Ministry of Public Health of Ukraine National O.O.Bohomolets Medical University Oncology Department STUDY GUIDE OF THE PRACTICAL COURSE “ONCOLOGY” Part I For the students of medical facultiesWorked out by I.B.Shchepotin MD, PhD, DSci, Prof; G.A.Vakulenko MD, PhD,DSci, Prof; V.E.Cheshuk MD, PhD, DSci; A.S.Zotov MD, PhD; O.I.Sidorchuk MD, PhD; V.V.Zaychuk MD, PhD; L.V.Grivkova MD, PhD; O.E.Lobanova MD; I.N.Motuzyuk MD; Y.V.Levchishin MD. Kyiv - 2008
Ministry of Public Health of Ukraine National O.O.Bohomolets Medical University Oncology Department “APPROVED” Vice-Rector for Educational Affairs Professor O. Yavorovskiy ______________ “___” __________ 2008 STUDY GUIDE OF THE PRACTICAL COURSE “ONCOLOGY” Part I For the students of medical facultiesWorked out by I.B.Shchepotin MD, PhD, DSci, Prof; G.A.Vakulenko MD, PhD,DSci, Prof; V.E.Cheshuk MD, PhD, DSci; A.S.Zotov MD, PhD; O.I.Sidorchuk MD, PhD; V.V.Zaychuk MD, PhD; L.V.Grivkova MD, PhD; O.E.Lobanova MD; I.N.Motuzyuk MD; Y.V.Levchishin MD. Kyiv - 2008
The texts of the lectures are approved by the methodical counselof Oncology Department.Protocol № 19 « 17 » march 2008.
CONTENTS 7. Tumors of the bones. 8. Tumors of the soft tissue. 9. Skin cancer. Melanoma. 10. Cervical cancer. Ovarian cancer. Uterine cancer.
7. Tumors of the bones Sarcomas can attack people without differentiating the age; however they occurvery rarely, accounting for just about a percentage all cases of cancers put together.Although, close to a half of occurrences are in the limbs, generally sarcomas arereally unusual and that they can appear in any place of our bodies with a fewexamples being muscle, skin, cartilage, bones, nerves and any of the internal organsPrimary skeletal neoplasms (bone tumors) • account for only 1 - 1,5% of malignant tumors (0,2% of all human tumors), (1–1,5 for 100.000 of population), • metastatic disease is much more common. Benignant bone tumors • occur 2-3 times frequently than malignant ones. Malignant skeletal tumors • more common for men (1,5-2 times frequently, than for women) • soft tissue-related counterparts outnumber bone tumors by a margin of approximately 10:1. • bone tumors are mostly of mesenchymal origin • Ewing sarcoma, reticulosarcoma, etc. have neuroectodermal precursor cells. bone tumors dispose in long tubular bones (40-70%) • affect lower extremities 2-2,5 times more frequently than upper ones • tumors, located in proximal parts of extremities are malignant • few of the bone tumors affect small bones of feet and hands • malignant bone tumors accounts for the age from 10 to 40 years • primary bone tumors are more common for children. The commonest benignant bone tumors, which affect children are: • chondroblastoma • bone fibroma • osteoma The commonest malignant bone tumors ones are:
• Ewing’s and osteogenic sarcomas. After 40 years the commonest bone tumors are: • chondrosarcoma, • reticulosarcoma • fibrosarcoma. Because of their rarity, not much is known about the etiology and risk factorsof bone tumors. • Radiation is associated with increased risk of soft tissue sarcomas. Other factors that may increase risk of soft tissue sarcomas, : • Vinyl chloride, used in making plastics • Dioxin, an unwanted byproduct of incineration • Herbicides that contain the chemical phenoxyacetic acid The route of metastasis • is usually hematogenous, and • the lung (up for 80%) are the most frequent site of involvement. • Lymphatic spread occurs less often (3-20%) and usually late in the course of the disease.Clinical presentationTriad of symptoms are typical for bone tumors: 1. the presence of the tumor, 2. the pain & 3. malfunction of the defeated skeletal segment. • In the beginning of the malignant process poor symptom data can be discovered. The patients general condition & preproduction testing data have not remarkable changes. • When the tumor is localized in the scull, vertebrae & near the big nerves, neurological symptoms occur.Diagnosis is made on: 1. the anamnesis data, 2. clinical presentation,
3. Rö-logical examination, 4. CT, MRI & angiography, 5. osteoscintigraphy (if it is necessary). 6. To evaluate the extend of soft-tissue defeating sonography, especially dopplerography can be used. 7. The biopsy should be planned with the future surgical procedure in mind. • Excisional biopsy is indicated for lesions less than 3cm in diameter, • otherwise, incisional biopsy is indicated. • Aspirate needle biopsy & trepan-biopsy are not descriptive.Treatment of the bone tumors includes : • surgery, • radiotherapy & • chemotherapy. Surgical treatment includes:1. both cripple operations – • amputation or • exarticulation of the extremity2. & limb-sparing operations – • excochleation, • resection of the defeated bone, • resection of the joint parts of the bones with the following substitution of this defect by the plastic materials, bone transplants, polymers like hydroxilapatite), • endoprosthesis of the big joints by modern prosthetic devices, • distractive osteosynthesis. • Sometimes cryotherapy can be used. • Amputation & exarticulation are indicated when local resection cannot be accomplished without jeopardizing of the function of the extremity (i.e. involvement of major nerves or vessels occurs).
• If it is possible to remove the tumor completely, bone plastics or endoprosthesis with the following radio- & chemotherapy are accomplished even when solitary metastases are detected. • radiotherapy Bone sarcoma is a radioresistable tumor, that‘s why radiotherapy is applyingonly as adjuvant for the surgery. • chemotherapy Endoarterial chemotherapyis more effective then intravenous one. Treatment of the bone tumors, begins fromendoarterial chemotherapy during 4 days (2-6 courses with the 21-28 days intervals,depending from the treatment effect) with the cisplatin, doxorubicin, metotrexat, with the following radiotherapy (Σ dose 20-25Gy). Surgery after chemo- &radiotherapy is developed.System chemotherapyAfter the operative treatment 5-6 courses of the system chemotherapy are usuallyindicated: • ifosfamid 3 mg/m2 & vincristin 1,4 mg/m2 during the 1 day, mesna 660 mg/m2 every 4 hours during 48 hours after the infusion of ifosfamid, cisplatin 100 mg/m2 during the 3 day. • Or: doxorubicin 25 mg/m2 from the 1 to the 3 day, cisplatin 100 mg/m2 (prolonged infusion) during the 1 day. Cycles must be repeated every 3-4 weeks.bone tumors treatment • If the patient refuses to undergo the operation, radiotherapy (Σ dose 50-60Gy) & system chemotherapy (6 courses) can be used. • The possibility of the chemotherapy dose escalation with the synchronous use of the haemopoetic grows factors (G-GSF – granulocytostimulated grows factor, GM-CSF – granulocyto- & macrofagostimulated grows factor) is investigated now .
