Gynaecological tumours Gynaecological tumours Prof.Dr.Póka Róbert Prof.Dr.Póka Róbert
Dec 30, 2015
Gynaecological tumoursGynaecological tumours
Prof.Dr.Póka RóbertProf.Dr.Póka Róbert
Female genital cancer Female genital cancer incidenceincidence
(N/100.000 population/year) (N/100.000 population/year) in 2008in 2008Eurostat, 2010Eurostat, 2010
EUREUR HUHU
BreastBreast 88,488,4 78,778,7
CervixCervix 12,812,8 19,519,5
EndometriumEndometrium 16,716,7 17,717,7
OvaryOvary 13,713,7 13,713,7
Female genital cancer Female genital cancer mortality mortality
(N/100.000population/year) (N/100.000population/year) in 2008in 2008Eurostat, 2010Eurostat, 2010
EUREUR HUHU
BreastBreast 24,324,3 22,622,6
CervixCervix 5,25,2 5,75,7
EndometriumEndometrium 3,83,8 3,63,6
OvaryOvary 7,97,9 8,38,3
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 Indications and types of surgical treatmentsurgical treatment
Preserve fertilityPreserve fertility Classical Wertheim-Meigs operationClassical Wertheim-Meigs operation Neoadjuvant chemo followed by Neoadjuvant chemo followed by
radical surgeryradical surgery Surgery for recurrent diseaseSurgery for recurrent disease
Trachelectomy’s necessityTrachelectomy’s necessity
Changing morbidityChanging morbidityChanging demographyChanging demographyChanging technologyChanging technology
Prerequisites of Prerequisites of trachelectomytrachelectomy
Ca.cx.ut. Std. Ia1,Ia2,Ib1Ca.cx.ut. Std. Ia1,Ia2,Ib1Parametrial spread excluded by CT, Parametrial spread excluded by CT, MRMRFitness for surgeryFitness for surgeryFertility preservation is desiredFertility preservation is desired
Trachelectomy cases I.Trachelectomy cases I.
IDID AgeAge StgStg ThTh Follow-up grav.Follow-up grav.1.1. 3131 Ib1 (12*3mm)Ib1 (12*3mm) VTRVTR 2x delivery (SC) 2x delivery (SC) 2.2. 2828 Ia1 (7*2mm)Ia1 (7*2mm) VTR+LNDVTR+LND 1x deliver (SC)1x deliver (SC)3.3. 2525 Ia2 (7*3mm)Ia2 (7*3mm) VTR+LNDVTR+LND 1x deliver (SC)1x deliver (SC)4.4. 3434 Ib1 (12*7)Ib1 (12*7) VTR+LNDVTR+LND 1x deliver (SC)1x deliver (SC)5.5. 3636 Ia2 (5*3) Ia2 (5*3) VTRVTR(R1)(R1)TAH+LNDTAH+LND
TR: trachelectomyTR: trachelectomyLND: lymphadenectomyLND: lymphadenectomy
Trachelectomy cases II.Trachelectomy cases II.ID Age Stg Th Follow-up 6. 34 Ia1 (3*1mm) VTR 61mths NED
7. 36 Ib1 (12*8mm) VTR+LND N1! 41mths NED
8. 34 Ib1adeno ATR(R1N1)WM 23mths DOD9. 30 Ia1adeno ATR+LND 39mths NED10. 34 Ib1 ATR(N1)WM
25mths DOD11. 30 Ib1 ATR+LND 17mthsNED
TR: trachelectomyTR: trachelectomyLND: LSC lymphadenectomyLND: LSC lymphadenectomy
Aims of neoadjuvant Aims of neoadjuvant chemoterapy chemoterapy
Prevent spreadPrevent spread Down-stagingDown-staging Tumour-demarcationTumour-demarcation
Modes of administrationModes of administration
Monotherapy or combined Monotherapy or combined chemotherapychemotherapy
CyclicalCyclical Systemic or regionalSystemic or regional
Mechanism of actionMechanism of action
AlkilatingAlkilating Cytoxan,IfosfamidCytoxan,Ifosfamid AntimitoticAntimitotic Vincristin, TaxolVincristin, Taxol AntimetabolitesAntimetabolitesMethotrexat, FluorouracilMethotrexat, Fluorouracil AntibioticsAntibiotics Bleomycin, Mitomycin, Bleomycin, Mitomycin,
