Cervical cancer Ovarian cancer Endometrial cancer Vulval and vaginal cancers Gestational trophoblastic disease

2. Common Gynecological Cancers in Sri
Lanka
• Cervical cancer
• 16/100,000
• Ovarian cancer
• 12/100,000
• Endometrial cancer
• 8/100,000
• Vulval and vaginal cancers
• 2/100,000
• Gestational trophoblastic disease

3. Types of Gynaecological Cancers

4. Carcinoma of the
Cervix

5. Cervical Carcinoma
Commonest
malignancy in
female genital
tract in
developing
countries

6. Aetiology
• Persistent infection with oncogenic HPV is the necess
ary cause of cervical cancer
• 70% due to HPV types 16 and 18

8. Risk factors
• Exclusively in a sexually active women
• Multiple sexual partners( women or man )
• Early age of intercourse
• Multiparity
• Immunosuppression eg: HIV, smoking , organ trans
plant
• Long term use of OCPs more than 10 years

9. Development of invasive disease
• CIN III 30% will develop invasive disease in 10 years.
• 1% of patients treated for CIN III will have unsuspect
ed invasion
•No symptoms
•Lesion not seen to naked eye.
•Risk of spread to lymph nodes are rare
•Complete excision may be curative
Micro-invasive disease

10. Clinical presentation
symptoms and signs
• Intermenstrual bleeding
• Post coital bleeding
• Dyspareunia
• Vaginal discharge – may be blood stained, purulen
t or offensive
• Ulcer, nodule, friable growth
• Advanced stage
• Pelvic induration, erosion to rectum or bladder

11. Staging :- FIGO Classification
Stage 0 :- Carcinoma in situ
Stage 1 :- confined to the cervix
• 1A:- microinvasive diseases
• 1B :- macroscopically visible
Stage 2 :- beyond the cervix, not to pelvic wall
• 2A- upper 2/3 of vagina
• 2B – extends to parametrium
Stage 3 :- into lateral pelvic wall
• 3A – lower 1/3 of the vagina
• 3B – lateral pelvic wall/ hydronephrosis/ nonfunctioning kidney
Stage 4 :- beyond true pelvis/ bladder and/or rectal mucosa
• 4A – involving the rectal or bladder mucosa
• 4B – distant spread

12. Diagnosis
• If there is a lesion
• Do punch biopsy
• Send for histology

13. Histology
• 85%- 90% squamous cell type
• 10% - 15% adenocarcinoma
• Spread
Direct
Lymphatics

14. Treatment
Complete local excision
• for microinvasive disease- (cone biopsy)
Depth >3mm and <4cm invasion
• hysterectomy
Nodal involvement
• node excision and radiotherapy 1A2 upto stage 2A
Beyond 2A radiotherapy
Palliative surgery

15. Radical Hysterectomy
• Stage 1A,1B1 beyond that not indicated
• Surgery is not offered because of the signific
ant risk of positive margins and positive nod
es
• If the tumor is larger than 4cm surgery is not
recommended
• FIGO 1B2, 2, 3, 4 Chemo-radiation

16. • Complete local excision
• Simple hysterectomy
1A1
• Radical trachelectomy+ LN excision
• Radical hysterectomy
1A2
• Radical hysterectomy
1B1
• Chemoradiotherapy
1B2,2,3,4

17. Prognosis
5 year survival ;
stage 1 85%
stage 2 50%
stage 3 25%
stage 4 5%
Results for surgical and radiotherapy treatment
for up to stage 2A nearly same.

18. Prevention of cervical cancer
• Community awareness
• HPV vaccination before commencing sexual life
• Limiting sexual relationship to one mutually trusted
partner
• Use of condoms in high risk sexual relationships
• Stops smoking
• Improves socio economic status
• Cervical cancer screening

19. Secondary Prevention
• Methods
• PAP smear
• Liquid based cytology
• Visual inspection with acetic acid and Lugol’s iodine
• HPV DNA

20. Ovarian Malignancies

21. Ovarian
Malignancy
Primary Tumours
Epithelial ovarian Tumours
80%
Sex cord Stromal Tumours
10%
Germ Cell Tumour
10%
Secondary
Tumours/Metastasis

22. Epithelial cell Tumours
• 60%- 70% of all ovarian malignancies
• More common among young females (20yrs)
• Early stage disease has better prognosis
Histological Types
• Serous Cyst Adenocarcinoma
• Mucinous Cyst Adenocarcinoma
• Endometroid Adenocarcinoma
• Clear cell Carcinoma
• Undifferentiated

