pseudostratification
Complex Hyperplasia Without Cytologic Atypia
Increased number of glands relative to stroma
Back-to-back glands (crowded glands with little or no intervening stroma)
Hyperplasia With Cytologic Atypia
Variation of size and shape of nuclei
Nuclear enlargement
Loss of polarity
Coarse chromatin clumping
Prominent nucleoli
Endometrial hyperplasia
Cystic hyperplasia
Simple hyperplasia
Endometrial hyperplasia
Atypical hyperplasia
Simple hyperplasia
Endometrial biopsy
Diagnosis and treatment
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Intramuscular progesterone
therapy. MPA (500mg)therapy for 3
months;
Micronized progesterone -cyclic
natural micronized progesterone for 3
to 6 months;
Levonorgestrel intrauterine device
GnRH analogue for 6 months with
sampling every 3 months is a
reasonable option in patients without
atypia.
According to the U.S. Gynecologic Oncology Group
histologic grading system,1
grade 1, well-differentiated carcinoma, consists of a
neoplasm with less than 5% of solid cancer
grade 2, moderately differentiated carcinoma,
contains between 6% and 50% solid cancer
grade 3, poorly differentiated carcinoma, is made up
of more than 50% of solid tumor.
Modified WHO classification
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endometrioid
adenocarcinoma
serous carcinoma
clear cell carcinoma
mucinous carcinoma
serous carcinoma
mixed types of
carcinoma
undifferentiated
carcinoma
Clinical signs
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Irregular vaginal
bleeding,
intermenstrual or post
menopausal
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Watery vaginal
discharge may be
present in
postmenopausal
women
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Mass in late stages
Endometrial cancer:
investigations
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T.V.S. and biopsy
Hysteroscopy and
biopsy
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? M.R.I. Or C.T. scan
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Endometrial cancer:
investigations
Endometrial cancer: treatment
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Operative: total
abdominal hysterectomy
and Bilateral Salpengooophorectomy +/_ lymph
node dissection is the
operation of choice.
Adjuvant Radiotherapy
for >1b
Chemotherapy ineffective
Hormonal therapy,
progestogens, in early or
recurrent cases
5 – year survival rate
for endometrial cancer
Ovarian Cancer
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The 2nd most common gynecologic malignancy
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The most frequent cause of death from gynecologic
cancers
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27% of gynecologic cancers
Due to advanced stage at the time of diagnosis
53% of all deaths from gynecologic cancers
Incidence increases with age, most marked beyond
50 years, with increase continuing to age 70 years,
and decrease after age 80 years
Risk factors
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Family history of cancer
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Personal history of
cancer: Women who
have had cancer of the
breast, uterus, colon, or
rectum have a higher risk
of ovarian cancer
Age over 55
Never pregnant:
Menopausal hormone
therapy: estrogen taking
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OVARIAN CANCER
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primary
(neoplasms
derived
from
the
ovarian
surface
epithelium,
i.e.
epithelial tumors),
secondary (neoplasms
derived from papillary
or
pseudomucinous
cystadenomas)
metastatic (intestinal
and
breasts’
metastasis).
Classification
3.Germ cell tumors – 510%:
Serous (tubal)
 Teratoma –
Mucinous (endocx & intestinal)
 Benign cystic (dermoid
Endometrioid
cysts)
Transitional cell - Brenners.
 Solid immature
Clear cell
 Monodermal – struma
Stromal – 15-20%:
ovarii, carcinoid
Granulosa-cell tumor
 Dysgerminoma
Thecoma
 Yolk sac tumor
Choricarcinoma
Fibroma
 Mixed germ cell tumor
Sertoli-Leydig cell
4.Metastatic tumors – 5%
tumors
1.Surface epithelial – 6570%:
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2.
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Serous Cystadenoma
Papillary serous cystadenoma
(solid/cystic)-borderline
Papillary cystadenoma (bor)
Thecoma
•Solid tumor with
variegated yellow - orange
appearance.
•Produces estrogens
Krukenberg
Tumor
FIGO classification
Ovarian cancer - “silent
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killer”
Bloating
Pelvic or abdominal pain
Pain in the back or legs
Diarrhea, gas, nausea,
constipation, indigestion
Difficulty eating or feeling
full quickly
Urinary symptoms
(urgency or frequency)
Pain during sex
Abnormal vaginal bleeding
Trouble breathing
Diagnosis
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Physical examination
Pelvic examination
Rectovaginal examination
Ultrasound
Magnetic resonance
imaging
CA-125
high
falsepositive rate
HE4
marker
more
sensitive than CA125
Laparoscopy, microscopy
The combination of HE4 and CA 125
was more sensitive than either marker
alone - Risk of Ovarian Malignancy
Algorithm (ROMA) is calculated
Treatment
Prognosis
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The five-year survival
rate for all stages of
ovarian
cancer
is
45.5%.
For cases where a
diagnosis is made early
in the disease, when
the cancer is still
confined to the primary
site,
the
five-year
survival rate is 92.7%.