A basic discussion on the topic of gynaecologic cancer.

1. OVERVIEW OF GYNAECOLOGIC CANCERS
TREATMENT
DR. A.B HALIMI
CONSULTANT O&G (MBBS, FMCOG)
UITH ILORIN
04-Mar-18 1

2. INTRODUCTION
• Gynaecologic cancers are cancers that arise from the female reproductive tract.
• The most common of them is cancer of the cervix, followed by endometrial,
ovarian, vulva and vagina
• For lower genital tract, aetiopathogenesis is similar with infective origin implicated.
• Generally the risk factors are multifactorial, and in some instances can not be
identified.
• Some are gene related eg Nonpolyposis colorectal cancer….. Endometrial and
ovarian
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3. INVESTIGATIONS
• FBC / Absolute platelet count
• LFT
• Serum U/E/C
• Blood sugar
• Urinanalysis
• Radiological eg USS… TVS/AbdPelvic, CT Scan, MRI, Doppler
• Endoscopy eg Laparoscopy, Hysteroscopy, Cystoscopy etc
• CA125
• BRA CA 04-Mar-18 3

4. 04-Mar-18
Cancer Screening 4
CERVICAL CANCER
 Cervical ca develop from the transformation zone of the cervix is usually as a result of
Human papilloma virus (HPV) infection (commonly High risk strains HPV-16, 18, 31,
33 and 45).
 HPV infections often occur in their teens, 20s, 30s
 Cervical ca can develop up to 20 years after HPV infection
 It is the leading cause of cancer death in women in the developing world.
 >500 000 new cases of cervical ca, of which over 90% were in developing countries.
 It is estimated that over 1 million Women worldwide currently have cervical cancer
 ~ 95% of women in developing countries have never been screened for cervical ca.
 Over 80% of women newly diagnosed with cervical cancer live in developing
countries; most are diagnosed when they have advanced disease.

5. RISK/ AETIOLOGICAL FACTORS
• Lack of cervical screening programs
• HPV infection(oncogenic subtypes)
• Other STI
• Advanced age
• Race Black>White
• Life style eg Obesity, Cigarette smoking
• Early coitache
• Low socioeconomic class
• Contraceptives
• Multiple sexual partners
• High parity
• Circumcision
• Dietary factors 04-Mar-18 5

6. SIGNS AND SYMPTOMS
• Few are asmptomatic
• Watery vaginal discharge
• Vaginal bleeding eg Postcoital/contact
• Systemic manifestation
 urinary symptoms
Cough, haemoptysis,
Jaundice, abdominal pain/tenderness
Pressure symptoms
Confusion, coma
Others
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7. STAGING
• Stage 0 Carcinoma in situ
• Stage ITumor confined to the cervix (disregard extension to corpus)
• Stage II Tumor extends beyond the cervix but not on to the pelvic side wall. Lower 1/3 of
vagina not involved
• Stage III Tumor extends to pelvic side wall; involves lower 1/3 of vagina; all cases of
hydronephrosis or non-functioning kidney
• Stage IV Tumor has extended beyond the true pelvis or has clinically involved the mucosa of
the rectum or bladder
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8. TREATMENT
Early stage
A
i. Conization/ simple hysterectomy/radical trachelectomy
ii. Radical hysterectomy with therapeutic lymphadenectomy
iii. Adjuvant postoperative radiation+/- concomitant chemotherapy
B
10 Radiation +concomitant chemotherapy
5yr cure rate of A&B are the same
Locally advanced
Radiotherapy + Concomitant chemotherapy (cisplatin based)
Advanced
Chemotherapy for palliative treatment
Others. 04-Mar-18 8