• Metastatic lesions in the lungs can be resected if the primary tumor is under good control and there is no evidence of other sites of involvement.prognosis • In the I-II stages 5-year survival achieves 70-80%. • In the advanced cases (III-IV stages) 5-year survival is less than 30%. • The more common reason of the death are the distant metastases (to the lungs, bones, liver & brain).
bone tumors algorithm Treatment: R Treatment: E surgical: excochleation, C surgical: resection of the defeated bone resection of the U or exarticulation with the endoprosthesis defeated bone or R of the joint, in exclusive cases – exarticulation with the R Benignant endoprosthesis of the E N amputation of the limb . bone tumors joint. C E Radical treatment: neoadjuvant Radical treatment (except endoarterial & system chemotherapy chondrosarcoma, reticulosarcoma & with the radiotherapy & the following Diagnostics: Ewing´s sarcoma): neoadjuvant operation reresection of the defeated Rö-graphia of the endoarterial & system chemotherapy with part of the bone, defeated skeletal the radiotherapy & the following operation amputation/reamputation orClinical exarticulation of the limb with the segment (2 resection of the defeated part of the bonepresen- (with the bone plastic or endoprosthetic), following chemo- & radiotherapy. projections), CT, MRTtation: osteoscintigraphy, amputation or exarticulation of the limbPresence of angiography, with the following chemo- & radiotherapy.the tumor, the sonography if it´spain &/or necessary, biopsymalfunction ofthe defeatedskeletalsegment RECURRENCE Radical treatment of the fibro- , chondrosarcomas: resection of the bone, if it´s possible, more common – high amputation or exarticulation of the limb. Treatment of the reticulo- & Ewing´s sarcomas: Malignant radiotherapy & system chemotherapy bone tumors Palliative treatment (if the patient refuse to undergo the radical operation or/& if the radical treatment is impossible): radiotherapy & system chemotherapy are indicated
1. The more common symptoms of the bone sarcomas are: a. the presence of the tumor, appearance of the the pain and malfunction of the nearest joint b. the presence of the tumor, appearance of the the pain and high temperature c. the presence of the tumor, bleeding and malfunction of the stomach2. Diagnosis of the bone sarcoma may be proved by: a. physical, Rő-logical examination, sonography b. physical, Rő-logical examination, sonography, biopsy, CT, MRT c. physical examination, sonography, ECG3. Bone sarcomas often occur in the age of: a. less than 20 years b. from 20 to 45 years c. elder than 50 years4. Bone sarcomas are: a. the rare tumors b. common tumors5. Treatment options for soft tissue sarcomas include: a. surgery b. radiation therapy c. chemotherapy d. all answers are correct
8. Tumors of the soft tissue Connective (soft) tissues are are the ones that hold the body parts together andconnect one part to another. They are: • muscle • tendon • ligament • skin • fat • bone • cartilage • nerves • blood vessels • lymph vesselsSarcoma starts in the bodys connective tissues.Cartilage tumors start in the bone, not in the joint. Soft tissue tumors are developed from the nonepitelial and extraskeletaltissues (except CNS, internal organs & endocrine system). • These neoplasms constitute only 0,2-2,6% of the malignant tumors and affect • equal often men & women, • more common in the age of 20-50 years. • In 70% cases soft tissue sarcomas affect the extremities and in 30% - the body & pelvis. • The AIDS epidemic has introduced us to what was previously a very rare - Kaposis sarcoma. • Other soft tissue tumours may be associated with genetic syndromes such as neurofibromatosis. • Roughly 20 different types have been described, each with a slightly different tendency to metastasize or to invade locally.
Histological classification on the soft tissue tumors (WHO 1998)• Grading of bone tumors is roughly based on the cellularity of the lesion compared to the amount of extra cellular matrix, nuclear features, the presence of mitotic figures and necrosis. Staging via the TNM system is normally not used, because metastases in lymph nodes are not frequent in these lesions. Therefore staging is based on degree of differentiation of the tumor tissue and local and distant spread of the tumor.• I. Tumors & tumor-like lesions of the fibrous tissue.• А. Benignant: Fibromas: 1. Solid fibroma; 2. Soft fibroma (fibromyoma); 3. Dermatofibroma (Fibrous histiocytoma ); 4. Elastofibroma of the back.• B. Benignant: Fibromatosis : 1. Scar fibromatosis; 2. Keloid; 3. Fasciitis nodular; 4. Radiation fibromatosis; 5. Juvenile hyaline fibromatosis ; 6. Abdominal fibromatosis (abdominal desmoid); 7. Aggressive fibromatosis (nonabdominal desmoid); 8. Congenital fibromatosis.• C. Malignant: 1. Fibrosarcoma.• II. Fat tissue tumors.• А. Benignant: 1. Lipoma (including fibrolipoma, angiolipoma etc.); 2. Intermuscular lipoma; 3. Hibernoma; 4. Angiomyolipoma; 5. Lipoblastomatosis; 6. Diffuse lipomatosis.• Б. Malignant: 1. Liposarcoma.• histological classification on the soft tissue tumors (continuation)• III. Muscular tissue tumors• А. Smooth muscle tumors.• 1. Benignant: а) Leiomyoma; б) angiomyoma; в) leiomyoblastoma.• 2. Malignant: а) Leiomyosarcoma .• B. Striated muscle tumors.• 1. Benignant: а) Rhabdomyoma ;• 2. Malignant: а) Rhabdomyosarcoma .• IV. Blood vessels tumors.• А. Benignant.
