Cancer of the female genital tract by malj


									                                     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

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
        Lymphatic to pelvic and paraaortic lymph nodes
        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

Exact cause not known. Almost certainly sexually transmitted Human Papilloma Virus

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-

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
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

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.

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