Precancer diseases of the female sexual organs. Female cancer.

1. Precancer diseases of the female sexual organs. Female cancer. N. Bahnij

2. Precancer cervical lesions • Cervical intraepithelial neoplasia (CIN) • Erythroplakia with atypia • Leukoplakia with atypia • Adenomatosis

3. Risk factors for cervical dysplasia • Human papillomavirus is a common virus that most women will be infected with at some time in their life. • smoking • multiple sexual partners • pregnancy before the age of 20 • suffering from conditions that affect the immune system, like HIV

4. Layers of squamosus epithelium of cervix

5. CIN I: Mild dysplasia; abnormal cells can be found in 1/3 of the lining of the cervix CIN II: Moderate dysplasia; abnormal cells can be found in 2/3 of the lining of the cervix CIN III: Severe dysplasia; abnormal cells can be found in more than 2/3 of the lining of the cervix and up to the full thickness of the lining CIN Classification

7. Speculum examination PAP – smear Processing of 3 % acetic acid of a cervix and revealing a white spot Colposcopy Cervical biopsy Endocervical curettage HPV - testing Diagnosis of cervical dysplasia

8. Dysplasia is initially detected through a Pap smear

9. What is the thinnest and the more effected place of the cervix???

10. The smear should be taken from squamocolumnar junction – transition zone !

12. Types of PAP smears • I – normal • II a- inflammatory process • II b – mild dysplasia • III a - moderate dysplasia • III b – severe dysplasia • IV – carcinoma in situ • V – cancer • VI – smear is not informative

13. Frequency of Pap Smears • Begin no later than age 21. • If patient is sexually active - <21. • Once initiated, screening should be performed annually • After 30, for women who have had 3 consecutive, normal Pap smears, screening frequency may be reduced to every 3 years. • Screening may stop after total hysterectomy, >70 if the the patient is at low risk, and has had three consecutive normal Pap smears within the last 10 years.

14. Treatment for cervical dysplasiaCIN1 – 70 % spontaneous regression. CIN 2/3 lesions are usually surgically removed by:destruction (ablation) by carbon dioxide laser (photoablation) and cryocauteryand removal (resection) by electrosurgical excision procedure (LEEP), cold knife conization.

15. Cancer of the cervix is the most common female genital cancer in developing countries every year about 500,000 women , acquire the disease and 75% are from frame developing countries. About 300,000 women also die from the disease annually and of these 75% are from developing countries

16. Risk factors Human Papillomavirus (HPV) Infection - (16, 18, 31, 33, 35 and 6 more) Family History of Cervical Cancer Age – 35-55 Sexual and Reproductive History Socioeconomic Status Smoking HIV Infection In Utero DES Exposure Oral contraceptives CERVICAL CARCINOMA 10 years from CIN III to cancer From initial infection to CIN III – 6 years

17. Types • Squamous cell Carcinomas • Cancer of flat epithelial cell • 80% to 90% • Adenocarcinomas • Cancer from glandular epithelium • 10% - 20% • Mixed carcinoma • Features both types

18. Stages of Cervical Carcinoma

19. What are the symptoms of cervical cancer? Abnormal bleeding Between periods With intercourse After menopause Unusual vaginal discharge Other symptoms Leg pain Pelvic pain Bleeding from the rectum or bladder Some women have no symptoms

20. Diagnosis • Complaints • Speculum examination. • The cytological examination • HPV screening involves a Polymerase Chain Reaction (PCR) • Bimanual vaginal examination • Rectovaginal examination • Application of acetic acid and Colposcopy • Biopsy.

21. What should I do if I have just been diagnosed with cervical cancer? Discuss treatment options Conization Hysterectomy Radical trachelectomy Surgical removal of the cervix and upper vagina with the surrounding tissues. uterine body remains Radical hysterectomy Radiation with chemotherapy Ask about clinical trials (Gynecologic Oncology Group) Other considerations Preserve your fertility Preserve your ovaries

22. Cervical cancer: What is the chance of survival after treatment?

23. Vaccines

24. Who should get the vaccine? The FDA has recommended the following groups of women get vaccinated: Girls 11–12: Recommended Age Group (can be started as young as age 9). Women 13–26: the benefit of the vaccine may be lower depending on prior HPV exposure. The vaccine does not work to eliminate current HPV infections The vaccine only prevents certain types of HPV infection

26. Endometrial hyperplasia - an overgrowth of the lining of the uterus, is a precursor to the development of cancer. Abnormal uterine bleeding is usually the first symptom Endometrial cancer precursors