• 1. Hemangioma : а) hemangioendothelioma benignant; б) capillary hemangioma; в) cavernous; г) venous.• 2. Intermuscular hemangioma (capillary, cavernous, arterio-venous);• 3. System hemangiomatosis;• 4. Hemangiomatosis with/without congenital arterio-venous fistula;• 5. Hemangiopericytoma benignant, б) glomus tumor.• 7. Angiolipoma.• В. Malignant.• 1. Hemangioendothelioma malignant (angiosarcoma);• 2. Hemangiopericytoma malignant.• V. Lymphatic vessels tumors.• А. Benignant.• 1. lymphangioma: а) capillary; б) cavernous: в) cystic;• 2. Lymphangiomyoma;• 3. System lymphangiomyomatosis .• B. Malignant.• 1. Lymphangioendothelioma malignant (lymphangiosarcoma);• VI. Synovial tissue tumors.• А. Benignant.• 1. Benignant synovioma.• B. Malignant.• 1. Synovial sarcoma.• VII. Mesothelial tissue tumors .• А. Benignant mesothelioma .• B. Malignant mesothelioma .• VIII. The tumors of the peripheral nerves.• А. Benignant.• 1. Traumatic neuroma;• 2. Neurofibroma;• 3. Neurilemmoma (schwannoma );
• 4. Neurofibromatosis.• B. Malignant.• 1. Malignant schwannoma (neurofibrosarcoma);• 2. Primitive neuroectodermal tumor (peripheral neuroepitelioma PNET).• IX. Tumors of the sympatic ganglia.• А. Benignant. 1. Ganglioneuroma.• B. Malignant. 1. Neuroblastoma, ganglioneuroblastoma.• Х. Tumors of the paraganglious stuctures.• А. Pheochromocytoma: 1. Benignant; 2. Malignant.• B. Chemodectoma: 1. Benignant; 2. Malignant.• C. Nonclassified paraganglioma.• XI. Plurypotential mesenchymal tumors• А. Benignant: mesenchymoma.• B. Malignant : Malignant mesenchymoma.• ХII. Tumors of the possible extragenital origin.• А. Benignant. 1. Teratoblastoma.• B. Malignant.• 1. Teratocarcinoma;• 2. Embrional carcinoma.• XIII. Tumor with nonelucidated hystogenesis.• А. Benignant.• 1. Granular cell tumor ;• 3. Soft tissue osteoma;• 4. Myxoma.• 2. Soft tissue chondroma;• B. Malignant.• 1. Alveolar soft part sarcoma ;• 2. Malignant granular cell tumor ;• 3. Chondrosarcoma extraskeletal;• 4. Osteosarcoma extrasceletal;
• 5. Malignant giant cell tumor of soft tissue/soft parts; • 6. Malignant fibroxanthoma; • 7. Kaposis sarcoma ; • 8. Giant cell tumor of tendon sheath . • ХIV. Nontumorous or tumor-like lesions of the soft tissue. • А. Xanthomas. • B. Ganglia. • C. Myositis ossi´ficans. • D. Proliferative myositis. • ХV. Nonclassified tumors of the soft tissue. • The route of metastasis is usually hematogenous, and the lung (60-80%) are the most frequent site of involvement. • Lymphatic metastasis occurs less often (<20%) and usually later then hematogenous ones. Not much is known about the etiology and risk factors of the soft tissuetumors. Most of the authors consider, that the trauma (even chronic one), doesntleads to the soft tissue sarcomas. There are few reports about the viral origin of thesarcomas. Sometimes sarcomas may occur after the chronic inflammatory process orbenignant tumors.Clinical presentation These tumors usually present as an enlarging mass, wich is frequently painless.If they occur in deep location, such as retroperitoneum, they are often quite large atthe time of diagnosis. In the beginning of the malignant process poor symptom datacan be discovered. The patients general condition & preproduction testing data havenot remarkable changes.The more common symptoms of the soft tissue sarcomas are: • the presence of the tumor, • appearance of the pain & • (sometimes) the malfunction of the nearest joint.When the tumor squeezes the big nerves or/& vessels, neurological symptoms occur.
Diagnosis is made on the 1. anamnesis data, 2. clinical presentation, 3. sonography (especially dopplerography), 4. Rö-logical examination, 5. CT, MRI & angiography, osteoscintigraphy if it is necessary. 6. Biopsy : • excisional biopsy is indicated for lesions less than 3cm in diameter: otherwise, • incisional biopsy is indicated. The biopsy should be planned with the future surgical procedure in mind. • Aspirate needle biopsy & trepan-biopsy are not descriptive.Treatment These tumors are frequently treated inadequately because they often have apseudocapsule, which may lead the surgeon to assume falsely that all of the tumorhas been removed. In reality, these tumor extend along tissue planes well beyondtheir apparent margins. As a rule, the main method of the treatment of the soft tissue tumors is surgicalone. When the tumor is benignant, the local excision is indicated.Radical operations: • limb sparing surgery, which is indicated when wide local excision (excision of the tumor together with the surrounding tissues, taking into account fascial zones) can be accomplished without jeopardizing the function of the extremity (i.e., when the process is without involvement of major nerves &/or vessels) ; • amputation or exarticulation of the extremity (with the endoprosthesis of the joints, when it is possible). Sometimes cryotherapy can be used. If the recurrence arises, reexcision must be accomplished.soft tissue tumors treatmentRadiotherapy can be used for adjuvant or neoadjuvant reason.
• Adjuvant radiotherapy is realized in a classic regimen of the fractions with Σ dose 30-60Gy. • Neoadjuvant radiotherapy is conducted by the big fractions (5Gy) during 4-5 seances. • As a single method, or together with the chemotherapy, radiotherapy is possible in the tumor is inoperable or/& the patient refuses from the operation.ChemotherapyEndoarterial chemotherapy is more effective then intravenous one. Treatment of the soft tissue tumors, begins from endoarterial chemotherapyduring 4 days (1-4 courses with the 21-28 days intervals, depending from thetreatment effect) with the cisplatin, doxorubicin, metotrexat.System chemotherapy : are usually indicated 5-6 courses of the adjuvant systemchemotherapy: • ifosfamid 2,5 mg/м2 & mesna 660 mg/m2 every 4 hours during 48 hours after the infusion of ifosfamid during 3 days, cisplatin 100 mg/m2 during the 1 day.Or: doxorubicin 50 mg/m2, cyclophosphan 750 mg/m2, vincristin 1,4 mg/m2,bleomycin 5 mg/m2 during the 1 day, prednisolon 60 mg/m2 1-5 days. Or: cisplatin100 mg/m2 (prolonged infusion) during the 1 day, doxorubicin 50 mg/m2 during2-4days, vincristin 1,5 mg/m2 at the 5 day, cyclophosphan 600 mg/m2 at the 6 day.Cycles must be repeated every 3-4 weeks with the 21-28 days intervals. The survival of the patients with the soft tissue sarcomas greatly depends on • the staging of the disease & • the grade of the differentiation of the cells.In the I-II stages 5-year survival achieves 70-80%.In the advanced cases (III-IV stages) 5-year survival is less than 30%.The more common reason of the death are the distant metastases (to the lungs, bones,liver & brain).
