Broad overview of staging and treatment of Gynaecological cancers

1. +
Chemotherapy & Radiotherapy in Gynaecogical cancers
Dr Sai L Daayana
MBBS, MRCOG, MD, Sub-specialty training in
Gynaecology Oncology (UK)
Consultant in Surgical Gynaecology Oncology
Apollo Cancer Institutes, Hyderabad

2. +
Gynaecological cancers
n Cancer of the fallopian
tubes / ovaries
n Cancer of the endometrium
n Cancer of the cervix
n Cancer of the vagina
n Cancer of the vulva

3. +
Treatment of early-stage
Gynaecological Cancers
n Early stage - treated surgically if resection can be
accomplished without substantial tissue disruption.
n Postoperative chemo / radiotherapy is reserved for cases in
which histopathologic analysis of the removed specimen
reveals features suggesting a high risk for recurrence.

4. + FIGO Staging of Ovarian Cancer
I Limited to ovaries
Ia One ovary
Ib Both ovaries
Ic Stage Ia or Ib + ascites, tumour on ovarian surfaces or
ruptured capsule
II Pelvic extension
IIa To uterus or tubes
IIb To other pelvic tissues
IIc IIa or IIb + ascites or +ve peritoneal washings

5. + FIGO Staging of Ovarian Cancer
(Cotd.)
III Peritoneal implants or +ve retroperitoneal LNs
IIIa Microscopic seedlings on peritoneal surfaces, -ve LNs
IIIb Tumour implants each <2cm diameter, -ve LNs
IIIc Tumour implants >2cm or +ve LNs
IV Distant metastases
If pleural effusion, must have +ve cytology

6. +
Treatment of Ovarian Cancer
n Stage IA, IB – Surgery
n (laparotomy, total abdominal
hysterectomy, bilateral salpingo
oopherectomy, omentectomy,
pelvic and para-aortic lymph
node sampling)
n Stage III – no bulk disease but
peritoneal disease or extensive
stage IV disease –
n 3 cycles of IV chemotherapy
(carboplatin and paxlitaxel),
Surgery followed by 3 more
cycles of chemotherapy
n Stage 1c, Stage II, Stage III, Stage IV –
Surgery + adjuvant chemotherapy
n No role for radiotherapy in the
standard treatment for ovarian
cancer

7. +
Chemotherapy for Ovarian Cancer
Carboplatin
Taxol (Paclitaxel)
• Intravenous
• Every 3 weeks (before surgery and / or start within 6 weeks
after surgery)
• for 6 treatments (@ 18 weeks)
• Well tolerated
– (nausea, bone marrow suppression, hair loss, peripheral
neuropathy, fatigue)

8. +
Management of Recurrent
OVARIAN Cancer
n 1. Local recurrence:
Radiation – if not previously irradiated
Pelvic exenteration
n 2. Distant disease
Chemotherapy

9. +
FIGO Staging of Endometrial Cancer
I Tumour confined to the uterus
IA No or less than half myometrial invasion
IB Invasion equal to or more than half of the
myometrium
II Tumour invades cervical stroma, but not
beyond the uterus

10. +
FIGO Staging of Endometrial Cancer
(cont.)
III Local and/or regional spread of the tumour
IIIA Tumour invades the seros aof the uterus and/or adnexae
IIIB Vaginal and/or parametrial involvement
IIIC Metastases to pelvix and/or para-aortic lymph nodes
IIIC1 Positive pelvic lymph nodes
IIIC2 Positive para-aortic lymph nodes +/- positive pelvic
lymph nodes
IV Tumour invades bladder and/or bowel mucosa, and/or
distant metastases
IVA Tumour invasion of bladder and/or bowel mucosa
IVB Distant metastases, including intra-abdominal metastases
and/or inguinal lymph nodes

11. +
Treatment of Endometrial Cancer
n Stage IA – Extra fascial
hysterectomy and bilateral
salpingo oopherectomy
(TAH,BSO) is curative
n Stage IB – TAH,BSO +
pelvic lymph node
sampling
n Stage III and IV cancers –
TAH,BSO + pelvic lymph node
sampling + para-aortic lymph
node sampling + omentectomy
followed by chemotherapy and
radiotherapy
n Stage II - TAH,BSO +
pelvic lymph node
sampling + para-aortic
lymph node sampling
followed by pelvic
radiotherapy

12. +
Radiotherapy for Endometrial
Cancer
When hysterectomy is medically contraindicated, primary
radiotherapy can offer 5-year disease-specific survival rates of
80-90%, approaching those achieved with surgery.

