Gynaecology Oncology

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Gynaecology Oncology

• Ram Athavale
• Consultant Gynaecological Oncology
• University Hospitals Coventry Warwickshire
• NHS Trust

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Aims

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

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Gynaecological malignancies
Cases Incidence/100,000 Lifetime risk
Ovary 5409 21.2 148
Uterus 5029 19.7 173
Cervix 2221 8.7 1116
Vulva 824 3.3 1350
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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

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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

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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 indexlt 200Vulva- diagnostic
  excision of tumours less than 2 cms
• Refer all other cases to the Cancer Centre

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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

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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

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Treatment of cancer

• Surgery
• Chemotherapy
• Radiotherapy
• Palliative care
• Supportive therapy
• Multidisciplinary approach critical

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Qs
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Cervical cancer
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Histology

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

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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

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Pathology

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

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Clinical features at presentation

• Abnormal bleeding
• PCB,IMB,PMB
• Abnormal smears
• Advanced disease relatedoffensive PV
  dischargeneuropathic painrenal failureDVT

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FIGO Staging

• I Confined to cervixIA Micro invasive (lt5mm
  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 lt 4 cms, IB2 gt 4
  cms
• II Beyond cervixIIA Upper 2/3 of vagina IIB
  Parametrium not reaching side wall

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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

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Clinical Staging /- investigations

• Visible tumour
• PV/PR to check spread to parametrial/rectovaginal
  space
• EUA, cystoscopy
• /- Sigmoidoscopy,proctoscopy
• MRI
• CXR
• FBC,UE,LFT
• PET?

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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

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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

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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

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Fertility preservation- Radical trachylectomy

• IA2, small volume IB1excise cervix, limited
  parametriumlaparoscopic node dissection
  Fertility preservationLong term survival data
  unavailableExpertise not always available
  Pregnancy outcomes promising

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Palliative procedures

• ExenterationAnterior or posterior or both
• Radiotherapy
• Tumour embolisation
• Symptom control only

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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

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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

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Qs
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Ovarian cancer
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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

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Aetiology

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

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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

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Presentation

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

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Screening Diagnosis

• Clinical examination
• CA-125 Transvaginal scan/Abd. Scan
• Other tumour markers - CEA, CA 19-9
• CT/MRI abdomen pelvis
• FBC,UE, LFT, CXR
• Overlap between benign and malignant

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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 1postmenopausalscore
  3

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RMI score

• RMI lt 200more likely benignmanaged at Cancer
  Units
• RMI gt 200more likely malignantmanaged at Cancer
  Centre

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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

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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

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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

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UKCTOCS trialUK Collaborative trial for
ovarian cancer screening
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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

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Qs
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Endometrial / Uterine cancer
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Endometrial cancer

• Predominantly a disease of postmenopausal women
• lt5 risk under age 40
• Numbers increasing, probably obesity
  related?Diet influence

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Risk factors

• Excessive endogenous oestrogensPCOperipheral
  conversion (adipose)
• Unopposed oestrogensHRTTamoxifen
• Breast cancer
• HNPCC

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Presentation

• Postmenopausal bleeding (PMB)
• 10 of women with PMB have endometrial cancer
• Postmenopausal PV discharge/pyometra
• Peri/premenopausal women with IMB especially if
  do not respond to hormonal treatment.
• Glandular abnormalities on smear

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Pathology

• Endometrioid adenocarcinoma 80Grade 1,2,3
• 10 papillary serous, 4 clear cellremaining
  other types such as MMT, squamous
• Two typesstandard type- obese, low stage low
  grade, good prognosisnon-standard type not
  obese, high grade, high risk histotype
• Spread local / distant70-80 stage 1 confined
  to uterusperceived as not such a bad cancer

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Investigations

• Examination
• Transvaginal scanendometrial thickness gt 4 mms
  (5 mms) considered significantendometrial biopsy
  required all casesendometrial thickness lt 4 mms
  
• Endometrial biopsy
• Pipelle - outpatient
• Hysteroscopy OP/IP and curettage
• CXR, (MRI)