9. UTERINE CANCER
•Basically 2 types
Endometrial ie endometrial cancer
Myometrial ie sarcoma of the uterus
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10. Endometrial cancer
• White>black
• Survival of white is 8% > black at all stages of the dx
• Most common in postmenopausal (age>55yrs)
• Only ~20% in perimenopausal
• 2 types
• I tumour – estrogen dependent
• II tumour –independent of estrogen
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11. Risk factors
• Obesity
• PCOS
• Exogenous/ Unopposed estrogen
• Granulosa cell tumour of the ovary
• Tamoxifen
• Genetic background 5-6%
• Others eg nulliparity, infertility, HTN, DM
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12. EXAMINATION/ INVESTIGATION
• Fractional curettage
• Endometrial biopsy
• Pelvic USS
• Estrogen & Progesterone receptors Assay
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13. FIGO STAGING
Stages Characteristics
• I Tumor confined to the corpus uteri
• II Tumor invades cervical stroma, but does not extend beyond the
uterus
• III Local and/or regional spread of the tumor
• IV Tumor invades bladder and/or bowel mucosa, and/or distant
metastasis
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14. TREATMENT
• Mainstay is surgery; TH+BSO and staging with therapeutic lymphadenectomy
• Radiation – contraindication to surgery/ Advanced pelvic dx
• Pry chemotherapy- mostly in patient with metastatic dx
• Incr. MPA/Megestrol acetate dose
 non operable px
Young pt with fertility preservation
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15. Sarcoma of the uterus
• Acct for 3-4% of uterine malignancies
• Not age dependent, but common >40yrs
• Bimodal age reported, pre-and postmenopausal
• 2forms
Those that arise from smooth muscle, vessels etc
I. Leiomyosarcoma,
II. Haemangiosarcoma
III. Lymphoma
Those that arise from endometrial glands and stroma
I. Adenosarcoma,
II. endometrial stroma sarcoma and
III. malignant mixed mesoderma tumour or carcinosarcoma
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16. TREATMENT
• Mainstay is surgery; TAH +Lymphadenectomy and tumour debulking
• Chemotherapy – not effective in sarcoma treatment however,
Cisplatin,
Ifosfamide,
Doxorubicin
 Carboplatin,
Paclitaxel and
Gemcitabin
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17. OVARIAN CANCER
The third most common genital cancer after cervical and endometrial cancer
This include;
Epithelial ovarian ca -------------------------------90%
Germ cell tumour
Sex cord stroma ---------------------------------5-10%
Border line
Metastasis dx
Hereditary ovarian cancer syndrome
Germ cell tumours are the most common childhood and adolescent ovarian cancer
 the incidence of epithelial ovarian cancer tends to rise at age of 20yrs and exceeds
that of germ cell.
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18. CLINICAL FEATURES
• Asymptomatic 25%
• Abdominal distension (LGS)
• pelvic pain
• GIT symptoms eg Anorexia, nausea, vomiting, constipation etc.
• Subacute abdominal pain 85%
• Acute abdomen 10% (cyst rupture, torsion, intraperitoneal hemorrhage)
• heavy or irregular menses (GCT)
• pelvic mass
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19. Risk Factors for Developing Epithelial Ovarian Cancers
Family history of breast/ovarian cancer
Personal history of breast cancer
Nulliparity
Early menarche
Late menopause
White race
Increasing age
Residence in North America and Northern Europe
Ethnic background (European Jewish, Icelandic, Hungarian)
Postmenopausal hormone therapy
Pelvic inflammatory disease
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20. These are tumours that are found in patient of not >30yrs of age usually <20yrs, often
with varied prognosis.
GERM CELL TUMOURS
• Dysgerminomas
• Immature teratomas
• Endoderma Sinus Tumour
• Embryomal
• Choriocarcinoma
• Gonadoblastoma
• Mixed germ cell tumours
• Polyembryoma
SEXCORD-STROMA TUMOURS
• Granulosa cell
• Thecomas
• Sertoli-stroma cell
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21. OTHER FORMS OF OVARIAN CANCER
• Borderline tumours of the ovary ( serous tumour of low malignant
potential)
• Metastatic tumour eg Krukenberg tumour( Stomach to ovary)
• Hereditory ovarian cancer syndrome
10-15%
Breast (BRA1,BRAII)
Lynch II syndrome(HNPCC)
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22. FIGO STAGING
Stage Characteristics
I. Tumor confined to ovaries
II. Tumor involves 1 or both ovaries with pelvic extension (below the
pelvic brim) or primary peritoneal cancer
III.Tumor involves 1 or both ovaries with cytologically or histologically
confirmed spread to the peritoneum outside the pelvis and/or
metastasis to retroperitoneal lymph nodes
IV.Distant metastasis excluding peritoneal metastasis
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23. TREATMENT
• Early stage dx- TAH + BSO ± infracolic omentectomy, multiple biopsy
including LN pelvic and infrarenal paraaortic lymphadenectomy
• Advanced stage dx
Cytoreduction + chemotherapy(platinum based 6courses)
Neoadjuvant chemotherapy + interval cytoreductive surgery
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24. VULVA CANCER
• Typically occurs in postmenopausal women
• Age -60-70yrs ~65yrs, however, intraepithelial ca of the vulva in women 20-40yrs is
incr. due to incr. incidence of STI
• Acct for 4% of genital cancer
• 2forms
HPV dependent ---- seen in younger age
Xnic inflammation (vulva dystrophy)------ older women
Arises from
i. Skin
ii. Subcut tissues
iii. Glandular element of the vulva
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25. CLINICAL FEATURES
• Vulva irritation and pruritus
• Bloody vulva discharge
• ±Inguinal mass
• Early lesion– xnic vulva dermatitis
• Late lesion– large cauliflower, hard ulceration.
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26. RISK FAVTORS
• HPV infection
• Immunodeficiency syndrome
• Hx of Ca cervix/dysplasia
• Cigarette Smoking
• Past hx of LGT neoplasia
• Hypertension
• Obesity
• Chronic vulva irritation
DM
Granulomatous Veneral dx
Vulva dystrophy 04-Mar-18 26