soft tissue tumors algorithm Treatment R Benignant ec Treatment Surgical – local tumors excision ur re Surgical – local n ce reexcision Potent- R Treatmemt - Diagnosis: Treatmemt - wide local ec ial excision with the radiotherapy, ur wide local Sonography malig- in the case of an re excision with & Rö- nant extraabdominal localization, n the chemotherapy can be used ceClinical graphy, CT tumors radiotherapypresenta- or MRI,tion: angiography Treatment: endoarterial R Treatment: endoarterial•Tumor , incisive or chemotherapy & e chemotherapy &•Pain c•Malfunction excisive radiotherapy with the radiotherapy with the uof the limb biopsy. following surgery (wide e following surgery (wide local excision, amputation local reexcision, e or exarticulation of the limb. reamputation or e exarticulation of the limb. Postoperative chemo- &/or n Postoperative chemo- radiotherapy c Malignant &/or radiotherapy e tumors Treatment (if the tumor is inoperable or/& the patient refuses from the operation) chemo- radiotherapy is indicated
1. What are the soft tissue sarcomas? a. malignant tumors that develop in connect, support, or surround tissues b. benignant tumors that develop in connect, support, or surround tissues c. malignant tumors that develop in epithelial tissues d. benignant tumors that develop in epithelial tissues2. The more common symptoms of the soft tissue sarcomas are: a. the presence of the tumor, appearance of the the pain and malfunction of the nearest joint b. the presence of the tumor, appearance of the the pain and high temperature c. the presence of the tumor, bleeding and malfunction of the stomach3. Diagnosis of the soft tissue sarcoma may be proved by: a. physical, Rő-logical examination, sonography b. physical, Rő-logical examination, sonography, biopsy c. physical examination, sonography, ECG4. The most informative type of biopsy is: a. excisional or incisional biopsy b. core-needle biopsy c. fine-needle aspiration5. Treatment options for soft tissue sarcomas include: a. surgery b. radiation therapy c. chemotherapy d. all answers are correct
9. Skin cancer. Melanoma.Skin cancer (Cancroid)Etiology• high isolation• long-term contact with chemical carcinogens – the products of oil refining, coal, shale oils, arsenic combinations• ionizing radiation• constant skin injuries ( mechanical injuries, burns).Patamorphology • basal-cells (basalioma) • Squamous Cell Carcinoma ( keratinized and non-keratinized) • Epidemiology Bulgaria the sickness rate is 36 for 100.000 of inhabitants; England it is 1.9 for 100.000 of inhabitants; Ukraine – 35-38 of 100.000 inhabitants. It is observed that countrymen are more likely to have the skin cancer than thecity dwellers.Facultative precancerous forms:• keratosis• skin horn• senile skin atrophy• atheroma• deep skin mycosis• keratoachanthoma• papilloma• red flat herpesObligate precancerous • Bouen tumor • Xeroderma Pigmentosum • Cair disease
International classification according to the TNM system • T- primary tumor • TX-there is no enough evidence for the primary tumor • T0- the primary tumor is not identified • Tis- Carsinoma in situ • T1-the tumor is 2 cm in the maximum measurement • T2- the tumor is more than 2 cm, but less than 5 cm in the maximum measurement • T3- the tumor is more than 5 cm in the maximum measurement • T4- the tumor grows into the lower organs (cartilages, muscles, bones). N – regional lymph nodes • Nx- there is no enough evidence for the evaluation of the regional lymph nodes • N0- there is no evidence of the regional lymph nodes affection • N1- the regional lymph nodes are affected M – distant metastasis • Mx- there is not enough evidence to identify distant metastasis • M0- distant metastasis are not identified • M1- there are distant metastasis Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 T3 N0 M0 Stage III T4 N0 M0 Any T N1 M0 Stage IV Any T Any N M1Clinically forms of the skin cancer • superficial • infiltrative or deep-penetrative
• papillaryDiagnostics • examination • palpation • dermatoscopy • cytological analysis of the scrape, smear • incisionary biopsy • to diagnose the metastases in the regional lymph nodes it is common to use the sonography • of the distant metastases, the radiography of the pectoral cavity organs and the ultrasonography of the abdominal cavity.Differential diagnostics • Red Lupus • Tuberculosis • Syphilitic gumma • Actinomycosis • melanoma • Non-malignant skin growthsTreatment squamous cell carcinoma • Surgery (Stage I,II) wide ablation of the tumor with the healthy skin area around it (not less than 2 cm) together with the hypodermic cellular tissue and fascia • radiotherapy (Stage I,II) (closely-focused radiotherapy, total dose is 30-60 Gr). • medicines (Stage III,IV) (chemotherapy) • in the presence of the enlarged regional lymph nodes, on suspicion of having metastasis, lymphadenectomia is performed at the same time with the excision.Treatment basal-celled skin cancer • electroexcision (the recovery takes place in 95 % of cases) • closely-focused radiotherapy (the recovery takes place in 90 % of cases)
• excision (the recovery takes place in 95% of cases) • cryotherapy • the relapse is treated by the wide excision.Prognosis • In case of the regional lymph nodes metastases absence 5-years survival is guaranteed in 75-80 % of cases, and when it is early diagnosed almost 80-100 % of patients completely recover and do not have relapses. • 5-years survival with the regional lymph nodes -metastases and growing through the close organs and tissues is only 24%.Non-malignant skin tumors of the conjunctive tissue-like origin. • fibroma ( soft and hard) • dermatofibroma • lipoma • angioma • gemangioendotelioma • neurofibroma The treatment used here is surgical.Skin sarcomas (histological classification) • The tumors of formed dense conjunctive fibrous tissue ( fibrosarcoma and dermatosarcoma Darie). • The tumors of the fat base ( liposarcoma) • The tumors of muscle tissue ( miosarcoma) • The tumors of the blood and lymphatic vessels(angiosarcoma, angioendotelioma, Caposhy sarcoma, lymphangiosarcoma). • The tumors of the undifferentiated cells (undifferentiated sarcoma, mixosarcoma).The treatment of the skin sarcoma • surgical • closely-focused radiotherapy with corticosteroids.
