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Gynaecological tumours

Gynaecological tumours. Prof.Dr.Póka Róbert. Female genital cancer incidence (N/100.000 population/year) in 2008 Eurostat, 2010. EUR HU Breast 88,4 78,7 Cervix 12,8 19,5 Endometrium 16,7 17,7 Ovary 13,7 13,7.

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Gynaecological tumours

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  1. Gynaecological tumours Prof.Dr.Póka Róbert

  2. Female genital cancer incidence(N/100.000 population/year) in 2008Eurostat, 2010 EUR HU Breast 88,4 78,7 Cervix 12,8 19,5 Endometrium 16,7 17,7 Ovary 13,7 13,7

  3. Female genital cancer mortality (N/100.000population/year) in 2008Eurostat, 2010 EUR HU Breast 24,3 22,6 Cervix 5,2 5,7 Endometrium 3,8 3,6 Ovary 7,9 8,3

  4. 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

  5. Indications and types of surgical treatment • Preserve fertility • Classical Wertheim-Meigs operation • Neoadjuvant chemo followed by radical surgery • Surgery for recurrent disease

  6. Trachelectomy’s necessity Changing morbidity Changing demography Changing technology

  7. Prerequisites of trachelectomy Ca.cx.ut. Std. Ia1,Ia2,Ib1 Parametrial spread excluded by CT, MR Fitness for surgery Fertility preservation is desired

  8. Trachelectomy cases I. ID Age Stg Th Follow-up grav. 31 Ib1 (12*3mm) VTR 2x delivery (SC) 28 Ia1 (7*2mm) VTR+LND 1x deliver (SC) 25 Ia2 (7*3mm) VTR+LND 1x deliver (SC) 34 Ib1 (12*7) VTR+LND 1x deliver (SC) 36 Ia2 (5*3) VTR(R1)TAH+LND TR: trachelectomy LND: lymphadenectomy

  9. Trachelectomy cases II. ID Age Stg Th Follow-up 6. 34 Ia1 (3*1mm) VTR 61mths NED 36 Ib1 (12*8mm) VTR+LND N1! 41mths NED 34 Ib1adeno ATR(R1N1)WM 23mths DOD 30 Ia1adeno ATR+LND 39mths NED 34 Ib1 ATR(N1)WM 25mths DOD 30 Ib1 ATR+LND 17mthsNED TR: trachelectomy LND: LSC lymphadenectomy

  10. Aims of neoadjuvant chemoterapy • Prevent spread • Down-staging • Tumour-demarcation

  11. Modes of administration • Monotherapy or combined chemotherapy • Cyclical • Systemic or regional

  12. Mechanism of action • Alkilating Cytoxan,Ifosfamid • Antimitotic Vincristin, Taxol • Antimetabolites Methotrexat, Fluorouracil • Antibiotics Bleomycin, Mitomycin, Adriamycin, Peplomycin • Anticytosceletal Taxanes • Other Cisplatin, Carboplatin

  13. Side-effects • Immediate endothel necrosis • Early nausea, vomiting, emesis, myelodepression • Late alopecia,myelodepression,mucositis, fibrosis pulmonum, neuritis, diarrhoea,insuff.hepatorenalis, cardiomyopathy

  14. Protocol • BIP Bleomycin 30mg/12hrs 1.day CDDP 50mg/m2 2.day Ifosfamid 3 g/m2 3.day Mesna 1g/m2 3* 3-weekly

  15. Neoadjuvant BIP chemoterapyat 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

  16. Female genital cancerIncidence (n/100000/yr) in 2008Eurostat, 2010 EUR HU Breast 88,4 78,7 Cervix 12,8 19,5 Corpus 16,7 17,7 Ovary 13,7 13,7

  17. Female genital cancerMortality (n/100000/yr) in 2008Eurostat, 2010 EUR HU Breast 24,3 22,6 Cervix 5,2 5,7 Corpus 3,8 3,6 Ovary 7,9 8,3

