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GYNECOLOGICAL TUMORS. RATH 4412. EPIDEMIOLOGY AND ETIOLOGY. Incidence rates- 2010 Endometrial (uterine corpus) 43,470 new cases Ovarian 21,880 new cases Cervical 12,200 new cases of invasive cancer Other 2,300 Death rates- 2010 Ovarian, ranks 5 th among cancer deaths for women- 13,850
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GYNECOLOGICAL TUMORS RATH 4412
EPIDEMIOLOGY AND ETIOLOGY • Incidence rates- 2010 • Endometrial (uterine corpus) 43,470 new cases • Ovarian 21,880 new cases • Cervical 12,200 new cases of invasive cancer • Other 2,300 • Death rates- 2010 • Ovarian, ranks 5th among cancer deaths for women- 13,850 • Endometrial- 7,950 • Cervical- 4,210 • Other- 780
Approximately 83,750 new cases per year of gynecological tumors (2010)
Average age of onset • Clear cell vaginal 19 • Cervical cancer 48 • Uterine cancer 58 • Ovarian cancer 60 • Vulvar/vaginal 65+
Cervical Cancer • Cervical cancer is more prevalent among young women • Multiple partners • Early sexual activity • Oral contraceptives • Family- mother, sister • Lower socioeconomic status-won’t seek medical attention • Multiple births- 3 or more • Younger than 17 years for first baby
Multiple pelvic infections • Chlamydia infections • bacteria that can infect the sex organs. • Genital warts • Unprotected sex, HPV passed during sex • Diethylstilbestrol (DES) • Smoking • Smoking- women who smoke are twice as likely to get cervical cancer • Tobacco smoke produces chemicals that may damage DNA in cervical cells • Immunosuppression • HIV • Diet
HPV Virus • Cervical cancer is caused by the HPV virus • Spreads through sex • Cause infection • If infection is not treated can lead to cancer • No treatment for HPV- does not have symptoms, cannot be treated • The cell changes that HPV causes in the cervix can be treated
Endometrial Cancer • Endometrial cancer has increased due to: • Aging population • High calorie/high fat diets • Diabetes • hypertension • Estrogen use 60’s and 70’s • Most patients are 50 years of age and older • Linked to women taking tamoxifen
Vaginal and Vulvar Cancer • Vaginal and vulvar cancers are rare • Occur in older women • Vulvar cancer is 3x more common than vaginal cancer • Vulvar cancer is associated with • Diabetes • STD’s • Poor hygiene • Abnormal changes in the vaginal lining • Loss of hormone stimulation • Use of DES by pregnant mother
Ovarian Cancer • Ovarian cancer • Ages 50-70- develop after menopause • Late or few pregnancies • Late menopause • Lack of oral contraceptive use or the use of fertility drugs longer than 1 year • Family history
Personal history of breast, colon, endometrial cancer • Diet high in fat and red meat • Obesity • Industrialized nation • Estrogen replacement after menopause • BRCA1 or BRCA2 gene mutation
Women with a family history of ovarian cancer: • Lifetime risk increases from 1% to 40% • Must have annual rectovaginal pelvic exam • CA 125 serum determination • Transvaginal ultrasound
Endometrial cancer • Most endometrial cancers are of the glandular cells found in the lining of the uterus • Most endometrial cancers develop over several years • Is the most common gynecological cancer in female reproductive organs
SIGNS AND SYMPTOMS • Unusual bleeding, spotting, or other abnormal discharge • Vaginal bleeding is the most common symptom • Approx 1/3 of post menopausal bleeding is cancer related • Pelvic pain and/or mass and weight loss
EARLY DETECTION • No specific screening tests • Regular pelvic exams • If at high risk for hereditary nonpolyposis colon cancer, a yearly endometrial biopsy should be done beginning at age 35
Detection and diagnosis • Endometrial biopsy • A tissue sample is obtained by using a thin flexible tube and suction • Placed into the uterus through the cervix • Has approximately a 94% sensitivity rate • D and C (dilation and curettage) • Done when the biopsy is inconclusive • Cervix is dilated • Tissue is scraped from inside the uterus • Ultrasound
PATHOLOGY • Adenocarcinoma of the endometrial lining is the most common type • Grade 1- most cancer cells look like normal tissue • Grade 2- in between • Grade 3- more than half of the cells are unlike the normal cells • Progesterone receptors • Positive cells for this receptor are slow growing and spread more slowly
Cystoscopy • CT scan • MRI • Chest x-ray • IVP • CA 125 blood test • CA 125 is a substance released into the bloodstream by many endometrial and ovarian cancers • Very high CA 125 levels suggest that the cancer has probably spread beyond the uterus
STAGING • FIGO system • I-IV, the lower the number, the less the cancer has spread, page 816, Washington • Most endometrial cancers are stage I
Poor prognosis • Higher grade • Increased depth of invasion into the myometrial muscle • Lymph node involvement • Cancer cells in the peritoneal fluid or • Cancer cells on serosal surfaces
SPREAD • Lymphatic spread initially to the internal and external iliac pelvic nodes • If pelvic nodes are involved, there is about a 60% chance that there will be periaortic node involvement
TREATMENT • Surgery and/or • Radiation Therapy • Can be given pre- or post-op • Can be treated with photon or brachytherapy • Doses depend on treatment or combinations of treatment • Radiation therapy alone is usually used for inoperable patients and stages III and IV • Depends on the stage, grade and medical condition of the patient
PROGNOSIS • Depends on the stage and grade • Patients treated with radiation therapy and surgery have an overall survival rate of 81.6% • A five year disease free all stages 88%% • For all stage I, grade I (early stage) patients, 95% 5 year survival rate
