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Gynaecology Oncology
Ram Athavale
Consultant Gynaecological Oncology
University Hospitals Coventry & Warwickshire
NHS Trust
Aims


A framework for main
gynaecological cancers
To provide a foundation for further
study
Gynaecological malignancies
Cases
Ovary
5409
Incidence Lifetime
/100,000 risk
21.2
1:48
Uterus
5029
19.7
1:73
Cervix
2221
8.7
1:116
Vulva
824
3.3
1:350
National Cancer Regfistrations UK
2004
Gynaecological malignancies




5-yr survival better in the USA compared to
the UK
Differences in registries
advanced stage?
Post code lottery - practice variations
- under investment
Lack of specialised services
some managed by general gynaecologists
No specific referral pattern
Calman Hine report





A policy framework for commissioning cancer
services : A report by the Expert Advisory Group on
Cancer to the Chief Medical Officers of England and
Wales (1995)
Uniform high standard of care
Needs of patients and carers purchasers, planners
and professionals
Improving Outcomes for Gynaecological Cancers
1999 (IOG guidelines)
Hub
Spoke
- Cancer Centre
- Cancer Units
Cancer Unit




Diagnostic role
Rapid assessment units
2 week wait referral clinics
Colposcopy
MDT
Manage certain cancers/ suspected cancer
Cervix up to FIGO IA
Uterus IA/IB, grade 1 or 2
Ovary- risk of malignancy index< 200
Vulva- diagnostic excision of tumours less than 2
cms
Refer all other cases to the Cancer Centre
Cancer targets




Patient seen within 14 days of referral (2
week wait rule)
Specific criteria for referral of suspected
cancer
31 day target- max 31 days from decision
to treat to 1st treatment
62 day target max 62 days from urgent GP
referral to 1st treatment
Cancer Centre

Manage all referred cases from units
Function as units for the drainage
population

MDT
Chemotherapy, radiotherapy
Research
Training programmes

Role overlap based on service organisation



Treatment of cancer



Surgery
Chemotherapy
Radiotherapy

Palliative care
Supportive therapy

Multidisciplinary approach critical

Qs
Cervical cancer
Histology

Low grade disease



High grade disease




HPV changes
CIN I
CIN II
CIN III
Invasive cancer
CGIN
Cervical Cancer


Incidence 8.7/100,000 in England &
Wales
Associated with





Young age at first intercourse
Number of sexual partners
HPV 16,18,33
Smoking
Immunosuppresion
Pathology

Peaks 35-44 and 75-85

Squamous (70%)
Adenocarcinoma (12%)
Adenosquamous (12%)

Direct spread - anatomical


Clinical features at presentation

Abnormal bleeding



PCB,IMB,PMB
Abnormal smears
Advanced disease related
offensive PV discharge
neuropathic pain
renal failure
DVT
FIGO Staging



I – Confined to cervix
IA Micro – invasive (<5mm from basement
epithelium from which it originates)
IA1 up to 3 mm deep and 7 mm wide
IA2 3-5 mm deep and 7 mm wide
IB – macroinvasive tumour
IB1 < 4 cms, IB2 > 4 cms
II – Beyond cervix
IIA Upper 2/3 of vagina
IIB Parametrium not reaching side wall
FIGO stage cervical cancer


III – involves lower third vagina or side wall
IIIA lower 1/3 vagina
IIIB Pelvic side wall
IV – Beyond true pelvis
IVA Mucosa of bladder or rectum
IVB Distant spread
Clinical Staging +/- investigations




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Visible tumour
PV/PR to check spread to
parametrial/rectovaginal space
EUA, cystoscopy
+/- Sigmoidoscopy,proctoscopy
MRI
CXR
FBC,U&E,LFT
PET?
Treatment




Micro invasive up to IA1
cone biopsy to preserve fertility option
simple hysterectomy
IA2
radical hysterectomy, lymph nodes limited
parametrectomy
IB1 and IIA
radical hysterectomy
IB2 , IIB and above- chemoradiotherapy
Surgical treatment



Radical hysterectomy and pelvic node dissection
BSO in older women or adenocarcinoma
Complications







Haemorrhage
Infection
Damage to bladder/bowel
Atonic bladder
Fistulae
Laparoscopic RH
Coelio- Schauta
Radical vaginal hysterectomy, laparoscopic nodes
Chemoradiotherapy




