VIEWS: 225 PAGES: 4 POSTED ON: 3/16/2010
Cancer of the female genital tract Dr R. Chenoy Cancer of the female genital tract Learning Objectives Basic understanding of 1. Incidence, symptoms, signs, investigations and staging & grading of the common female genital tract cancers (cervix, endometrium and ovary) 2 Broad principles of management of the above cancers Staging of Gynaecological Cancers Cartoons showing 1. Para-aortic , inguinal and pelvic lymph nodes 2. Components of female genital tract: ovary, fallopian tube, uterus cervix, vagina, with sites of cancer in ovary, endometrium, cervix and vagina OVARIAN CANCER. Picture showing position of ovarian cancer in pelvis. Ovarian Cancer Introduction Disease of western industrialised countries. Highest incidence- Scandinavia, UK. Low incidence in Japan Most frequent gynaecological cancer in UK. >5,000 cases per year Most common cause of death from gynaecological cancer in UK. >4,000 deaths per year Ovarian Cancer: picture of 3 women Ovarian Cancer Symptoms What are the usual presenting symptoms? Vague and non specific: Abdominal bloating, distension. Gastrointestinal. Pain. Constitutional. Urinary. Rarely pelvic. Ovarian Cancer Signs. Picture of enlarged abdomen. Pelvic mass. Ascites. Abdominal mass Ovarian Cancer Investigations Ultrasound scan: Solid cystic mass. Presence of flow. Bilateral tumours. Ascites. Serum tumour marker: CA 125 (>30 U/l), AFP/HCG, Others Other imaging – CT / MRI Exploratory laparotomy Ovarian Cancer Ultrasound Ultrasound of abdomen: picture Photograph of abdomen with overlay of ultrasound image: picture Ovarian Cancer Classification Primary: Epithelial (90%), Serous, Mucinous, Endometrioid Sex cord / Stromal Germ cell / Sex cell: Teratoma Secondary / Metastatic Ovarian Cancer: Staging Pattern of spread Transcoelomic Lymphatic to pelvic and paraaortic lymph nodes Staging Stage I - confined to ovaries Stage II - spread to pelvis Stage III - spread within peritoneal cavity +/or to retroperitoneal lymph nodes Stage IV - to liver parenchyma or distant metastases Metastatic Spread Cartoons showing 1. Para-aortic , inguinal and pelvic lymph nodes 2. Components of female genital tract: ovary, fallopian tube, uterus cervix, vagina, with sites of cancer in ovary, endometrium, cervix and vagina Metastatic Spread Cartoon showing ovary Fallopian tube, uterus, cervix, and vagina. Treatment of Ovarian Cancer. Picture of resected ovaries, tubes, uterus, cervix and vagina. Ovarian cancer can be cured if caught in time. However, cure rates vary and depend on the extent of the cancer. Ovarian Cancer Exploratory laparotomy What is included in this procedure? Picture of laparotomy. Midline laparotomy, Peritoneal washings, Careful exploration, TAH + BSO, Omentectomy, Pelvic/para-aortic node sampling Ovarian Cancer. Primary treatment Surgery and cytoreduction. Maximum surgical effort to leave minimum residual disease. Usually includes : TAH BSO, Omentectomy, Pelvic/ paraaortic node sampling, Appendectomy, Removal of any large tumour masses Ovarian Cancer Adjuvant treatment Combination - Taxol + platinum Single agent - if taxol not tolerated. Cisplatinum 60-70% response rate. Nephrotoxic, neurotoxic, ototoxic. Carboplatinum is less toxic. Radiotherapy does not have a major role Ovarian cancer support network: Ovacome: picture of a tree. Cervical Cancer Picture of midline saggital section through pelvis showing bladder, uterus, cervical cancer Cervical Cancer Introduction Preventable disease. Well defined preinvasive phase. 3,000 cases/year. 1,500 deaths/year. Incidence decreasing. Mean age 52 years. Bimodal age distribution with peaks at 30-35y and 60-65y Cervical Cancer: picture of 3 women CAUSES OF CIN & CANCER CERVIX Exact cause not known. Almost certainly sexually transmitted Human Papilloma Virus RISK FACTORS : Sexual Behaviour & Coitarche. Heavy Smoking. Other Sexually Transmitted Infections. Parity and Age of First Pregnancy. Method of Contraception. Occupation and Social Class Cervical Cancer. HPV and Smoking. Possible link? Picture of ashtray + cigs. Cervical Cancer Symptoms. What are likely symptoms? Abnormal vaginal bleeding. Postcoital. Postmenopausal Abnormal vaginal discharge Advanced cases: lower limb oedema, haematuria, pelvic pain, renal failure, general symptoms Cervical Cancer Diagnosis & Assessment Smear. Colposcopy. Examination under anaesthesia. Cervical biopsy. Imaging - CT / MRI Cervix and the Transformation zone. Picture of cervix showing transformation zone. Normal cervical epithelium and the transformation zone. Diagram of uterus, cervical canal and vagina showing tall columnar cells in cervical canal, and flat stratified squamous epithelium on cervix and vagina. Squamo- columnar junction is on cervix near end of canal. Ectocervical epithelium – ‘stratified squamous’. Picture showing cross-section of epithelium with underlying connective tissue, basement membrane, basal layer, parabasal zone, intermediate zone, and superficial zone. Endocervical epithelium – ‘columnar’ or ‘glandular’ Picture of epithelium. Old Pap smear. Picture