Adriamycin, PeplomycinAdriamycin, Peplomycin Anticytosceletal Anticytosceletal Taxanes Taxanes OtherOther Cisplatin, CarboplatinCisplatin, Carboplatin
Side-effectsSide-effects
ImmediateImmediate endothel necrosisendothel necrosis
EarlyEarly nausea, vomiting, emesis, nausea, vomiting, emesis, myelodepressionmyelodepression
LateLate alopecia,myelodepression,mucositis,alopecia,myelodepression,mucositis,fibrosis pulmonum, neuritis, fibrosis pulmonum, neuritis, diarrhoea,insuff.hepatorenalis, diarrhoea,insuff.hepatorenalis,
cardiomyopathycardiomyopathy
ProtocolProtocol BIPBIP Bleomycin 30mg/12hrsBleomycin 30mg/12hrs 1.day1.day
CDDP 50mg/m2CDDP 50mg/m22.day2.day
Ifosfamid 3 g/m2Ifosfamid 3 g/m2 3.day3.dayMesna 1g/m2 3*Mesna 1g/m2 3*
3-weekly3-weekly
Neoadjuvant BIP Neoadjuvant BIP chemoterapychemoterapyat UD MHSCat UD MHSC
Ib2-IIb N=23 (out of 100 WM)Ib2-IIb N=23 (out of 100 WM) Mean age 50 yrs (33-66)Mean age 50 yrs (33-66) Adenoca = 2, Planocell = 21Adenoca = 2, Planocell = 21 pTy0N0M0=7pTy0N0M0=7 pTy1-3N1M0=6pTy1-3N1M0=6
Female genital cancerFemale genital cancerIncidence (n/100000/yr) in Incidence (n/100000/yr) in
20082008Eurostat, 2010Eurostat, 2010
EUREUR HUHU
BreastBreast 88,488,4 78,778,7
CervixCervix 12,812,8 19,519,5
CorpusCorpus 16,716,7 17,717,7
OvaryOvary 13,713,7 13,713,7
Female genital cancerFemale genital cancerMortality (n/100000/yr) in Mortality (n/100000/yr) in
20082008Eurostat, 2010Eurostat, 2010
EUREUR HUHU
BreastBreast 24,324,3 22,622,6
CervixCervix 5,25,2 5,75,7
CorpusCorpus 3,83,8 3,63,6
OvaryOvary 7,97,9 8,38,3
Gynecologic tumorsGynecologic tumorsStaging in generalStaging in general
II localized to organ of localized to organ of originorigin
IIII spread to adjacent spread to adjacent tissuestissues
IIIIII regional lymphatic regional lymphatic spreadspread
IVIV distant metastasisdistant metastasis
Endometrial cancer in Endometrial cancer in Hungary in 2005Hungary in 2005
1213 new cases1213 new cases
219 deaths219 deaths
Corpus cancer - OriginCorpus cancer - Origin
Endometrial cancerEndometrial cancer Endometrial stroma sarcomaEndometrial stroma sarcoma Myometrial sarcomaMyometrial sarcoma
Gynecologic tumorsGynecologic tumorsStaging in generalStaging in general
II localized to organ of localized to organ of originorigin
IIII spread to adjacent spread to adjacent tissuestissues
IIIIII regional lymphatic regional lymphatic spreadspread
IVIV distant metastasisdistant metastasis
Endometrial cancer Endometrial cancer stage-distribution (%)stage-distribution (%)
0
10
20
30
40
50
60
70
80
I II III IV
Frequency
Age distribution in endometrial Age distribution in endometrial cancercancer N=817N=817
05
1015202530354045
30 35 40 45 50 55 60 65 70 75 80 85 90
Age (yr)
N
Frequency
Histologic type distributionHistologic type distribution
EndometrioidEndometrioid 82 82 %%
AdenosquamousAdenosquamous 6 %6 %
MucinousMucinous 1%1%
Papillary serousPapillary serous 4 %4 %
Clear cellClear cell 2 %2 %
SquamousSquamous 0,5 %0,5 %
OtherOther 4,5 %4,5 %
PathogenesisPathogenesis
Estrogen-dependent proliferationEstrogen-dependent proliferation Lack of gestogen-suppressionLack of gestogen-suppression Insulin-resistance Insulin-resistance Tumorsuppressor-mutations Tumorsuppressor-mutations
