cervical carcinoma, endometrial carcinoma and vulval disease
Second most common gynaecological cancer.
Annual risk for women over 35 years of age is
16 per 100,000
Peak incidence in between 45 and 55 years
Mean age 51.4 years
Recent trend towards younger age.
Cervical cancer usually grows outwards; creating
a fungating mass. Occasionally inwards,
enlarging the cervix.
More than 85% of cervical cancers are squamous
Rest are adenocarcinomas.
With time cancer spreads:
1. Upwards to uterine cavity
2. Downwards to vagina
3. External iliac lymph nodes (47% cases)
4. Obturator lymph nodes (20%)
5. Hypogastric nodes (7%)
6. Paracervical nodes (2%)
In earlier stage abnormal smear is the only way
to detect as symptoms develop with invasive
Per speculum examination and cervical is
necessary if following symptoms are present:
1. Irregular per vaginal bleeding, particularly after
2. Pink vaginal discharge after urination
Diagnosis is confirmed by colposcopy or biopsy
and endocervical curettage.
Clinical staging is not able to detect spread to
the liver and lymph nodes.
Ultrasound computed tomography (CT) and
magnetic resonance imaging (MRI) are used.
CT can detects lymph node metastases, plus
liver, urinary tract and bone involvement.
MRI has a role in detecting parametrial spread
and is useful to evaluate pregnant women as
it avoids radiation exposure to fetus.
International Federation of Obstetrics and Gynaecology (FIGO) classification for
staging of carcinoma of uterine cervix
Stage 0 Cervical intraepithelial neoplasia 3 (CIN3)
Carcinoma in situ
Stage 1 The carcinoma is confined to the cervix
1A Invasion can only be diagnosed by microscopy with maximum
depths ≤5.0mm and horizontal spread of ≤7.0mm
1B Clinically visible
Stage 2 The carcinoma invades beyond the uterus but does not reach pelvic
wall or lower third of vagina
2A No obvious parametrial involvement
2B Obvious parametrial involvement
Stage 3 The carcinoma has reached the wall of the pelvis and/or the lower
third of the vagina
3A Reached lower third of the vagina
3B Extension to pelvic wall or hydronephrosis or non functioning
Stage 4 The carcinoma has spread beyond the true pelvis or has invaded the
bladder or rectum
4A Spread to adjacent organs
4B Spread to distant organs
Lymph node involvement and 5 year survival rates of cervical carcinoma related
to stage of the disease
Stage Lymph node involvement 5-year survival (%)
0 0 100
1A 0.5 95
1B 15 80
2A 25 66
2B 35 64
3 55 35
4 >65 14
Treatment of microinvasive (stage 1A) cancer
depends on whether the woman wants to retain
A cone biopsy with clear margins is an adequate
treatment, otherwise a simple hysterectomy.
Stage 1B and early 2A is treated by radical
hysterectomy followed by radiotherapy.
Radical hysterectomy involves removal of
parametrium and pelvic lymphadenectomy and
radiotherapy includes a combination of external
beam and intracavity radiation.
In younger women the ovaries can be preserved
and relocated out of the potential radiotherapy
More advanced cervical carcinoma is treated by
Bladder dysfunction, lymphoedema and sexual
dysfunction are complications of treatment.
Chemotherapy has been used in both early stage
(1B) and advanced disease.
This improves the 2 year survival rate from 79 to
89% and 63 to 75%
Disease of women in their middle years.
Peak incidence in 55-65 year age group.
Women whose menopause is delayed beyond the
age of 55, who are relatively infertile, and
overweight or hypertensive are more likely to
develop endometrial cancer.
If endometrial hyperplasia shows a pathology
with complex hyperplasia with atypia 17-43% of
women will develop endometrial cancer unless
The tumor may originate in any part of
endometrium and grows slowly, tending to
spread over a part of the endometrium before
If the growth starts in lower part of uterus, the
fungating mass block the cervix and fluid or pus
may collect in uterus(pyometra)
Various histological patterns of adenocarcinoma
are found on the histological examination of an
endometrial biopsy or curettage.
The more undifferentiated the endometrial cells
the worse the prognosis.
Bloody vaginal discharge.
Irregular bleeding; slight in amount and recurrent.
Watery vaginal discharge is uncommon.
Examination shows normal size uterus unless there is
associated myomata or pyometra.
Any peri- or postmenopausal woman who has
symptoms of irregular bleeding per vaginam or
bloody vaginal discharge must be examined and
endometrial and endocervical canal tissue sampled.