• in cases of the generalized forms of Kaposhy sarcomas the cytostatic therapy is used – the combination of doxorubicin, vinblastin and bleomicin, and also monochemotherapy with the prospidin.• as the biotherapy they use intron A.
Skin melanomaEtiologyThe exogenous risk factors • Physical factors: ultra-violet radiation from the sun, ionizing radiation, electromagnetic radiation, fluorescence illumination, nevus traumatism. • Chemical factors: harmful chemical agents used in the petrochemical, chemical ( in particularly producing nitric acid), producing rubber plants, in the production of vinyl chloride, polyvinyl chloride, plastic, benzol, pesticides. • Biological factors: the nutrition quality ( high level of daily protein and adipose consumption), medical products (exogenous estrogens).The endogenous risk factors Biological constitution features, which presence raises the risk of themelanoma development: racial and ethnic predisposition, the level of the bodypigmentation, hereditary ( family) factors, anthropometric indexes, immune failings,endocrine factors, reproductive women’ factors. Predecessors of the melanoma, that is such pathological skin changes , whichcan have the probability of the malignant mutation: pigmentary parchment-skin,Dubrei melanosis, nevusesMelanoma pathomorphology • Epithelial • spindle-celled • mixed • small-celledInternational classification according to the TNM system • T- primary tumor • Tis- melanoma in situ • T1-the tumor is less than 1mm thick; a) without ulceration and the invasion level is II/III b)with ulceration or invasion level is IV/V. • T2- the tumor is 1,01-2.0 mm thick, a) without ulceration b)with ulceration • T3- the tumor is 2,01-4,0 mm thick; a) without ulceration b)with ulceration
• T4- the tumor is more than 4 mm thick a) without ulceration b)with ulceration N- regional lymph nodes • N1- metastases in 1 gland a)micrometastases 1; b)macrometastases 2 • N2-metastases in 2-3 lymph nodes a) micrometastases1; b)macrometastases2 c)transitional metastases/satellites without metastatic lymph nodes • N3-4 and more metastatic lymph nodes or the conglomeration of lymph nodes, or transitional metastases/satellites with metastatic lymph nodes • 1-micrometastases are diagnosed after the observation or selective lymphodenectomia. • 2.- macrometastases - are clinically found metastases in the lymph nodes, confirmed by the therapeutical lymphodenectomia or extracapsular spreading of metastases in the lymph nodes. M-distant metastases • M1a- there are distant metastasis on the skin, hypodermic or in the lymph nodes. • M1b – metastases in the lungs. • M1c – other visceral or any distant metastases. Clinical stages TNM Morphological stages pTNM 0 Tis N0 M0 Tis N0 M0IA T1a N0 M0 T1a N0 M0IB T1b N0 M0 T1b N0 M0 T2a N0 M0 T2a N0 M0IIA T2b N0 M0 T2b N0 M0 T3a N0 M0 T3a N0 M0IIB T3b N0 M0 T3b N0 M0 T4a N0 M0 T4a N0 M0IIC T4b N0 M0 T4b N0 M0III Any T N1 M0 N2 M0 N3 M0IIIA T1-4a N1a M0 T1-4a N2a M0IIIB T1-4b N1a M0 T1-4b N2a M0
T1-4a N1b M0 T1-4a N2b M0 T1-4a/b N2c M0 IIIC T1-4b N1b M0 T1-4b N2b M0 Any T N3 M0 IV Any T Any N Any M 1 Any T Any N Any M1The main signs of nevuses malignisation • Disappearing of the skin pattern on the nevus surface; • appearance of the shiny, glossy nevus surface; • appearance of the asymmetry or contours irregularity (scalloped) contours of nevus, that is changes of its shape; • Horizontal nevus growth; • Appearance of the subjective heat sensation, itching or pain in the nevus area; • Appearance of the single nodules ( satellites) around nevus; • Appearance single nodules on the surface of the nevus without its visual growth • Peeling of the nevus surface with the formation of the withered “scabs”; • Absence of hair or shedding of the hair on the nevus surface • Partial (irregular) or complete color change of nevus –melanoma ( melanoma) – appearance of the areas of so called bound depigmentation; • Vertical growth of nevus- melanoma above the surrounding areas. • The consistence change of the nevus-melanoma, which is defined with palpation, that is its softening; • Ulceration of the epidermis above the nevus-melanoma; • Inflammation in the area of the nevus-melanoma and surrounding tissues; • Weeping of the nevus-melanoma surface • Bleeding of the nevus-melanoma.Clinical-anatomical forms of the melanoma • Superficial (70%) • Nodule-like ( nodous, nodular) (15%)
• Acral lentigous and mucous melanoma ( 10%). • Lentigo maligna melanoma (melanoma-like freckles)Melanoma diagnostics • studying anamnesis • previous skin changes • external tumor shape • the state of the lymph nodes system • dermatoscopy • echography • tumor thermography • cytological analysis of the smears – the tumor prints, a sentinel node biopsy • radioisotope scanning with the help of radio-active 32 P (300%)Differential diagnostics of melanoma • Youth melanoma ( Spits nevus) • Blue nevus • Galo-nevus • Displastic nevuses • Cavernous thrombotic gemangioma • Non-malignant skin tumors • Malignant skin tumors • underungual, and underepidermal haematoma • onihomikosis • extrasexual chancre • metastases of the other histogenesis tumors into the skinSkin melanoma treatment • The incision of the skin should be performed within the distance of 3-5 cm from the tumor, in this case it is necessary to step back in the direction of the regional lympho-outflow. • It is necessary to ablate in one block the skin, hypodermic cellular tissue and fascia.