27. INVASIVE VULVAR CANCER STAGING
Stages Characteristics
• I Tumor confined to the vulva
• II Tumor of any size wit extension to adjacent perineal structures (1/3 lower uret ra,
1/3 lower vagina, anus) with negative nodes
• III Tumor of any size wit or wit out extension to adjacent perineal structures (1/3
lower urethra, 1/3 lower vagina, anus) wit positive inguinofemoral lymp nodes
• IV Tumor invades ot er regional (2/3 upper uret ra, 2/3 upper vagina), or distant
structures
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28. TREATMENT
SURGICAL
Conservatives–
Wide local Excision/ Simple partial vulvectomy
• Micro-invasive dx
Radical partial vulvectomy ± lymphadenectomy
• clinically confined to the vulva
• Patients with a moderate size solitary tumor
• Patients with grossly normal vulva
Radical total vulvectomy + lymphadenectomy.
• large midline or multifocal vulvar cancers.
Chemo-Radiation- cisplatin, bleomycin and methotrexate
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29. VAGINAL CANCER
• Acct for 0.3%
• 20 cancer >>10
• Hypernephroma of the kidney(20 cancer) xtically metastasized to the lower
third of the anterior vaginal wall.s
• Upper 3rd of the anterior vaginal wall.------Sarcoma
• Upper 3rd of post. Vaginal wall---SCC
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30. TREATMENT
• Early stage dx ……. Radical Hysterectomy + radical vaginectomy and
bilateral pelvic lymphadenectomy ± radiotherapy
• Stage II-IV---Radiotherapy + Chemotherapy( cisplatin)
i. Superficial small lesion---- brachytherapy
ii. Large lesion-------------External beam radiation ± intra-cavitary
radiotherapy
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31. PREVENTION
• Community awareness
• Population based screening programs
• Identification and avoidance of risk factors
• Vaccination
• Early presentation and treatment of dx
• Palliative and complication treatment
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32. CONCLUSION
FOR ANY DISEASE, MOST ATIMES
THERE IS A WAY OUT, AND THE
WAY OUT FOR GENITAL CANCERS
IS PREVENTION .
………………BE VIGILANT!!!!!
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