27. Risk Indicators for Endometrial Cancer and Precursors • Age 60 years • Obesity (with upper body fat pattern)a • Estrogen-only replacement therapy • Previous breast cancer • Tamoxifen therapy for breast cancer • Chronic liver disease • Infertility • Low parity • Chronic anovulation (Polycystic ovarian disease, estrogen-secreting ovarian stroma or tumors)

28. WHO Classification and Diagnostic Criteria of Endometrial Hyperplasia Simple Hyperplasia Without Cytologic Atypia   Increased number of glands relative to stroma  Dilated glands with irregular outlines  Crowded, clustered glands  Tall, columnar epithelium with nuclear pseudostratificationComplex Hyperplasia Without Cytologic Atypia   Increased number of glands relative to stroma  Back-to-back glands (crowded glands with little or no intervening stroma)Hyperplasia With Cytologic Atypia   Variation of size and shape of nuclei  Nuclear enlargement  Loss of polarity  Coarse chromatin clumping  Prominent nucleoli  Hyperchromatism

29. Endometrial hyperplasia Cystic hyperplasia Simple hyperplasia

30. Endometrial hyperplasia Atypical hyperplasia Simple hyperplasia

32. Endometrial biopsy

33. Diagnosis and treatment • Intramuscular progesterone therapy. MPA (500mg)therapy for 3 months; • Micronized progesterone -cyclic natural micronized progesterone for 3 to 6 months; • Levonorgestrel intrauterine device • GnRH analogue for 6 months with sampling every 3 months is a reasonable option in patients without atypia.

36. Staging According to the U.S. Gynecologic Oncology Group histologic grading system,1 grade 1, well-differentiated carcinoma, consists of a neoplasm with less than 5% of solid cancer grade 2, moderately differentiated carcinoma, contains between 6% and 50% solid cancer grade 3, poorly differentiated carcinoma, is made up of more than 50% of solid tumor.

37. Modified WHO classification • endometrioid adenocarcinoma • serous carcinoma • clear cell carcinoma • mucinous carcinoma • serous carcinoma • mixed types of carcinoma • undifferentiated carcinoma

38. Staging

39. Clinical signs • Irregular vaginal bleeding, intermenstrual or post menopausal • Watery vaginal discharge may be present in postmenopausal women • Mass in late stages

40. T.V.S. and biopsy Hysteroscopy and biopsy ? M.R.I. Or C.T. scan Endometrial cancer:investigations

41. Endometrial cancer:investigations

42. Endometrial cancer: treatment • Operative: total abdominal hysterectomy and Bilateral Salpengo-oophorectomy +/_ lymph node dissection is the operation of choice. • Adjuvant Radiotherapy for >1b • Chemotherapy ineffective • Hormonal therapy, progestogens, in early or recurrent cases

43. 5 – year survival rate for endometrial cancer

44. Ovarian Cancer • The 2nd most common gynecologic malignancy • 27% of gynecologic cancers • The most frequent cause of death from gynecologic cancers • Due to advanced stage at the time of diagnosis • 53% of all deaths from gynecologic cancers • Incidence increases with age, most marked beyond 50 years, with increase continuing to age 70 years, and decrease after age 80 years

45. Risk factors • Family history of cancer • Personal history of cancer: Women who have had cancer of the breast, uterus, colon, or rectum have a higher risk of ovarian cancer • Age over 55 • Never pregnant: • Menopausal hormone therapy: estrogen taking

46. OVARIAN CANCER • primary (neoplasms derived from the ovarian surface epithelium, i.e. epithelial tumors), • secondary (neoplasms derived from papillary or pseudomucinous cystadenomas) • metastatic (intestinal and breasts’ metastasis).

47. Classification 1.Surface epithelial – 65-70%: • Serous (tubal) • Mucinous (endocx & intestinal) • Endometrioid • Transitional cell - Brenners. • Clear cell 2. Stromal – 15-20%: • Granulosa-cell tumor • Thecoma • Fibroma • Sertoli-Leydig cell tumors 3.Germ cell tumors – 5-10%: • Teratoma – • Benign cystic (dermoid cysts) • Solid immature • Monodermal – struma ovarii, carcinoid • Dysgerminoma • Yolk sac tumor Choricarcinoma • Mixed germ cell tumor 4.Metastatic tumors – 5%

48. Serous Cystadenoma

49. Papillary serous cystadenoma (solid/cystic)-borderline

50. Papillary cystadenoma (bor)