(p53,p21)(p53,p21) Extragonadal aromatase-activityExtragonadal aromatase-activity
Characteristic associated Characteristic associated disorders and medical disorders and medical
historyhistory HypertensionHypertension Diabetes mellitusDiabetes mellitus ObesityObesity PCOPCO Anovulatory cyclesAnovulatory cycles Less pregnanciesLess pregnancies Shorter lactationShorter lactation
DiagnosisDiagnosis
Histologic verificationHistologic verification
Prognostic factors Prognostic factors in endometrial cancerin endometrial cancer
AgeAge Histologic typeHistologic type Degree of differentiationDegree of differentiation Depth of myometrial Depth of myometrial
invasioninvasion Cervical involvementCervical involvement Adnexal involvementAdnexal involvement Lymphatic spreadLymphatic spread Distant metastasisDistant metastasis
Pathologic stagingPathologic staging(changes in 2010)(changes in 2010)
IaIa Localized to endometriumLocalized to endometrium
IbIb (Ia)(Ia) Superficial myometrium-Superficial myometrium-invasioninvasion
IcIc (Ib)(Ib) Deep myometrium-invasionDeep myometrium-invasion
IIa IIa (Ib)(Ib) Spread to cervix mucosaSpread to cervix mucosa
IIb IIb (II)(II) Cervical stromal involvementCervical stromal involvement
IIIaIIIa Adnex/serosa involvementAdnex/serosa involvement
IIIbIIIb Vaginal metastasisVaginal metastasis
IIIc IIIc (IIIc1/IIIc2)(IIIc1/IIIc2) Pelv./paraaort. nodal Pelv./paraaort. nodal metastasismetastasis
IVaIVa Bladder/rectum invasionBladder/rectum invasion
IVbIVb Distant metastasisDistant metastasis
I
II (FIGO 2010)
IB (FIGO 2010)
IB (FIGO 2010)
IA (FIGO 2010)
IIIc2 (FIGO 2010)
IIIc1 (FIGO 2010)
TreatmentTreatment
Surgery (TAH+BSOSurgery (TAH+BSO++lymphadenect)lymphadenect) Radiotherapy (adjuvant or primary)Radiotherapy (adjuvant or primary) Chemotherapy (adjuvant or Chemotherapy (adjuvant or
primary)primary) Gestogen therapy (adjuvant)Gestogen therapy (adjuvant)
Five-year survivalFive-year survivalSurgerySurgery 84%84%
RadiotherapyRadiotherapy 45,3%45,3%
RadiosurgeryRadiosurgery 83,6%83,6%
Surgery+RadiotherapySurgery+Radiotherapy 82,4%82,4%
Surgery+ChemotherapySurgery+Chemotherapy59,8%59,8%
Hormonal therapyHormonal therapy 42,9%42,9%
PreventionPrevention
Combined oral contraceptives Combined oral contraceptives >10yrs>10yrs
Bodyweight controlBodyweight control Oncological surveillanceOncological surveillance Progestogenic oppositionProgestogenic opposition
Cases of endometrial cancer Cases of endometrial cancer at UD MHSC n=1368at UD MHSC n=1368
0
10
20
30
40
50
60
70
80
90
Count
20 30 40 50 60 70 80 90 100AGE
Histogram
Endometrial cancer young Endometrial cancer young casescases
All casesAll cases 13681368
Age <45 yrsAge <45 yrs 9696
Age <45 yrs without hysterectomyAge <45 yrs without hysterectomy 66
Endometrial cancer cases Endometrial cancer cases at UD MHSC without at UD MHSC without
hysterectomyhysterectomy
IDID AgeAge StgStg Th Th GravGrav Follow-upFollow-up
1.1. 2727 IaG1IaG1 6*Cu 6*Cu P2 P2 25yrs PD25yrs PD
2.2. 4343 IaG1IaG1 2*Cu 2*Cu 00 8yrs NED8yrs NED
3.3. 2929 IIG1IIG1 Cu+2*IC Cu+2*IC 00 24yrs ov.ca.III/b24yrs ov.ca.III/b