• The surgery should be necessarily performed with the general anesthesia. • When there is a suspicion of regional lymph nodes having metastases the regional lymphadenectomy should be performed at the same time.Stage I treatment • The standard treatment in case of IA and IB stages - is wide excision of the tumor at the distance of 2 cm from the tumor borders.Stage II treatment • The standard excision is at the distance of 3 cm from the tumor borders. • Besides the tumor excision it is possible to perform immunotherapy using interferon a-2b 3 ml ME/m2 of hypodermic injection 3 times per week during 3 years or until the relapse and melanoma metastases.Stage III treatment • The medical standard is wide excision of the primary tumor within 3 cm and more combined with the regional lymphodenectomia. • Chemotherapy ( chemoimmunotherapy), immunotherapy ( interferon a-2b, BCG), polychemotherapy should be performed in usual or modified ( hyperthermia, hyperglycemia etc) conditions. As polychemotherapy dacarbasin is used combined with the medications of platinum ( cisplatin), alkaloids of periwinkle ( vinblastin), the medications of urea nitromesil group (lomustin).Stage IV treatment • standard of this tumor treatment is systemic chemotherapy • The surgical treatment of IV stage melanoma can be performed in the presence of the single metastases in the lungs, gastrointestinal tract, bones or brain. Palliative resections are done, which in some cases are very effective and significantly prolong life. • palliative radiotherapy can relieve the patients state • in addition to melanoma treatment main schemes it is common to use antiestrogens ( tamoksifen).Prognosis
• in case of the localized process 5-years survival is possible in 75-86 %, 10- years – 47%• in case of the regional metastases - 33-52% and 13% accordingly• in case of the distant metastasis 5-years survival does not exceeds 5-12%.
1. 45 years old patient has a star-shaped scar on the back of the right hand. This scar appeared after the professional trauma 8 years ago. Recently the scar began to seal and then ulcerated in the center. Biopsy showed the squamous cell carcinoma. Regional lymph nodes did not change. Treatment tactics? a. radiotherapy b. chemotherapy c. surgery d. surgery and radiotherapy e. surgery and polychemotherapy2. An oncologist was approached by the 55 years old patient. A year ago the cancer of the lower lip was diagnosed. After a course of shortfocused X-ray therapy his ulcer healed. A month ago the ulcer appeared once again in the same area as well an enlarged solid lymph node submaxillary. Treatment tactics? a. chemotherapy and radiotherapy b. surgery and polychemotherapy c. surgery d. polychemotherapy e. radiotherapy3. 25 years old man complained of the tumor in the area of the left arm-pit and the dark birth-mark on his shoulder-blade. He was born with this birth-mark but during the last half of the year (six months) it increased noticeably. 2 weeks ago a tumor appeared in the left armpit and consist of several painless nodes. The skin – remains unchanged. Treatment tactics? a. polychemotherapy b. immunotherapy c. radiotherapy d. radiotherapy and chemotherapy e. surgery and polychemotherapy4. 28 years old women has a problem with her birthmark in the area of the small of the back that extends over the skin for 2-3 mm, and which she traumatized
several times with her girdle. Regional nodes are not increased. By way isotope diagnostics radioactive phosphorus is accumulating nevus in amount of 180%. Diagnosis? a. basal-cells (basalioma) b. squamous cell carcinoma c. skin melanoma d. displastic nevuses e. cavernous thrombotic gemangioma5. 48 years old women complains of the dark intumescences on the sole of her right foot. Objective: in the area of the arch of the right foot there is a pigmental formation 1*2 sm, it extends over the skin fjr 1-2 mm, and it is covered with the thin blood – crust. Regional nodes are not increased. Diagnosis? a. displastic nevuses b. cavernous thrombotic gemangioma c. basal-cells (basalioma) d. squamous cell carcinoma e. skin melanoma
10. Cervical Cancer. Uterine cancer. Ovarian cancer.Cervical CancerEPIDEMIOLOGY Cervical cancer is the 2nd most common cancer in women (after breast cancer) and is the 3rd leading killer (behind breast and lung cancer). It affects about 16 per 100,000 women per year and causes death in about 9 per 100,000 per year. In the Ukraine, howeever, cervical cancer is the 3rd most common cancer of women. About 12,800 women in the Ukraine are diagnosed with cervical cancer and about 4,800 die each year. Among gynecological cancers it ranks behind endometrial cancer and ovarian cancer.HISTORY1. Cervical cancer was common in female sex workers.2. It was rare in nuns, except for those who had been sexually active before enteringthe convent.3. It was more common in the second wives of men whose first wives had died fromcervical cancer.4. It was rare in Jewish women.5. In 1935, Syverton and Berry discovered a relationship between HPV and skin cancer in rabbits.ETIOLOGY 1. The main cause of development of cervical cancer is human papillomavirus (HPV) infection which responsible for more than 90% of the cases of cervical cancer. 2. There are 230 types of HPV but only 7 common types of HPV which cause of the cervical cancer: 16, 18, 31, 33, 42, 52 and 58. 3. Types 16 and 18 are the most dangerous in development of the cancer
Infect by HVP in worldArgentina & Honduras - 40%USA – 26%;Canada – 22%;Sweden – 12,8%;Denmark – 15,4%;Japan – 10,7%Spain – 5%.RISK FACTORS Human papillomavirus infection Smoking HIV infection Chlamydia infection Dietary factors Oral contraceptives Multiple pregnancies Use of the hormonal drug diethylstilbestrol (DES) Family history of cervical cancerPATHOPHYSIOLOGY HPV subtypes 16 and 18 introduce two genes called E6 and E7 which code for proteins that inhibit p53 and Rb, which are two important tumor suppressor genes in humans. The p53 gene product is involved in regulation of apoptosis (cell suicide), and Rb is responsible for halting the cell cycle at the G1-phase.HISTOLOGYTypes of malignant cervical tumors include the following: squamous cell carcinoma (about 80-85%) (Fig.3-7) adenocarcinoma adenosquamous carcinomas small cell carcinoma