Current gold standard for IB2, IIB or above
(apart from some cases with stage 4
disease)
External beam (teletherapy)
 Pelvic spread especially nodes
 Para-aortic
Intracavity (brachytherapy)
cervical tumour
Concurrent chemotherapy
platinum agent
Fertility preservation
- Radical trachylectomy

IA2, small volume IB1
excise cervix, limited parametrium
laparoscopic node dissection
Fertility preservation
Long term survival data unavailable
Expertise not always available
Pregnancy outcomes promising
Palliative procedures

Exenteration
Anterior or posterior or both

Radiotherapy

Tumour embolisation

Symptom control only
Prognosis
Average 5 year survival




Stage I – 80%,
higher for IA disease(95%), role for
prevention
Stage II – 61%
Stage III – 32%
Stage IV – 15%
Follow up






Clinical examination
Reassurance
Symptom relief – side effects of treatment
HRT
Psychosexual
Early detection of recurrence
Vault smears limited role after radical
surgery
Not recommended after radiotherapy
Qs
Ovarian cancer
Ovarian cancer





Killer disease
60-75% stage 3 or 4
Incidence increases with age,
plateaus by 60
Early imaging - More lesions
identified
About 6% of all ovarian cysts are
malignant
Aetiology


Majority sporadic (90%)
Genetic origin (up to 10%)
BRCA1 gene – 40-60 % risk
BRCA2 – 10-30%
Two or more 1st degree relatives affected
HNPCC

Increased risk in nullips, early menarche,
late menopause, ovarian stimulation,
abnormal ovarian development
Pathology

85% of all ovarian cancers are
epithelial in origin
Sex cord stromal -6%
Germ cell 2-3%
Secondary tumours – 6%

Epithelial - Borderline or malignant



Presentation






Asymptomatic
Pelvic mass (diff. diagnosis)
Pressure symptoms/abdominal
distension/GI symptoms
Pain
Abnormal bleeding
Hormonal effects
Screening & Diagnosis


Clinical examination
CA-125 & Transvaginal scan/Abd. Scan

Other tumour markers - CEA, CA 19-9
CT/MRI abdomen & pelvis
FBC,U&E, LFT, CXR

Overlap between benign and malignant


Benign or malignant?

Risk of malignancy index (RMI)
RMI = U X M X CA-125(direct value)
U= ultrasound score 1 or 3
bilateral, solid area, septation
ascites, other deposits
each criterion 1 point
0-1 criterion = score 1
2-5 criteria = score 3
M = menopausal status
premenopausal= score 1
postmenopausal=score 3
RMI score


RMI < 200
more likely benign
managed at Cancer Units
RMI > 200
more likely malignant
managed at Cancer Centre
FIGO Staging





Surgical/ pathological
I – Confined to ovaries
with or without malignant ascites
II – Confined to pelvis
includes spread to uterus/ tubes
pelvic tissues
III – Confined to peritoneal cavity
size of omental mets decides IIIA/B/C
IV – Distant metastases
e.g. liver / lung mets, malignant pleural
effusion
Management

Cancer centre
Surgery – Laparotomy,peritoneal washings,
TAH BSO, omentectomy lymph nodes,
peritoneal and diaphragmatic biopsies

Aim for Complete /Optimal cytoreduction



Adjuvant chemotherapy
 Platinum based – carboplatin
 Taxane – paclitaxel
 Second line agents - caelyx, topotecan
Neoadjuvant chemotherapy followed by
surgery
CHORUS trial
Follow up




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5 years
History, Pelvic exam
CA-125 in most cases
Prognosis for recurrent disease poor
Overall 5 year survival, all stages
together 30-35%
Early stage disease 60- 85% depending
upon histological type, role for screening
UKCTOCS trial
UK Collaborative trial for ovarian
cancer screening
UKCTOCS trial



No screening v/s USS or CA-125 or
combined modalities
Examine role for early diagnosis
Morbidity of surgery
Survival benefit in cancer cases
Results by 2012
Qs
Endometrial / Uterine cancer
Endometrial cancer



Predominantly a disease of
postmenopausal women
<5% risk under age 40
Numbers increasing, probably
obesity related
?Diet influence
Risk factors




Excessive endogenous oestrogens
PCO
peripheral conversion (adipose)
Unopposed oestrogens
HRT
Tamoxifen
Breast cancer
HNPCC
Presentation




Postmenopausal bleeding (PMB)
10% of women with PMB have
endometrial cancer
Postmenopausal PV discharge/pyometra
Peri/premenopausal women with IMB
especially if do not respond to hormonal
treatment.
Glandular abnormalities on smear
Pathology




