Malignancy of the endometrium, ov, ft

24/03/2017 #DLSHSI_GYNEONCO2017 @doc_magno

MalignantNeoplasmoftheEndometrium,Ovary,FallopianTube

andPeritoneumAngelitoMagnoM.D.,FPOGS,FSGOP,FPSCPC

DeLaSalleHealthSciencesInsRtuteMarch24,2017

EndometrialCancer

•  13thMCcancerinbothsexes•  7thleadingsiteamongwomen•  3rdMCgynecologicmalignancy•  MostcommonmalignancyofthefemalegenitaltractintheUSandotherdevelopedcountries

EndometrialCancer

•  PerimenopausalandPostmenopausalage(50-65yearsold)

•  10-15%-youngerthan50years•  5%-womenlessthan40yearsold

EndometrialPathology:Progression

Normal Hyperplasia Cancer

UnopposedEstrogen

EarlyMenarcheHPNCC/Lynchsyndrome

SYMPTOMSandSIGNS

•  Postmenopausalbleeding•  Abnormalpremenopausalandperimenopausalbleeding

•  Discharge•  Pelvicpain•  Uterineenlargement

Transvaginalultrasonography

•  Threshold:Endometrialthickness

•  ReproducRveage–  ProliferaRvephase:8mm–  Secretoryphase:upto1.4cm

•  Postmenopausalage:<5mm

•  NotausefultoolforasymptomaRcTamoxifenusers

DIAGNOSIS

•  HistologicexaminaRonoftheendometrium•  OfficeEndometrialBiopsy

– Novak’scuret–  Pipelle-usefuliftheendometrialthicknessof>6mm–  1stlineinthediagnosisofendometrialcancer–  Endometrialsampleisobtainedintheclinicwithnoanesthesia

– Advisableonlyforpostmenopausalwomenwiththickenedendometrium(notforpre-menopausalwomen)

OfficeEndometrialBiopsy

Diagnosis

•  IfinadequateoutpaRentevaluaRonorsample– FracRonal/Endometrialcurefage– Hysteroscopy

FracRonalcurefage

•  Underregionalanesthesia•  Completescrapingoftheendocervicalandendometriallinings

DIAGNOSIS HYSTEROSCOPY

•  Videoscopeisintroducedtranscervicallytovisualizeendometrialcavity

•  Togetherwithbiopsy,consideredthegoldstandardfortheinvesRgaRonofwomenwithsymptomsofendometrialpathology

Papsmear

•  Screeningtoolforcervicalcancer

•  NOTagoodscreeningtoolforendometrialcancer

•  Only50%orlessofcasesdetectedbypapsmear

Endometrioidadenocarcinoma

•  Mostcommontypeofendometrialcancer•  Glandsareinbacktobackpafernwithminimalornoinbetweenstroma

Backtobackpafern

DegreeofdifferenRaRon•  Grade1-well-differenRated,<5%solidcomponents

•  Grade2-moderatelydifferenRated,6-50%solidcomponent

•  Grade3-poorlydifferenRated,>50%solidcomponent

Adenocarcinomawithsquamouscomponent

•  Previouslytermedasadenoacanthomaoradenosquamouscarcinoma

•  Mixtureofglandular(adeno)andsquamousepithelium

•  PrognosisdependsonthedifferenRaRonoftheglandularcomponentandnotfromsquamouspart

UterinePapillarySerousCarcinoma

•  Highlyvirulent•  Uncommonhistologicsubtypeofendometrialcarcinomas(5%to10%)

•  Histologicallyresemblepapillaryserouscarcinomasoftheovary

•  Finger-like(papilla)projecRons

ClearCellCarcinoma

•  lesscommon(<5%)•  Resemblesclearcelladenocarcinomasoftheovary,cervix,andvagina

•  Hobnailcells•  Clearcytoplasmwithnucleusontheside

UPSCandClearcell

•  Prognosisisworsethanthetypicalendometrioidadenocarcinoma

•  Stage1endometrioidadenoarcinomahas5yearsurvivalof>90%butonly50%inbothUPSCandClearcellcarcinoma

24/03/2017 #DLSHSI_GYNEONCO2017 @doc_magno*ReporRngofposiRveperitonealcytology

StageI:confinedtotheCorpus

IA-Endometriumor<50%ofthemyometrium

IB->50%oftheendometrium

StageII:Cervicalstromabutnotbeyondtheuterus

II:tumorinvadesthecervicalstroma

*invasionofcervicalglandsisNOWstageIA

StageIII:Localorregionalspread

IIIA:Involvementofserosaofthecorpus

andAdnexa

*PosiRveperitonealcytologyisnolongerstageIIIA

IIIB:Vaginaland/orParametrialinvolvement

ParametrialRssue:paravaginalRssues,broadligament,cardinalligament,paracervicalRssues,otherpelvicRssues

IIIC:RegionalNodes

IIIC1:pelvicnodes

IIIC2:paraaorRc nodesw/orw/opelvicnodes

StageIVA:

IVA:bladdermucosaorrectal

mucosalinvolvement

StageIVBIVB:Distantmetastases

includingintra-abdominalorgansand

inguinalnodes

*intra-abdominalorgans=organsabovethepelvicbrim

PosiRvePeritonealcytology

•  Shouldbereportedseparatelywithoutchangingthestage

•  Example:– Endometrialadenocarcinoma,endometrioidtype,stageIB,(+)peritonealfluidcytology

PrognosRcFactors

ClinicalFactors PathologicFactorsAgeStageRace

TumorgradeHistologictypeTumorsizeDepthofmyometrialinvasion,VascularspacesinvolvementExtrauterineinvolvement(lymphnodes,peritoneumoradnexa)