showing vagina, cervix, uterus, speculum, and kit for smear. Cervical Smear Picture of applying cells to slide. New pap smear Thinprep pap test smear protocol Record the patient’s full name and date of birth on the vial, the patient information and medical history on the cytology requisition form. Obtain and adequate sample from the cervix using a Cervex brush (broom-like device) Insert the central bristles of the brush into the endocervical canal deep enoughto allow the shorter bristles to fully contact the endocervix. Push gently and rotate the brush in a clockwise direction 5 times. Rinse the Cervex brush immediately into the preserveCyt solution vial by pushing it into the bottom of the vial 10 times, forcing the bristles apart. As a final step, swirl the brush vigorously to further release material. Visually inspect the Cervex brush to ensure that no material remains attached. Discard the collection device. Tighten the cap so that the black torque line on the cap passes the black torque line on the vial. Do not over- tighten. CERVICAL INTRA-EPITHELIAL NEOPLASIA (CIN) Continuum of disease: over 10-15 yrs Normal- mild dyskaryosis – Moderate dyskaryosis – severe dyskaryosis – cancer. Malignant potential : CIN 3 → invasion ( 36% over 20 yrs) Picture showing transition from normal tissue to invasive cancer. Colposcopy: cartoon showing microscope Colposcopy: another cartoon showing microscope Colposcopy: picture of cervix Acetowhite’ Cervical Epithelial Changes Picture of cervix after painting with acetic acid Loop Excision Treatment: picture Large Loop Excision of the Transformation Zone (LLETZ). Diagram. See and treat. Cervical Cancer Pathology Squamous cell carcinoma. Approximately 80% of cases Adenocarcinoma. Less common. Increasing in incidence particularly amongst younger women Spread: Direct to parametrium. Via lymphatic to regional lymph nodes Cervical Cancer: Surgical Treatment Radical Hysterectomy and pelvic lymphadenectomy Radiotherapy is equally effective for >1b Cervical Cancer: Treatment of advanced disease Primarily Radiotherapy / Chemoradiotherapy Radiotherapy: Brachytherapy to treat central tumour. External beam radiotherapy to entire pelvis and regional LN’s. Dose 6,000 cGy to point B Chemotherapy rarely used as primary treatment Endometrial Cancer. Picture showing endometrial carcinoma Endometrial Cancer Introduction 2nd most common gynaecological malignancy in UK ~4,000 cases per year Traditionally regarded as having a ‘good prognosis’ 25% mortality at 5 years Characterised by early presentation with PMB Endometrial Cancer picture of same 3 women! Endometrial Cancer Pathology 90% are Adenocarcinomas. 75% well differentiated Remainder are uncommon and have a poor prognosis. Mixed Mullerian. Squamous. Sarcomas. Endometrial cancer Presentation Age distribution. Average age of onset 60 years. 75% of women are >50 and 95% are >40 years. Most are postmenopausal. Endometrial Cancer Symptoms Postmenopausal bleeding - 80% (~ 15% of women with PMB have endometrial cancer) Menstrual abnormality Leucorrhea Occasionally abnormal cervical cytology Rarely pelvic pressure or signs of metastatic disease Endometrial Cancer Investigations Endometrial biopsy. Outpatient sampling (pipelle aspirate). Hysteroscopy and curettage. Ultrasound - thickened endometrium MRI/CT imaging of pelvic/paraaortic lymphatics and myometrial invasion Hysteroscopy: diagram Endometrial Cancer Staging. Surgico-pathological Stage I confined to body of uterus Stage II involves cervix Stage III extends outside of uterus but not true pelvis Stage IV - involvement of bladder/rectal mucosa or distant spread including intra-abdominal Metastatic Spread. Cartoons showing 1. Para-aortic , inguinal and pelvic lymph nodes 2. Components of female genital tract: ovary, fallopian tube, uterus cervix, vagina, with sites of cancer in ovary, endometrium, cervix and vagina. Metastatic Spread Cartoon showing ovary Fallopian tube, uterus, cervix, and vagina. Endometrial Cancer picture Endometrial Cancer Primary treatment. Usually surgical Stage I well differentiated ~ 70% - Simple hysterectomy and BSO Stage II – radical hysterectomy Stage III/IV - cytoreductive surgery Endometrial Cancer Adjuvant treatment. Radiotherapy Indications: Positive pelvic nodes. Stage Ic-III Modalities: Brachytherapy, External beam pelvic RT, Extended field Endometrial Cancer Adjuvant treatment Hormonal therapy: Stage III/IV disease but uncertain benefit; Progestins or LHRH analogues Chemotherapy: Advanced disease Vulval Cancer Uncommon cancer Squamous cell cancers account for 90% of cases Disease of postmenopausal women (mean age of diagnosis 65 years) Vulval Cancer picture, same 3 women Vulval Cancer Vulval lump or mass Long history of pruritis Vulval bleeding, discharge, dysuria Primary treatment is surgical excision Various pictures of vulval carcinoma and treatment Statistics incidence and mortality. Picture, same 3 women. Gynaecological cancer support. Picture flowers.
Pages to are hidden for
"Cancer of the female genital tract"Please download to view full document