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FIGO stage and prognosis

• Stage I Confined to body of uterus IA Confined
  to endometrium IB Invasion less than
  50myometrium IC Invasion more than 50
  myometrium
• II Cervix involved A glands only B stromal
  invasionIII Serosa of uterus, peritoneal
  washingsve lymph nodes (IIIC)IV
  Local/distant mets
• Grade
• Histological type
• Lymphovascular space invasion

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Treatment

• SurgicalTAH BSO, peritoneal washings / LAVH BSO
• ASTEC trial lymph nodes or not
• Surgery alone sufficient endometrioid type,
  invasionlt50 thickness of myometrium, grade 1 or
  2i.e. up to FIGO stage IA/ IB, grade 1 or 2
• Radiotherapy, IC or grade 3, or higher stages
• Hormone therapy, palliative or recurrence
• Chemotherapy higher stagesresearch ongoing for
  benefit in lower and higher stages

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Prognosis

• 5 year survival
• I - 75
• II 58
• III 30
• IV 10

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Qs
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Vulvar intraepithelial neoplasia (VIN)
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Vulvar Intraepithelial Neoplasia

• Most in postmenopausal
• 41 cases in premenopausal
• Vulval skin is part of anogenital epithelium
• HPV thought to be involved

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Pathology

• VIN 2 or 3 grouped together- VINVIN 1 not
  recognised (ISSVD)
• Undifferentiated (usual) VINHPV
  associatedBowenoidgenerally good
  prognosismultifocality main problem
• Differentiated VINassociated with lichen
  sclerosus/ squamous hyperplasiarelatively older
  women

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Presentation

• Pruritus
• Asymptomatic
• During investigations for CIN/ VaIN
• Lesions may be raised/flat/sing/multiple/diffuse/d
  iscrete
• Investigation by vulvoscopy /- acetic acid
• Adequate biopsies8 mm punch

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Treatment

• Multifocal
• Discomfort/mutilation
• VIN 3 may progress to cancerlife time risk up to
  9
• Single lesions excised
• Multiple lesions excision or individualised
  depending upon location
• Photodynamic therapy- research
• HPV vaccine / Topical Imiquimod

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Follow up

• Vulvoscopy every 6 months until 2 years then
  individualised
• Colposcopy and smears as routine (unless CIN
  identified)

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Vulvar cancer
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Vulval cancer

• Uncommon
• Elderly gt65 years
• 90 squamous
• Other types - more aggressive
• Associated with smoking, cervical neoplasia,
  immunosupression

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Presentation

• Longstanding vulval pruritus
• Pain, discharge, bleeding
• Most common on labia majora
• Exophytic, ulcerated or flat
• Younger patients - multicentric disease
• Diagnosis - Vulvoscopy and punch biopsy or
  excision biopsy (single lesionlt 2 cms)

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Spread staging

• Lymphatic (groin nodes) and local
• CXR cervical cytology where appropriate
• If multicentric local inspection of cervix,
  vagina
• FIGO (clinical surgical) Staging

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FIGO stage

• I - tumours less than 2 cmsIA up to 1 mm depth
  of invasionIB more than 1 mm
• II Tumour gt 2 cms irrespective of depth
• III Spread to lower third vagina, unilateral
  groin nodes
• Bilateral groin nodes, bladder/ rectum, distant
  spread

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Treatment

• Surgery
• Wide excision with good margins
• Vulvectomy and groin incisions for nodes
• Sentinel nodes research
• Radiotherapy
• Node positive
• Insufficient margins
• Chemotherapy/chemoradiotherapy

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Morbidity

• 50 wound breakdown
• Lymphoedema
• Lymphocyst formation
• Rectocele cystocele
• Sexual dysfunction

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Follow up

• Detect early recurrencemore visible
• Poor outcome for recurrenceand node positive
  cases
• Five year survival
• Stage I 90- 97
• Stage II 85
• Stage III 74
• Stage IV 30

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Qs