23. Sex Cord Stromal Tumours
About 5% of all ovarian carcinoma
Presents in all ages
• Granulosa theca cell carcinoma
• Fibroma
• Androblastoma (sertoli- leydig cell)
• Gynandroblastoma

24. Germ Cell Tumours
10-15% of all carcinoma
common in young age
• Dysgerminoma
• Teratoma
• Choriocarcinoma
• Yolk sac tumours

25. Aetiology
• Incessant ovulation theory
• nulliparity
• early menarche
• late age at menopause
• high estimated numbers of years of ovulation
• Spontaneous somatic mutations (85%)
• Subfertility treatment
• Genetic & familial tendency
• Hormone replacement therapy

26. Protective Factors
• Multiparity
• Breast feeding
• Hysterectomy
• Oral contraceptive pills
• Tubal ligation
• Spontaneous somatic mutations

27. • Early ovarian cancers may be asymptomatic or may
only minimal non specific symptoms
• History
• Persistent Pelvic & Abdominal pain
• Increase Abdominal size / persistent bloating
• Pressure effects
• Indigestion and acid reflux
• Shortness of breath / Tiredness
• Weight loss /Early satiety
• Menstrual disturbances occur only with hormone secreting tumours
• Examination
• Fixed hard mass arising from pelvis
• Adenexial mass(sometimes)
• Pleural fluid
• Enlarged lymph nodes in groin
Diagnosis Hx + Ex + Ix
Common
symptoms

28. Investigations
• Basic Ix – FBC, Urea, SE, Liver function test
• Chest X Ray
• Tumour markers – CA 125 ( increase in >80% EOC)
• CEA (mucinous ovarian
carcinoma)
• Beta hCG (chorio carcinoma)
• embryonal CA
• USS[ TVS / TAUS] – morphology , B/L involvement ,
Ascites , omental deposits
• CT/MRI- staging

29. Risk Malignancy Index (RMI)
Feature RMI Score
Ultrasound features:
• multilocular cyst
• solid areas
• bilateral lesions
• Ascites
• Intra abdominal
metastases
0= none
1= one
abnormality
3= two or more
abnormalities
Premenopausal
Postmenopausal
1
3
RMI =
ultrasound
score
x
menopausal
score
x
CA125 level in
U/ml
RMI>200 – risk of malignancy is High
RMI<200 – risk of malignancy is low

30. FIGO Staging
Stage I – Growth limited to ovaries
•IA- limited to one ovary, no external tumour, capsule intact, no Ascites
•IB- limited to both ovaries, no external tumour, capsule intact, no Ascites
•IC- either A/B, tumour on surface of ovary/ capsule ruptured/ Ascites
Stage II – Growth limited to pelvis
•II A- mets to uterus
•II B- extension to pelvic organs
•II C- A/B, tumour on surface of ovary/ capsule ruptured/ Ascites
Stage III - Growth limited to abdominal peritoneum/ +ve retroperitoneal /
inguinal LN
•III A- grossly limited to pelvis / negative LN
•III B- Abdominal implants <2cm in diameter
•III C- Abdominal implants >2cm in diameter/ retroperitoneal or inguinal LN +ve
Stage IV – Distant metastasis

31. Management
Stage I Epithelial tumours
• TAH+ BSO
• Omentectomy
• Para Aortic Lymphadenectomy
Advanced stage Tumour
• TAH+ BSO
• Debulking surgery- remove as much as possible
• Remaining tissue <2cm
• omentectomy + para Aortic lymph adenectomy

32. Advanced stage Tumour – Cont.
• Chemotherapy –
• Neoadjuvant
• Adjuvent
• Improve 5 yrs survival
• Minimizes recurrences
• Combinations are effective Eg. Cisplatin +Paclitaxel
• Radiotherapy – not much Use
• (Dysgerminoma is radiosensitive)
Germ cell Tumours
• Common in young Females
• Conservative surgery
• Highly chemo sensitive
Sex cord Tumours
• Same as epithelial tumour

33. Follow up
• Use Tumour markers
• USS
• Six weekly for 1 year and then yearly for 5 years
 5 year survival depends on
• Stage of the disease
• Age
• Type of Tumour

34. Endometrial Carcinoma

35. Presentation
• Post-menopausal bleeding (commonest)
• 5-10% PMB- endometrial CA
• Post-menopausal discharge
• Heavy, irregular or inter-menstrual bleeding
• Dyspareunia
In advanced stage,
• Lower abdominal pain
• Urinary dysfunction
• Bowel disturbances
• Respiratory symptoms

36. Classification
Type 1
Endometrial
adenocarcinoma (75-80%)
Type 2
Serous
papillary CA
Clear cell
CA
Oestrogen dependent.
Endometrial hyperpalsia.
In younger women.
Good prognosis.
Atrophic endometrium.
Non-oestrogen dependent.
In elderly women.
Poor prognosis.