4.4. 2525 IaG1IaG1 Cu+5*IC Cu+5*IC 00 4yrs PCOD4yrs PCOD
5.5. 3030 IaG1IaG1 Cu+MPA Cu+MPA 00 2yrs NED2yrs NED
6.6. 2323 IaG1IaG1 Cu+MPA Cu+MPA 00 1yr NED 1yr NED
Ovarian cancerOvarian cancer
EpidemiologyEpidemiology Incidence, mortalityIncidence, mortality StagingStaging Diagnostic work-upDiagnostic work-up Debulking surgery (pathological staging)Debulking surgery (pathological staging) Adjuvant chemotherapyAdjuvant chemotherapy Neoadjuvant chemotherapyNeoadjuvant chemotherapy
Vulval carcinoma, Vulval carcinoma, EpidemiologyEpidemiology
Disease of the elderlyDisease of the elderly 2-3% of all genital cencers2-3% of all genital cencers In Hungary 122 new cases in 1994, 205 in In Hungary 122 new cases in 1994, 205 in
20052005 90% squamous90% squamous
FIGO stagesFIGO stages
IaIa <2cm, <2cm, <<1mm invasion1mm invasion IbIb <2cm, >1mm invasion<2cm, >1mm invasion IIII >2cm>2cm IIIIII urethra/vagina/perineum/anus urethra/vagina/perineum/anus
involvement, unilateral inguinal metinvolvement, unilateral inguinal met IVaIVa rectal/bladder involvement, rectal/bladder involvement,
bilateral inguinal metbilateral inguinal met IVbIVb distant metdistant met
TNM stagesTNM stages FIGOFIGO TT NN MM IaIa 1a1a 00 00 IbIb 1b1b 00 00 IIII 22 00 00 IIIIII 1-31-3 0-10-1 00 IVaIVa 1-31-3 22 00 IVaIVa 44 0-20-2 00 IVbIVb 1-41-4 0-20-2 11
Macroscopic appearanceMacroscopic appearance
SuperficialSuperficial 5-15%5-15% ExophyticExophytic 40%40% EndophyticEndophytic 45%45%
SpreadSpread
1.1. Inguinal and femoral lymph Inguinal and femoral lymph nodesnodes
2.2. Cloquet/Rosenmüller nodesCloquet/Rosenmüller nodes
3.3. Parailiac nodesParailiac nodes
Evolution of surgical Evolution of surgical treatmenttreatment
Parré-JonesParré-Jones Inguinali radiotherapyInguinali radiotherapy <1 mm invasion warrants no <1 mm invasion warrants no
nodal diseasenodal disease Sentinel nodesSentinel nodes Neville HackerNeville Hacker
Progression free survival Progression free survival improved by improved by
lymphadenectomylymphadenectomy
0
,2
,4
,6
,8
1
0 10
20
30
40
50
60Műtét óta eltelt idő hónapokban kifejezve
Túlé
lési
hán
yad
0
,2
,4
,6
,8
1
0 10
20
30
40
50
60Műtét óta eltelt idő hónapokban kifejezve
Túlé
lési
hán
yad Vulvectomy+lymphadenectomy -
Vulvectomy
Overall survival improved Overall survival improved by lymphadenectomyby lymphadenectomy
0
,2
,4
,6
,8
1
Túlé
lésih
án
yad
0 10
20
30
40
50
60Műtét óta eltelt idő hónapokban kifejezve
0
,2
,4
,6
,8
1
Túlé
lésih
án
yad
0 10
20
30
40
50
60Műtét óta eltelt idő hónapokban kifejezve
Vulvectomy+lymphadenectomy -
Vulvectomy
Summary of treatment for Summary of treatment for vulval cancervulval cancer
Survival of vulval cancer with no spread to urinary or GI tracts is Survival of vulval cancer with no spread to urinary or GI tracts is improved by adding lymphadenectomy to wide excision of improved by adding lymphadenectomy to wide excision of primary tumour.primary tumour.
Advanced or regional metastatic disease treated with Advanced or regional metastatic disease treated with radiotherapyradiotherapy
Disseminated tumours require chemotherapyDisseminated tumours require chemotherapy