Endometrioid adenocarcinoma 80%
Grade 1,2,3
10% papillary serous, 4% clear cell
remaining other types such as MMT, squamous
Two types
standard type- obese, low stage low grade, good
prognosis
non-standard type – not obese, high grade, high
risk histotype
Spread : local / distant
70-80% stage 1 confined to uterus
perceived as ‘not such a bad cancer’
Investigations


Examination
Transvaginal scan
endometrial thickness > 4 mms (5 mms)
considered significant
endometrial biopsy required all cases
endometrial thickness < 4 mms

Endometrial biopsy



Pipelle - outpatient
Hysteroscopy OP/IP and curettage
CXR, (MRI)
FIGO stage and prognosis





Stage I Confined to body of uterus
IA – Confined to endometrium
IB – Invasion less than 50%myometrium
IC – Invasion more than 50% myometrium
II – Cervix involved
A glands only
B stromal invasion
III – Serosa of uterus, peritoneal washings+ve
lymph nodes (IIIC)
IV – Local/distant mets
Grade
Histological type
Lymphovascular space invasion
Treatment






Surgical
TAH +BSO, peritoneal washings / LAVH BSO
ASTEC trial – lymph nodes or not
Surgery alone sufficient endometrioid type,
invasion<50% thickness of myometrium, grade 1
or 2
i.e. up to FIGO stage IA/ IB, grade 1 or 2
Radiotherapy, IC or grade 3, or higher stages
Hormone therapy, palliative or recurrence
Chemotherapy – higher stages
research ongoing for benefit in lower and higher
stages
Prognosis

5 year survival




I - 75%
II – 58%
III – 30%
IV – 10%
Qs
Vulvar intraepithelial neoplasia
(VIN)
Vulvar Intraepithelial Neoplasia




Most in postmenopausal
41% cases in premenopausal
Vulval skin is part of anogenital
epithelium
HPV thought to be involved
Pathology



VIN 2 or 3 grouped together- VIN
VIN 1 not recognised (ISSVD)
Undifferentiated (usual) VIN
HPV associated
Bowenoid
generally good prognosis
multifocality – main problem
Differentiated VIN
associated with lichen sclerosus/
squamous hyperplasia
relatively older women
Presentation






Pruritus
Asymptomatic
During investigations for CIN/ VaIN
Lesions may be
raised/flat/sing/multiple/diffuse/discrete
Investigation by vulvoscopy +/- acetic acid
Adequate biopsies
8 mm punch
Treatment







Multifocal
Discomfort/mutilation
VIN 3 may progress to cancer
life time risk up to 9%
Single lesions excised
Multiple lesions – excision or
individualised depending upon location
Photodynamic therapy- research
HPV vaccine / Topical Imiquimod
Follow up


Vulvoscopy every 6 months until 2
years then individualised
Colposcopy and smears as routine
(unless CIN identified)
Vulvar cancer
Vulval cancer





Uncommon
Elderly >65 years
90% squamous
Other types - more aggressive
Associated with smoking, cervical
neoplasia, immunosupression
Presentation






Longstanding vulval pruritus
Pain, discharge, bleeding
Most common on labia majora
Exophytic, ulcerated or flat
Younger patients - multicentric disease
Diagnosis - Vulvoscopy and punch biopsy
or
excision biopsy (single lesion< 2 cms)
Spread & staging




Lymphatic (groin nodes) and local
CXR
cervical cytology where appropriate
If multicentric – local inspection of
cervix, vagina
FIGO (clinical +surgical) Staging
FIGO stage




I - tumours less than 2 cms
IA up to 1 mm depth of invasion
IB more than 1 mm
II Tumour > 2 cms irrespective of
depth
III Spread to lower third vagina,
unilateral groin nodes
Bilateral groin nodes, bladder/
rectum, distant spread
Treatment

Surgery




Radiotherapy



Wide excision with good margins
Vulvectomy and groin incisions for
nodes
Sentinel nodes – research
Node positive
Insufficient margins
Chemotherapy/chemoradiotherapy
Morbidity





50% wound breakdown
Lymphoedema
Lymphocyst formation
Rectocele & cystocele
Sexual dysfunction
Follow up



Detect early recurrence
more visible
Poor outcome for recurrence
and node positive cases
Five year survival
Stage
Stage
Stage
Stage
I – 90- 97%
II – 85%
III – 74%
IV – 30%
Qs