neuroendocrine carcinoma melanoma lymphomaSTAGING Cervical cancer is staged by the FIGO staging system which is based on clinical examination, rather than surgical findings. For premalignant dysplastic changes, the CIN (cervical intraepithelial neoplasia) grading is used.The TNM staging systemStage 0 - full-thickness involvement of the epithelium without invasion into thestroma (carcinoma in situ) Stage I - limited to the uterus (Fig.6) – IA - diagnosed only by microscopy; no visible lesions IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or lessTreatment consists of surgery (including local excision) in early stages – IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm IB1 - visible lesion 4 cm or less in greatest dimension IB2 - visible lesion more than 4 cm Stage II - invades beyond uterus – IIA - without parametrial invasion – IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm IB1 - visible lesion 4 cm or less in greatest dimension IB2 - visible lesion more than 4 cm Stage II - invades beyond uterus – IIA - without parametrial invasion
Treatment consists of surgery and radiotherapy in advanced stages of thedisease IIB - with parametrial invasion Stage III - extends to pelvic wall or lower ⅓ of the vagina – IIIA - involves lower ⅓ of vagina – IIIB - extends to pelvic wall and/or causes hydronephrosis or non- functioning kidney IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis IVB - distant metastasisTreatment consists of chemotherapy and radiotherapyClinical presentation 1. Vaginal bleeding 2. Contact bleeding or (rarely) a vaginal mass. 3. Moderate pain during sexual intercourse 4. Vaginal dischargeSymptoms of advanced cervical cancer may include: Heavy bleeding from the vagina Loss of appetite Weight loss Fatigue Pelvic pain Back pain Leg pain Single swollen leg Leaking of urine or feces from the vagina Bone fracturesDIAGNOSIS • Palpation • Visual inspection of the cervix aided by using an acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix
• Colposcopy • Endocervical curettage is made by doing a biopsy of the cervix • Hysteroscopy • Cystoscopy • Proctoscopy • Intravenous urography • X-ray examination of the lungs and skeleton • Cervical conization.Rules of taking biopsy. 1. Target 2. From 3 areas 3. Use special brush for biopsyTREATMENTTreatment consists of : 1. Surgery (including local excision) 2. Chemotherapy 3. Radiotherapy 4. The HPV vaccine, for the two most common strains of HPV has recently been licenced •Stage IA (microinvasive cancer) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina) * An alternative for patients who desire to maintain fertility is a local surgical procedure such as a LEEP or cone biopsy. •Stage IA2 can be treated by hysterectomy with removed the lymph nodes •Stages IB1 and IIA (less than 4 cm): 1. radical hysterectomy with removal of the lymph nodes 2. radiation therapy as external beam radiotherapy and brachytherapy (internal radiation). •Stage IB2 and IIA (more than 4 cm): 3. radiation therapy and cisplatin-based chemotherapy
4. hysterectomy (which then usually requires adjuvant radiation therapy), 5. cisplatin chemotherapy followed by hysterectomy. •Stage (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy. Vaccine 1. Vaccine against four strains of HPV (6,11,16,18) is called Gardasil™ (Merck & Co.). 2. Gardasil is targeted at girls of age 9 before they begin having sex and women of age 26. 3. The vaccine works if given before infection occurs. 4. Vaccine is called Cervarix™ (Glaxosmithkline) has been effective in preventing HPV strains 16 and 18PROGNOSIS5-year survivalIa - 98%Iб - 78-95%III - 18-53%IV - 6-20%
Uterine cancerEPIDEMIOLOGY•Uterine cancer is the 1st most common cancer of the female reproductive system.•It affects about 140 000 women each year and causes death in about 9 - 10 per100,000 per year in world and 7 – 8 per 100,000 in Western Europe, in Ukraine -24,2 per 100,000RISK FACTORS•Women who experience menstruation begins before the age of 12 years old andcontinues into a woman’s 50’s.•Women who have never experienced pregnancy•Women who do not experience regular cycles•Women with Type 2 diabetes or women who are obese•Women who participate in Estrogen-only Replacement Therapy (ERT)•Uterine cancer is more prevalent in older women (over the age of 40)•Women who have gone through menopause are especially encouraged to consult aphysicianHISTOLOGY Types of malignant endometrial cancer, or cancer of the uterus, include the following:• Endometrioid adenocarcinoma• Serous-papillary adenocarcinoma• Adenosquamous carcinoma• Light-cells adenocarcinoma• Mucinous adenocarcinoma• Squamous adenocarcinoma• Secretory carcinoma• Non-differentiated carcinoma Сlinical presentationSigns and symptoms of endometrial cancer include:
•watery discharges from the vagina •abnormal vaginal bleeding •bleeding after menopause •spotting from the vagina •discharges from the vagina •pelvic pain •weight lossDIAGNOSIS Palpation Rectal exam Hysological exam include endometrial curettage is made by doing a biopsy of the edometrium Cytological exam Hysterography Hysteroscopy, UltrasonographyTREATMENTThe most common treatments for uterine cancer are: surgery, radiation therapy, chemotherapy, hormone therapy. I. Surgery involves having a hysterectomy. 1. Simple hysterectomy (removal of the entire uterus) 2. Radical hysterectomy (removal of the uterus, surrounding tissues, andcervix) II. The option of radiation therapy involves using high-energy radiation.III. Chemotherapy is most often used when the cancer has spread to other areas of the body.