Using a hysteroscope the uterine cavity can
be inspected and a biopsy taken under direct
An alternate is to measure endometrial
thickness by transvaginal ultrasonography.
If the endometrium is less than 5mm
thick, endometrial cancer can be excluded.
Confirmation by hysteroscopy and biopsy or
by curettage either using a biopsy curette or
a formal curettage under general anesthesia
Two biopsy curettes are used Gynescan and
They are introduced through the cervix and
rotated in the uterine cavity.
It is relatively a painless procedure. 60%
women experience discomfort or pain.
A negative biopsy in a symptomatic woman
should be followed by a formal hysteroscopy
and biopsy/curettage under anesthesia as
there is a 10% false negative rate
Mass screening for endometrial cancer is neither practical
nor justifiable with current techniques.
Pap smears detect 50% cases but is too unreliable to
screen asymptomatic women.
Three groups are at high risk:
1. Postmenopausal women taking unopposed oestrogen
2. Females with family history of non-polyposis colorectal
3. Premenopausal women with anovualatory cycles
They should be offered regular surveillance
Women using tamoxifen are at risk if they have
abnormal vaginal bleeding
Over 75% women are diagnosed in early stage.
Total hysterectomy and bilateral oophorectomy is the
treatment of choice.
Pelvic lymphadenectomy is performed with:
1. Grade 3 disease (>50% non squamous or non
morular growth pattern)
2. Grade 2 (6-50% non squamous or non morular
3. Tumors >2cm in diameter
4. Adenosquamous or clear cell or papillary serous
5. >50% myometrial invasion
6. Those who have cervical extension
The excised uterus is examined histologically; if
more than half of myomtrium’s thickness is
invaded either whole pelvis irradiation (50Gy over
5 weeks) or hormone treatment is given.
3-4weeks after hysterectomy intravaginal
irradiation is given of 40Gy to prevent recurrence
Vagina may become stenosed making intercourse
Bladder and rectal symptoms may arise as a
result of radiation damage.
Medroxyprogesterone acetate 200-400mg is
given orally if patient is unfit for surgery.
Depends on the stage of disease, the histological
grade of tumor, the age and health of woman.
Women who have received treatment for low stage
endometrial carcinoma and who have severe
menopausal symptoms may be prescribed hormonal
replacement therapy with no increased development
of any residual cancer.
Follow up is recommended at 4 monthly intervals for
first 3 years and annually thereafter.
The woman is examined abdominally and
vaginally, checked to detect any large lymph nodes
The recommended treatment and 5-year survival rate of endometrial cancer
related to the stage of the disease
Stage Recommended treatment 5-year survival rate (%)
1A Hysterectomy 88
1B Hysterectomy followed by vaginal vault and
IIA As for carcinoma of cervix 77
IIB As for carcinoma of cervix 67
III Hysterectomy and bilateral salpingo-
oophorectomy if feasible plus radiation
IV Palliative surgery, radiation therapy and
This condition is being increasingly diagnosed during
colposcopic investigation of women presenting with
pruritus vulvae or vulval warts.
The treatment options are watchful expectancy or local
excision of the area in high grade VIN 3
Follow up is important as one third of patients have
Between 4 and 8% of women with Paget’s disease have an
Treatment is by wide excision including the underlying
Long term surveillance is needed due to recurrence.
Accounts for 3% of genital tract cancers.
Affects elderly women.
Growth starts as a lump or an ulcer on one
labium majus (50% of cases) or on a labium
minus (25% of cases)
In some cases various areas are affected.
In recent years a number of young women have
been presenting with malignant change in a
Affected woman may have vulval itching for
months and years or has had few symptoms
or noticed the ulcer recently.
The lesion is hard nodule or ulcer with
sloughing base and raised edges, which
maybe small or large depending on duration
If cancer is large, lymph node involvement
may have occurred in more than 50% of cases
Either simple vulvectomy with dissection of
the inguinofemoral lymph nodes for stage 1
disease (tumor = 2cm) or radical vulvectomy
for stage 2 (confined to the vulva and >2cm
in diameter) with inguinal, femoral and pelvic
Wound necrosis is a troublesome
complication after radical vulvectomy, and
persistent leg oedema occurs in 20% of
For advanced disease treatment needs to be
individualized and depends on the degree of
spread, age of woman and her general state
Modalities employed include surgical
excision, radiotherapy and chemotherapy.
5-year survival is 70% overall, for stage I 90%,
stage II 75%, stage III 50% and stage IV 15%