  18. Gynecologic tumorsStaging in general I localized to organ of origin II spread to adjacent tissues III regional lymphatic spread IV distant metastasis

  19. Endometrial cancer in Hungary in 2005 1213 new cases 219 deaths

  20. Corpus cancer - Origin • Endometrial cancer • Endometrial stroma sarcoma • Myometrial sarcoma

  21. Gynecologic tumorsStaging in general I localized to organ of origin II spread to adjacent tissues III regional lymphatic spread IV distant metastasis

  22. Endometrial cancer stage-distribution (%)

  23. Age distribution in endometrial cancerN=817

  24. Histologic type distribution Endometrioid 82 % Adenosquamous 6 % Mucinous 1% Papillary serous 4 % Clear cell 2 % Squamous 0,5 % Other 4,5 %

  25. Pathogenesis • Estrogen-dependent proliferation • Lack of gestogen-suppression • Insulin-resistance • Tumorsuppressor-mutations (p53,p21) • Extragonadal aromatase-activity

  26. Characteristic associated disorders and medical history • Hypertension • Diabetes mellitus • Obesity • PCO • Anovulatory cycles • Less pregnancies • Shorter lactation

  27. Diagnosis Histologic verification

  28. Prognostic factors in endometrial cancer • Age • Histologic type • Degree of differentiation • Depth of myometrial invasion • Cervical involvement • Adnexal involvement • Lymphatic spread • Distant metastasis

  29. 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 IVb Distant metastasis

  30. I IA (FIGO 2010) IB (FIGO 2010) IB (FIGO 2010) II (FIGO 2010) IIIc2 (FIGO 2010) IIIc1 (FIGO 2010)

  31. Treatment • Surgery (TAH+BSO+lymphadenect) • Radiotherapy (adjuvant or primary) • Chemotherapy (adjuvant or primary) • Gestogen therapy (adjuvant)

  32. Five-year survival Surgery 84% Radiotherapy 45,3% Radiosurgery 83,6% Surgery+Radiotherapy 82,4% Surgery+Chemotherapy 59,8% Hormonal therapy 42,9%

  33. Prevention • Combined oral contraceptives >10yrs • Bodyweight control • Oncological surveillance • Progestogenic opposition

  34. Cases of endometrial cancer at UD MHSC n=1368

  35. Endometrial cancer young cases All cases 1368 Age <45 yrs 96 Age <45 yrs without hysterectomy 6

  36. Endometrial cancer cases at UD MHSC without hysterectomy ID Age Stg Th Grav Follow-up 27 IaG1 6*Cu P2 25yrs PD 43 IaG1 2*Cu 0 8yrs NED 29 IIG1 Cu+2*IC 0 24yrs ov.ca.III/b 25 IaG1 Cu+5*IC 0 4yrs PCOD 30 IaG1 Cu+MPA 0 2yrs NED 23 IaG1 Cu+MPA 0 1yr NED

  37. Ovarian cancer • Epidemiology • Incidence, mortality • Staging • Diagnostic work-up • Debulking surgery (pathological staging) • Adjuvant chemotherapy • Neoadjuvant chemotherapy

  38. 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

  39. 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

  40. TNM stages • FIGO T N M • Ia 1a 0 0 • Ib 1b 0 0 • II 2 0 0 • III 1-3 0-1 0 • IVa 1-3 2 0 • IVa 4 0-2 0 • IVb 1-4 0-2 1

  41. Macroscopic appearance • Superficial 5-15% • Exophytic 40% • Endophytic 45%

  42. Spread • Inguinal and femoral lymph nodes • Cloquet/Rosenmüller nodes • Parailiac nodes

  43. Evolution of surgical treatment • Parré-Jones • Inguinali radiotherapy • <1 mm invasion warrants no nodal disease • Sentinel nodes • Neville Hacker

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