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Gynaecology Oncology

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. Gynaecological malignancies.

cynthia-mcmahon
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Gynaecology Oncology

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  1. Gynaecology Oncology Ram Athavale Consultant Gynaecological Oncology University Hospitals Coventry & Warwickshire NHS Trust

  2. Aims • A framework for main gynaecological cancers • To provide a foundation for further study

  3. Gynaecological malignancies National Cancer Regfistrations UK 2004

  4. Gynaecological malignancies • 5-yr survival better in the USA compared to the UK • Differences in registriesadvanced stage?Post code lottery - practice variations - under investment • Lack of specialised servicessome managed by general gynaecologists • No specific referral pattern

  5. 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 - Cancer Centre Spoke - Cancer Units

  6. Cancer Unit • Diagnostic roleRapid assessment units2 week wait referral clinicsColposcopy • MDT • Manage certain cancers/ suspected cancerCervix up to FIGO IA Uterus IA/IB, grade 1 or 2Ovary- risk of malignancy index< 200Vulva- diagnostic excision of tumours less than 2 cms • Refer all other cases to the Cancer Centre

  7. 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

  8. Cancer Centre • Manage all referred cases from unitsFunction as units for the drainage population • MDT • Chemotherapy, radiotherapy • Research • Training programmes • Role overlap based on service organisation

  9. Treatment of cancer • Surgery • Chemotherapy • Radiotherapy • Palliative care • Supportive therapy • Multidisciplinary approach critical

  10. Qs

  11. Cervical cancer

  12. Histology • Low grade disease • HPV changes • CIN I • High grade disease • CIN II • CIN III • Invasive cancer • CGIN

  13. 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

  14. Pathology • Peaks 35-44 and 75-85 • Squamous (70%) • Adenocarcinoma (12%) • Adenosquamous (12%) • Direct spread - anatomical

  15. Clinical features at presentation • Abnormal bleeding • PCB,IMB,PMB • Abnormal smears • Advanced disease relatedoffensive PV dischargeneuropathic painrenal failureDVT

  16. FIGO Staging • I – Confined to cervixIA Micro – invasive (<5mm from basement epithelium from which it originates)IA1 up to 3 mm deep and 7 mm wideIA2 3-5 mm deep and 7 mm wide • IB – macroinvasive tumourIB1 < 4 cms, IB2 > 4 cms • II – Beyond cervixIIA Upper 2/3 of vagina IIB Parametrium not reaching side wall

  17. FIGO stage cervical cancer • III – involves lower third vagina or side wall IIIA lower 1/3 vaginaIIIB Pelvic side wall • IV – Beyond true pelvisIVA Mucosa of bladder or rectumIVB Distant spread

  18. Clinical Staging +/- investigations • Visible tumour • PV/PR to check spread to parametrial/rectovaginal space • EUA, cystoscopy • +/- Sigmoidoscopy,proctoscopy • MRI • CXR • FBC,U&E,LFT • PET?

  19. Treatment • Micro invasive up to IA1cone biopsy to preserve fertility option simple hysterectomy • IA2radical hysterectomy, lymph nodes limited parametrectomy • IB1 and IIA radical hysterectomy • IB2 , IIB and above- chemoradiotherapy

  20. 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

  21. 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

  22. Fertility preservation- Radical trachylectomy • IA2, small volume IB1excise cervix, limited parametriumlaparoscopic node dissectionFertility preservationLong term survival data unavailableExpertise not always available Pregnancy outcomes promising

  23. Palliative procedures • ExenterationAnterior or posterior or both • Radiotherapy • Tumour embolisation • Symptom control only

  24. 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%

  25. Follow up • Clinical examination • Reassurance • Symptom relief – side effects of treatment • HRT • Psychosexual • Early detection of recurrenceVault smears limited role after radical surgeryNot recommended after radiotherapy

  26. Qs

  27. Ovarian cancer

  28. 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

  29. Aetiology • Majority sporadic (90%) • Genetic origin (up to 10%)BRCA1 gene – 40-60 % riskBRCA2 – 10-30%Two or more 1st degree relatives affectedHNPCC • Increased risk in nullips, early menarche, late menopause, ovarian stimulation, abnormal ovarian development

  30. 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

  31. Presentation • Asymptomatic • Pelvic mass (diff. diagnosis) • Pressure symptoms/abdominal distension/GI symptoms • Pain • Abnormal bleeding • Hormonal effects

  32. 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

  33. Benign or malignant? • Risk of malignancy index (RMI)RMI = U X M X CA-125(direct value)U= ultrasound score 1 or 3bilateral, solid area, septationascites, other depositseach criterion 1 point0-1 criterion = score 12-5 criteria = score 3M = menopausal statuspremenopausal= score 1postmenopausal=score 3

  34. RMI score • RMI < 200more likely benignmanaged at Cancer Units • RMI > 200more likely malignantmanaged at Cancer Centre

  35. FIGO Staging • Surgical/ pathological • I – Confined to ovarieswith or without malignant ascites • II – Confined to pelvisincludes spread to uterus/ tubespelvic tissues • III – Confined to peritoneal cavitysize of omental mets decides IIIA/B/C • IV – Distant metastasese.g. liver / lung mets, malignant pleural effusion

  36. 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 surgeryCHORUS trial

  37. Follow up • 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

  38. UKCTOCS trialUK Collaborative trial for ovarian cancer screening

  39. UKCTOCS trial • No screening v/s USS or CA-125 or combined modalities • Examine role for early diagnosisMorbidity of surgerySurvival benefit in cancer cases • Results by 2012

  40. Qs

  41. Endometrial / Uterine cancer

  42. Endometrial cancer • Predominantly a disease of postmenopausal women • <5% risk under age 40 • Numbers increasing, probably obesity related?Diet influence

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