13. + Types of
Radiotherapy
for
Endometrial
Cancer
External
beam
radiotherapy
Brachytherapy

14. +
Chemotherapy for Endometrial
Cancer
The drugs used most often are paclitaxel, doxorubicin,
and either carboplatin or cisplatin.These drugs are
often used together in combination.

15. +
FIGO Staging of Cervical Cancer
Stage 1 - Carcinoma strictly confined to cervix
1A1 Stromal inv of ≤ 3mm in depth and extension of ≤ 7 mm
1A2 Stromal inv of 3-5mm with extension of not >7mm
IB Clinically visible lesions limited to cervix or preclinical cancers >IA
IB1 Clinically visible lesion ≤4cm in greatest dimension
IB2 Clinically visible lesion >4cm in greatest dimension
II Carcinoma invades beyond the uterus, but not to pelvic wall or to
the lower third of the vagina
IIA without parametrial invasion
IIA1 Clinically visible lesion ≤ 4cm in greatest dimension
IIA2 Clinically visible lesion > 4 cm in greatest dimension
IIB with obvious parametrial invasion

16. + FIGO Staging of Cervical Cancer
(cont.) IIIA Extends to lower third of vagina
IIIB Extension to pelvic side-wall and/or hydronephrosis or
non-functioning kidney
IV Biopsy proven carcinoma extended beyond true pelvis/
mucosa of bladder or rectum

17. TREATMENT OF CERVICAL CANCER
Treatment options:
LLETZ (loop excision)
Cone biopsy
Total hysterectomy
Radical trachelectomy
Radical abdominal
hysterectomy
External beam &
intracavity radiotherapy
Chemotherapy
Treatment depends on the stage of the disease
Stage IA
Stage IB, IIA
Stage IIB or more, high grade
disease with other stages

18. +
Indications for radiotherapy
following Wertheim’s hysterectomy
n Positive pelvic lymph nodes.
n Tumour close to resection margins and/or parametrial
extension.

19. +
Chemoradiation for cervical cancer
Concurrent chemoradiation – Chemo helps radiation work
better
Options:
Cisplatin given weekly during radiation.This drug is given into
a vein (IV) about 4 hours before the radiation appointment.
Cisplatin plus 5-fluorouracil (5-FU) given every 4 weeks during
radiation.
Sometimes chemo is also given (without radiation) before and/
or after chemoradiation.

20. + Staging ofVAGINAL cancer
— Stage I - Lesions confined to the mucosa
— Stage II- Subvaginal 7ssue involved but no extension to
pelvic sidewall
— IIA: Subvaginal infiltra7on only
— IIB: Parametrial extension
— Stage III- Pelvic sidewall extension
— Stage IV- Bladder or rectal extension and/or direct
extension outside of true pelvis

21. +Treatment of VAGINAL cancer
n Radiation therapy is the preferred treatment for
most carcinomas of the vagina
n Surgical therapy
n Irradiation failures
n Non-epithelial tumors
n Stage I Clear cell adenocarcinomas in young
women

22. +Staging of VULVAL carcinoma
Stage 1 2 cm lesion
size Or less
Confined to the vulva or perineum nodes
histo-Logically negative.
Stage 2 > 2cm lesion
size
Confined to the vulva or perineum nodes
histo-Logically negative.
Stage 3 Tumor of any size spread to lower urethra
vagina anus +/- Unilateral metastasis
Stage 4 A Involvement of :
Upper urethra
Bladder mucosa
Rectal mucosa
Pelvic bone
Bilateral L.N.metastasis
B Distant metastases and / or pelvic nodes

23. Treatment Options by Stage for Vulval
cancer
Treatment OptionStage
Partial Vulvectomy excision of the tumor, with a 1 cm safe margins. No need
for node removal.
Ia
Ib
Modified radical vulvectomy with either of the following:
1) Ipsilateral groin lymph node dissection: in cases of lateralized
lesion
2) Bilateral groin node dissection: in cases of centralized lesions
Modified radical vulvectomy with bilateral groin node dissection.
II
- Combined approach:
1- Preoperative external beam radiation therapy.
2- Chemotherapy (e.g. 5-fluorouracil, cisplatin).
3- Radical excision with bilateral inguinal & femoral node dissection.
4- Preoperative RT, then surgical excision of the tumor.
III
Individualized
IV

24. +
Difference between chemotherapy
and radiotherapy
n Use of one or more cytotoxic
drugs
n Used when cancer effects
more than one part of the body
or the whole body
n Use of ionizing radiation
n Used when cancer effects
single part of the body