IV. Hormone therapy is mainly used to treat patients with endometrial stromal sarcomas. A progesterone-like hormone drug or a drug which stops the production ofestrogen can be used. Synthetic progestin - Depostat .PROGNOSIS5-year survivalIa - 98%Iб - 78-95%III - 18-53%IV - 6-20%
Ovarian cancerEPIDEMIOLOGY Ovarian cancer is the 2nd most commonly diagnosed gynecologic malignancy and the 5th leading cause of cancer death in women. The disease is more common in industrialized nations, with the exception of Japan. In the United States, females have a 1.4% to 2.5% (1 out of 40-60 women) lifetime chance of developing ovarian cancer. In the Ukraine – 15,5 causes of 100 000 womenETIOLOGY Ovarian cancer is idiopathic, meaning that the exact cause is usually unknown. The risk for developing ovarian cancer appears to be affected by several factorsRISK FACTORS Age between 55 and 74 years old Women who havent been pregnant and never have a baby Older ages of first pregnancy Mutations of the BRCA1 or the BRCA2 gene Personal history of breast cancer or a family history of breast Syndrome hereditary nonpolyposis colorectal cancer (HNPCC, also known as Lynch II syndrome)CLASSIFICATION Ovarian cancer is classified according to the histology of the tumor. Lesions differ significantly in clinical features, management, and prognosis (ICD-O codes provided where available). I. Histology Surface epithelial-stromal tumours are the most common and prototypic ovarian cancers. They are include: serous cystadenocarcinoma mucinous cystadenocarcinoma. Sex cord-stromal tumors include lesions that are hormonally active: estrogen-producing granulosa cell tumor
virilizing Sertoli-Leydig cell tumor or arrhenoblastoma. Germ cell tumors originate from dysplastic germ material and tend to occur in young women and girls. Lesions include: the dysgerminoma, a form of the choriocarcinoma malignant forms of the teratoma. II.History Primary is the tumor which growth in ovary originally. Secondary, the result of metastasis from primary cancers elsewhere in the body. For example, from breast cancer, or from gastrointestinal cancer (in which case the ovarian cancer is a Krukenberg cancer)StagingOvarian cancer staging is by the FIGO staging system and uses information obtainedafter surgery.The AJCC stage is the same as the FIGO stage. Stage I - limited to one or both ovaries • IA - involves one ovary; capsule intact; no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings • IB - involves both ovaries; capsule intact; no tumor on ovarian surface; negative washings • IC - tumor limited to ovaries with any of the following: capsule ruptured, tumor on ovarian surface, positive washings Stage II - pelvic extension or implants • IIA - extension or implants onto uterus or fallopian tube; negative washings • IIB - extension or implants onto other pelvic structures; negative washings • IIC - pelvic extension or implants with positive peritoneal washings Stage III - microscopic peritoneal implants outside of the pelvis; or limited to the pelvis with extension to the small bowel or omentum • IIIA - microscopic peritoneal metastases beyond pelvis
• IIIB - macroscopic peritoneal metastases beyond pelvis less than 2 cm in size • IIIC - peritoneal metastases beyond pelvis > 2 cm or lymph node metastases* Stage IV - distant metastases--in the liver, or outside the peritoneal cavity * Para-aortic lymph node metastases are considered regional lymph nodes (StageIIIC).DIAGNOSISOvarian cancer at its early stages (I/II) is difficult to diagnose until it spreads andadvances to later stages (III/IV). This is due to the fact that most of the commonsymptoms are non-specific.Diagnosis includes:•Symptoms•Physical examination•Pelvic examination•Instrumental examination•Laboratory examination sense of pelvic heaviness vaginal bleeding weight gain or weight loss abnormal menstrual cycles unexplained back pain that worsens over time increased abdominal girth non specific gastrointestinal symptoms: vague lower abdominal discomfort increased gas indigestion lack of appetite nausea and vomiting Bloody stool
inability to ingest usual volumes of food bloating Additional symptoms that may be associated with this disease: increased urinary frequency/urgency excessive hair growth Fluid buildup in the lining around the lungs (Pleural effusions) Positive pregnancy readings (in the absence of pregnancy. This is for germ cell tumors only) Note: There may be no symptoms until late in the disease. Physical examination may reveal increased abdominal girth and /or ascites (fluid within the abdominal cavity). Pelvic examination may reveal an ovarian or abdominal mass. The pelvic exam can include a rectovaginal component for better palpation of the ovaries. Instrumental examination 1. Abdominal ultrasound 2. Ultrasound of small pelvis 3. Trans-vaginal ultrasound 4. CT scan of the abdomen and pelvis 5. MRI Laboratory examination The blood test called CA-125 is useful in differential diagnosis and in follow up of the disease, but it has not been shown to be an effective method to screen for early-stage ovarian cancer and is currently not recommended for this use. The blood test on levels of lysophospholipids (a type of fatty acid)TREATMENTThe treatment consist of 1. Surgery 2. Chemotherapy 3. Radiation therapy
4. Hormonal therapyI. Surgery is the preferred treatment and is frequently necessary for diagnosis. Thetype of surgery depends upon how widespread the cancer is when diagnosed (thecancer stage), as well as the type and grade of cancer.The types of surgery are:Unilateral oophorectomy or bilateral oophorectomy - make only in stage 1, lowgrade or low-risk disease, especially in young females who wish to preserve theirfertilityPanhysterectomy + omentectomy (in stage 1’2’3)In advanced disease as much tumor as possible is removed (debulking surgery)II. Chemotherapy can be used before and after surgery and to treat women who havea recurrence.1). Cysplatinum (Р) - 100 mg/м2 number 1 in 3 weeks; or2). Cysplatinum (Р) - 50 mg/м2 number 1in week during 6-8 weeks; or3). Carboplatinum (СвР) AUC 5-7 number 1 in 3 weeks; or4). Cysplatin - 75 mg/м2 + cyclophophanum 750 mg/м2 number 1 in 3 weeks; or5). Carboplatinum (СвР) AUC 5 + cyclophophanum 750 mg/м2 number 1 in 3weeks;III. Radiation therapy is not effective for treatment ovarian cancer.IV. Hormonal therapy can be used androgens or/and ant estrogensCOMPLICATIONS•spread of the cancer to other organs•progressive function loss of various organs•ascites (fluid in the abdomen)•blockage of the intestines PROGNOSISSize of residual tumor Duration of life< 0,5 cm 40 months.0,5 – 2 cm 18 months2 cm 6 months
Ovarian cancer has a poor prognosis. It is disproportionately deadly because symptoms are vague and non-specific. More than 50% of women with ovarian cancer are diagnosed in the advanced stages of the disease because no cost- effective screening test for ovarian cancer exists. The 5-year survival rate for all stages is only 35% to 38%. If, however, diagnosis is made early in the disease, 5-year survival rates can reach 90% to 98%.Frequency of recidivations: ♦ in early stages - 20-30% ♦ in advanced stages - 65-96%.
1. What is the main cause of development cervical cancer? a. simple herpes virus b. human papillomavirus c. mechanical trauma d. radiation2. What are kinds of special treatment stage Ia cervical cancer you will choose? a. radical hysterectomy b. radiation therapy c. cisplatin chemotherapy d. LEEP3. What are complications of ovarian cancer? a. pathological fractures b. ascites (fluid in the abdomen) c. bleeding d. pancreatitis4. What is main laboratory test of ovarian cancer? a. level of leukocytes b. CA-125 c. level of glucose d. level of blood protein5. Radical hysterectomy is: a. removal of the entire uterus b. removal of the uterus, surrounding tissues, and cervix c. removal of the uterus, surrounding tissues, cervix, omentumectomy d. removal of the entire uterus without ovaries