37. Exposure to
oestrogen
unopposed by
progesterone.
Proliferation of
endometrial cells.
Endometrial
carcinoma
Risk Factors
• Early menarche
• Late menapause
• Nulliparity
• PCOS
• Obesity
• Diabetes mellitus
• Unopposed oestrogen
therapy
• Tamoxifen therapy
Protective factors
• COCP
• Progestine based
contraceptives
• LNG-IUS
• Pregnancy

38. Other risk factors
• Age - Around 80% post-menapaused.
• Genetic predisposition - Lynch Syndrome
• Family histroy of colorectal and endometrial
CA
Other protective factors
• Hysterectomy
• Cu - IUD
• Smoking

39. Investigations
Transvaginal USS
Endometrial thickness
< 4mm
• Cancer is unlikely
• Further investigations not
necessary
Endometrial thickness
> 4mm
• Assessment of endometrium
• Hysterescopy & biopsy - Gold
standard
• Dilatation & Curettage
• Pipelle biopsy

40. Pathology Report
• Histology type & grade of tumour
• Hyperplasia with atypia - pre malignant condition.
• Risk of progression to CA 25- 50%.
• Frequently co-exist with low grade endometrial
tumour.

41. Staging
FIGO classification on staging of carcinoma of uterus

42. Management
• Surgery is the mainstay of the treatment.
• Extent of surgery depends on,
- Grade & Stage of the disease
- Patient's co-morbidities & fitness for surgery.
• Standard surgery
TAH+BSO
• If cervical involvement +
Radical hysterectomy
• High grade or Type 2 histology
Pelvic and para aortic lymph node dissection
• If lymph node sampling positive
Adjuvant therapy - Teletherapy / Brachytherapy
• Post-op radiotherapy reduces the local recurrence rate but do
not improve survival
• Chemotherapy ??

43. Hormone treatment
• High dose oral or intrauterine progestins
• For women who are not fit for surgery
• For women with fertility sparing reasons
• { Only for women with low grade stage
IA endometrial tumours }

44. Prognosis
• Overall five year survival is about 80%
• This varies depending on
• Tumour type
• Stage
• Grade of Tumour
Stage 5 year survival (%)
I 88
II 75
III 55
IV 16

45. Adverse prognostic Features
• Advanced age
• Grade III Tumours
• Type 2 histology
• Deep myometrial invasion
• Lymphovascular space invasion
• Nodal involvement
• Distant metastasis

46. Past SEQs

47. November 2020
• A 48 yr old estate labourer presents to the
gynaecology clinic with a hx of post coital bleeding for
4 months duration. Speculum ex reveals a friable
growth at the ant lip of cervix suspicious of cervical
CA.
1. How would you confirm the diagnosis
2. Name two main histological types of cervical CA
3. Briefly describe principles of management of this patient
if the diagnosis is FIGO stage I CA of the cervix

48. June 2020
• A 46 year old woman was found to have high grade
squamous epithelial lesion( CIN III) on her routine
cervical smear. Discuss the management of this
patient. (100)

49. March 2019
1. List 5 risk factors for endometrial carcinoma
2. Discuss the strategies for early identification of
endometrial carcinoma in sri lanka.
3. Discuss the management of a 52 year old woman
with endometrial carcinoma detected on
endometrial biopsy.

50. November 2018
• A 48 year old mothe rof 5 children presented to
gynaecology clinic with a history of irregular per
vaginal bleeding for 6 months duration.
• List 5 causes for the above presentation other than
endometrial carcinoma
• Discuss the methods available to assess her
endometrium
• Outline the basic principles of management if the
diagnosis is stage 1 endometrial carcinoma

51. November 2014
• Outline the primary measures which could be
adopted to reduce the incidence of cervical
carcinoma
• Discuss the secondary measures which could be
adopted to reduce the morbidity and mortality due
to cervical carcinoma.

52. Thank
you !