Ovarian cancer • Ovarian cancer is the most deadly of all the gynecologic cancers • It has few symptoms until it is widely spread • The number of new cases of ovarian cancer have been going down since 1991 • 3 in 4 women will survive at least 1 year after diagnosis
Almost half of women with ovarian cancer will reach 5 year survival • When younger than 65 years of age, better survival
DETECTION AND DIAGNOSIS • By the time ovarian cancer may be suspected, it may have already spread beyond the ovaries • Seek a doctor if any of these signs are unusual or have symptoms daily for a few weeks • Specific Signs • Bloating • Pelvic/abdominal pain • Trouble eating • Early satiety • Urination frequency/urgency
Pelvic Ultrasound • Abdominopelvic CT scan • MRI • Chest x-ray • Laparoscopy with biopsy • CA 125 • Renal and liver function blood work
PATHOLOGY AND STAGING • The AJCC/TNM system is used • Describes the cancer in terms of extent of the tumor, spread to nearby lymph nodes, and to other organs • 90% are epithelial (surface of ovary) • 7% stromal • 3% ovarian germ cell- includes dysgerminomas which are treated like seminomas • Page 817, Washington
TREATMENT • Surgical evaluation and debulking of the tumor • Postoperative therapy may include: • Single agent or combination chemotherapy and/or • Whole abdominal and pelvic radiation therapy • Radiation therapy might include external beam or • Brachytherapy
PROGNOSIS • 5 year survival rates • Well differentiated stages IA and IB, 90%-100% • Microscopic residual disease, stage II, treated with radiation therapy, 74% • Residual disease less than 2 cm, 58% • Residual disease greater than 2 cm, 39%
CERVICAL CANCER • Cervical cancer is a slowly progressive disease • Noninvasive carcinoma in situ occurs approx 10 years earlier before becoming invasive • Dysplasia • Cervical cancer begins in the lining of the cervix
According to the ACS there will be about 12,2000 new cases of invasive cervical cancer in the US in 2010 • Non-invasive cervical cancer is about 4 times as common as the invasive type • When found and treated early, there is a high cure rate
SIGNS AND SYMPTOMS • Any unusual discharge from the vagina • Blood spots or light bleeding other than a normal period • Bleeding or pain during sex- common
DETECTION AND DIAGNOSIS • Pap test- finds changes in the cells of the cervix caused by HPVs • The death rate declined 74% from 1955-1992 due to pap test • Pelvic exam • HPV cannot be cured or treated, but the cell changes that it causes can be treated • Biopsy of any suspicious lesions
Colposcopy- use a colposcope to look at the cervix. Can destroy or remove pre-cancerous lesions • Cystoscopy- looks at spread to the bladder • Proctoscopy- looks at spread to the rectum • Chest x-ray • CT • MRI
PATHOLOGY AND STAGING • There are two main types of cancer: • Squamous cell carcinoma, 80-90% • Adenocarcinoma, 10-20% • Features of both types, mixed carcinoma • Small cell and clear cell make up a small percentage and have a higher metastatic potential • FIGO Staging, page 785, Washington
TREATMENT • Early stage 0 (carcinoma in situ) and stage Ia1, invasive cancer • Total abdominal hysterectomy with a small amount of vaginal tissue (vaginal cuff) • Stage Ia2 • TAH or an aggressive modified radical hysterectomy • Medically inoperable patient • Tandem and ovoid implant delivering 60-70 Gy
Surgery is often used for younger women • Radiation is usually used for women who have a higher risk for surgical complications • Radiation is used with a combination of external beam therapy and implants • External beam doses increases with advanced disease • Implant doses may stay the same or decrease depending on critical organ doses
Kinds of surgery • Cryosurgery- used for pre-invasive cancer • Laser surgery- used for pre-invasive cancer • Cone biopsy- cone shaped piece of tissue is removed from the cervix • Simple hysterectomy- removal of uterus either through the abdomen or vagina.
Radical hysterectomy and pelvic lymph node dissection- removal of the uterus, tissues next to the uterus, upper part of the vagina, and pelvic lymph nodes • Pelvic exenteration- radical hysterectomy and pelvic node dissection including removal of the bladder, vagina, rectum and part of the colon
Five year survival • Early invasive cancer, 92% • All stages combined, 71%
Cervical Cancer and Pregnancy Very early stage cancer • Safe to continue the pregnancy to term • Several weeks after delivery, a hysterectomy is recommended • Later stage cancer- decide whether or not to continue pregnancy • If pregnancy is continued, the baby should be delivered by cesarean section as soon as it is able to survive outside of the womb • Advanced cancer • Immediate treatment is the safest option • All of these options should be discussed with the patient’s doctor
VULVa cancer • Usually presents with a subcutaneous lump or mass • Advanced disease- exophytic mass • Most common location- labia majora • Patient has had a long history of irritation
PATHOLOGY AND STAGING • Squamous cell carcinoma, 90% • Adenocarcinomas, 10% • Staging- stage I-IVa
TREATMENT • Surgery- radical vulvectomy with a groin node dissection • More conservative approach using wide local excision with external irradiation of the primary and inguinal nodes
Five year survival • Overall five year survival rate, 70% • Disease free with surgery • Stage I 100% • Stage II 86% • Stage III 59% • Stage IV 25% • The five year survival goes down with nodal involvement
SIDE EFFECTS OF GYNECOLOGIC TREATMENT • acute effects • Fatigue bleeding • Diarrhea nausea • Dermatitis • dysuria • Subacute effects • Menopause enteritis • Vaginal dryness obstruction • Chronic cystitis • proctosigmoiditis
A simulation radiograph demonstrating a treatment field used to treat the vulva, pelvic, and inguinofemoral lymph nodes