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Gynaecological tumours
Prof.Dr.Póka Róbert
Female genital cancer incidence
(N/100.000 population/year)
in 2008
Eurostat, 2010
Breast
Cervix
Endometrium
Ovary
EUR
88,4
12,8
16,7
13,7
HU
78,7
19,5
17,7
13,7
Female genital cancer mortality
(N/100.000population/year)
in 2008
Eurostat, 2010
Breast
Cervix
Endometrium
Ovary
EUR
24,3
5,2
3,8
7,9
HU
22,6
5,7
3,6
8,3
Cervical cancer treatment
dilemmas
•Early stg disease - Op, advanced - Rad
•Rad limited by normal tissue tolerance
•Clinically early might be biologically
advanced
•In early stg Op and Rad results are similar
Indications and types of surgical
treatment




Preserve fertility
Classical Wertheim-Meigs operation
Neoadjuvant chemo followed by radical
surgery
Surgery for recurrent disease
Trachelectomy’s necessity
Changing
morbidity
Changing demography
Changing technology
Prerequisites of trachelectomy
Ca.cx.ut.
Std. Ia1,Ia2,Ib1
Parametrial spread excluded by CT, MR
Fitness for surgery
Fertility preservation is desired
Trachelectomy cases I.
ID
1.
2.
3.
4.
5.
Age
31
28
25
34
36
Stg
Ib1 (12*3mm)
Ia1 (7*2mm)
Ia2 (7*3mm)
Ib1 (12*7)
Ia2 (5*3)
TR: trachelectomy
LND: lymphadenectomy
Th
Follow-up grav.
VTR
2x delivery (SC)
VTR+LND
1x deliver (SC)
VTR+LND
1x deliver (SC)
VTR+LND
1x deliver (SC)
VTR(R1)TAH+LND
Trachelectomy cases II.
ID
6.
7.
8.
9.
10.
11.
Age
34
36
34
30
34
30
Stg
Ia1 (3*1mm)
Ib1 (12*8mm)
Ib1adeno
Ia1adeno
Ib1
Ib1
TR: trachelectomy
LND: LSC lymphadenectomy
Th
Follow-up
VTR
61mths NED
VTR+LND N1!
41mths NED
ATR(R1N1)WM 23mths DOD
ATR+LND
39mths NED
ATR(N1)WM
25mths DOD
ATR+LND
17mthsNED
Aims of neoadjuvant
chemoterapy



Prevent spread
Down-staging
Tumour-demarcation
Modes of administration



Monotherapy or combined
chemotherapy
Cyclical
Systemic or regional
Mechanism of action






Alkilating
Antimitotic
Antimetabolites
Antibiotics
Anticytosceletal
Other
Cytoxan,Ifosfamid
Vincristin, Taxol
Methotrexat, Fluorouracil
Bleomycin, Mitomycin,
Adriamycin, Peplomycin
Taxanes
Cisplatin, Carboplatin
Side-effects

Immediate endothel necrosis

Early
nausea, vomiting, emesis,
myelodepression

Late
alopecia,myelodepression,mucositis
fibrosis pulmonum, neuritis,
diarrhoea,insuff.hepatorenalis,
cardiomyopathy
Protocol

BIP
Bleomycin 30mg/12hrs
1.day
CDDP 50mg/m2
2.day
Ifosfamid 3 g/m2
3.day
Mesna 1g/m2 3*
3-weekly
Neoadjuvant BIP
chemoterapy
at UD MHSC





Ib2-IIb N=23 (out of 100 WM)
Mean age 50 yrs (33-66)
Adenoca = 2, Planocell = 21
pTy0N0M0=7
pTy1-3N1M0=6
Female genital cancer
Incidence (n/100000/yr) in 2008
Eurostat, 2010
Breast
Cervix
Corpus
Ovary
EUR
88,4
12,8
16,7
13,7
HU
78,7
19,5
17,7
13,7
Female genital cancer
Mortality (n/100000/yr) in 2008
Eurostat, 2010
Breast
Cervix
Corpus
Ovary
EUR
24,3
5,2
3,8
7,9
HU
22,6
5,7
3,6
8,3
Gynecologic tumors
Staging in general
I
II
III
IV
localized to organ of origin
spread to adjacent tissues
regional lymphatic spread
distant metastasis
Endometrial cancer in
Hungary in 2005
1213 new cases
219 deaths
Corpus cancer - Origin
Endometrial

Endometrial stroma sarcoma

Myometrial sarcoma
cancer
Gynecologic tumors
Staging in general
I
II
III
IV
localized to organ of origin
spread to adjacent tissues
regional lymphatic spread
distant metastasis
Endometrial cancer
stage-distribution (%)
80
70
60
50
40
Frequency
30
20
10
0
I
II
III
IV
Age distribution in endometrial
cancer
N=817
45
40
35
30
25
N
20
15
10
5
0
Frequency
30
35
40
45
50
55
60
65
Age (yr)
70
75
80
85
90
Histologic type distribution
Endometrioid
%
Adenosquamous
Mucinous
Papillary serous
Clear cell
Squamous
Other
82
6%
1%
4%
2%
0,5 %
4,5 %
Pathogenesis





Estrogen-dependent proliferation
Lack of gestogen-suppression
Insulin-resistance
Tumorsuppressor-mutations (p53,p21)
Extragonadal aromatase-activity
Characteristic associated
disorders and medical history







Hypertension
Diabetes mellitus
Obesity
PCO
Anovulatory cycles
Less pregnancies
Shorter lactation
Diagnosis
Histologic verification
Prognostic factors
in endometrial cancer








Age
Histologic type
Degree of differentiation
Depth of myometrial invasion
Cervical involvement
Adnexal involvement
Lymphatic spread
Distant metastasis
Pathologic staging
(changes in 2010)
Ia
Localized to endometrium
Ib (Ia)
Superficial myometrium-invasion
Ic (Ib) Deep myometrium-invasion
IIa (Ib) Spread to cervix mucosa
IIb (II) Cervical stromal involvement
IIIa Adnex/serosa involvement
IIIb Vaginal metastasis
IIIc (IIIc1/IIIc2) Pelv./paraaort. nodal
metastasis
IVa Bladder/rectum invasion
I
IA (FIGO 2010)
IB (FIGO 2010)
IB (FIGO 2010)
II (FIGO 2010)
IIIc2 (FIGO 2010)
IIIc1 (FIGO 2010)
Treatment




Surgery (TAH+BSO+lymphadenect)
Radiotherapy (adjuvant or primary)
Chemotherapy (adjuvant or primary)
Gestogen therapy (adjuvant)
Five-year survival
Surgery
Radiotherapy
Radiosurgery
Surgery+Radiotherapy
Surgery+Chemotherapy
Hormonal therapy
84%
45,3%
83,6%
82,4%
59,8%
42,9%
Prevention




Combined oral contraceptives >10yrs
Bodyweight control
Oncological surveillance
Progestogenic opposition
Cases of endometrial cancer at
UD MHSC n=1368
Histogram
90
80
70
Count
60
50
40
30
20
10
0
20
30
40
50
60
AGE
70
80
90
100
Endometrial cancer young cases
All cases
1368
Age <45 yrs
96
Age <45 yrs without hysterectomy 6
Endometrial cancer cases at
UD MHSC without
hysterectomy
ID Age
1.
27
2.
43
3.
29
4.
25
5.
30
6.
23
Stg
IaG1
IaG1
IIG1
IaG1
IaG1
IaG1
Th
6*Cu
2*Cu
Cu+2*IC
Cu+5*IC
Cu+MPA
Cu+MPA
Grav
P2
0
0
0
0
0
Follow-up
25yrs PD
8yrs NED
24yrs ov.ca.III/b
4yrs PCOD
2yrs NED
1yr NED
Ovarian cancer







Epidemiology
Incidence, mortality
Staging
Diagnostic work-up
Debulking surgery (pathological staging)
Adjuvant chemotherapy
Neoadjuvant chemotherapy
Vulval carcinoma, Epidemiology




Disease of the elderly
2-3% of all genital cencers
In Hungary 122 new cases in 1994, 205 in 2005
90% squamous
FIGO stages






Ia <2cm, <1mm invasion
Ib <2cm, >1mm invasion
II >2cm
III urethra/vagina/perineum/anus
involvement, unilateral inguinal met
IVa
rectal/bladder involvement,
bilateral inguinal met
IVb
distant met
TNM stages








FIGO
Ia
Ib
II
III
IVa
IVa
IVb
T
1a
1b
2
1-3
1-3
4
1-4
N
0
0
0
0-1
2
0-2
0-2
M
0
0
0
0
0
0
1
Macroscopic appearance



Superficial
Exophytic
Endophytic
5-15%
40%
45%
Spread
1.
2.
3.
Inguinal and femoral lymph
nodes
Cloquet/Rosenmüller nodes
Parailiac nodes
Evolution of surgical treatment





Parré-Jones
Inguinali radiotherapy
<1 mm invasion warrants no nodal
disease
Sentinel nodes
Neville Hacker
Progression free survival improved
by lymphadenectomy
Túlélési hányad
1
Vulvectomy+lymphadenectomy -
,
8
,
6
Vulvectomy
,
4
,
2
0
0
1
2
3
4
5
Műtét
óta eltelt
idő hónapokban
kifejezve
0
0
0
0
0
6
0
Overall survival improved by
lymphadenectomy
1
Vulvectomy+lymphadenectomy -
Túlélési hányad
,
8
Vulvectomy
,
6
,
4
,
2
0
0
1
2
3
4
5
0 óta eltelt
0 idő hónapokban
0
0 kifejezve
0
Műtét
60
Summary of treatment for vulval
cancer



Survival of vulval cancer with no spread
to urinary or GI tracts is improved by
adding lymphadenectomy to wide
excision of primary tumour.
Advanced or regional metastatic disease
treated with radiotherapy
Disseminated tumours require
chemotherapy