FactorsthataffectprognosisofthepaRents

MYOMETRIALINVASION

PafernofSpread•  A.Directextension

– Transtubalortranscervical/transvaginalspread•  B.LymphaRcs•  C.Hematogenous

PafernofSpread(LymphaRcs)(1)asmalllymphaRcbranchalongtheroundligamentthatrunstotheinguinalfemoralnodes

PafernofSpread(LymphaRcs)(2)branchesfromthetubal(3)ovarianpedicles(infundibulopelvicligaments),whicharelargelymphaRcsthatdrainintothepara-aorRcnodes;

PafernofSpread(LymphaRcs)(4)thebroadligamentlymphaRcsthatdraindirectlytothepelvicnodes

PafernofSpread(LymphaRcs)(1)asmalllymphaRcbranchalongtheroundligamentthatrunstotheinguinalfemoralnodes(2)branchesfromthetubal(3)ovarianpedicles(infundibulopelvicligaments),whicharelargelymphaRcsthatdrainintothepara-aorRcnodes;(4)thebroadligamentlymphaRcsthatdraindirectlytothepelvicnodes2,3,4-clinicallymostimportant

EvaluaRon

•  Imagingtechniques-CTScan,MRI,PET/CTScan

•  ColorDopplerUltrasound•  CA125

IMAGINGTECHNIQUES

-SGOP2015CPG

ColorDopplerUltrasound

•  adjunctultrasound•  DetectsneovascularizaRon(abnormalvesselformaRon)

•  Highresistanceindex-featureofmalignancy

CancerAnRgen(Ca)125

•  Generallyusedinepithelialovariancancer•  Usedinadvancedstageendometrialcancertodetectextrauterineinvolvementandaspost-operaRvemonitoring

•  Notusefulinearlystagedisease•  Non-specifictoendometrialcancer

SURGERY

•  primarytreatmentmodality•  Surgicopathologicstaging(usingthe2009FIGOStagingsystem)

•  ExcepRons:– PaRentswithpoorsurgicalriskduetounstablemedicalcondiRons

– YoungcancerpaRentsdesirousoffutureferRlity– Willusethe1971FIGOClinicalStagingSystemofEndometrialcancer

Surgery

Completestaging•  Peritonealfluidwashing•  Totalhysterectomywithsalpingo-oophorectomy

•  Bilateralpelviclymphadenectomy•  *Para-aorRclymphadectomy

– Notdoneforlowriskcancer

Surgery

•  Surgicalstaging(1) tumorspreadwithintheuterus(2) degreeofpenetraRonintothemyometrium(3) extrauterinespreadtoretroperitoneal

nodes,adnexa,and/ortheperitonealcavity

Surgery

•  Opensurgery/Laparotomy•  Minimallyinvasiveapproach

– ConvenRonalLaparoscopy– RoboRc

Minimallyinvasivetechniques

Advantages•  Samepathologicoutcome(adequacyofRssues,nodenumber)

•  Shorterhospitalstay•  Smallerwound•  BeferQOLpost-operaRvely•  Lessbloodloss,lesscomplicaRons

OthertreatmentmodaliRes

•  UnstablemedicalcondiRons•  YoungpaRentsdesirousofpregnancy

•  RadiaRonalone•  Medicaltherapy

RadiaRon

•  RadiaRonalone:Inferiorthansurgery– Stage1surgeryalone:87%5yrsurvivalversus67%forradiaRonalone

– NotrecommendedforpaRentsdesirousofpregnancy(radiaRonwillkilltheovaries)

•  Asadjuvanttherapy:givenpost-operaRvetreatmentifwithpoorprognosRcfactors–  IncreasessurvivalofpaRentswithadvancedendometrialcancer

Stage1

SGOP2015CPG

StageII

SGOP2015CPG

StageIII

SGOP2015CPG

StageIV

SGOP2015CPG

UPSCandClearCellHistology

SGOP2015CPGSimilarsurgicaltreatmentwithovariancancerbecauseUPSCandclearcellcancerbehavelikeovariancancer

Medical/ConservaRvetreatmentConservaRvetreatmentisonlyofferedtopaRentswhohave:•  WelldifferenRatedtumor(endometrioidtype)•  Nomyometrialinvasion(asevaluatedbyMRI)•  Nocervicalinvolvement•  Noextrauterineinvolvement:

–  Noadnexalinvolvement–  Noparametrialinvolvement–  Novaginalinvolvement–  Nosuspiciousretroperitonealnodesornoevidenceoflymphnodemetastasis

–  NegaRvePFC•  NoLVSI(lymphovasularspaceinvasion)•  NocontraindicaRonsformedicalmanagement

SGOP2015CPG

Medical/ConservaRvetreatmentThefollowingarealsoessenRal:•  ProgesRnreceptorposiRvity•  PaRentunderstandsandacceptsthatthisisnotstandardtreatment–  (Informedconsent)–InformpaRentsthattheprocedureofpreservaRonofferRlityissRllexperimentalandthereislowpregnancyrate

•  PaRentwithstrongdesiretopreserveherchildbearingpotenRal

Medical/ConservaRvetreatment•  Agentsused:DuraRonoftreatmentisvariable

•Megestrolacetate40-60mg/day•Medroxyprogesteroneacetate(MPA)100-800mg/day•Levonorgestrel-containingintrauterinesystem(LNG-IUS)•Tamoxifen+ProgesRns•Anastrozole+ProgesRns

Medical/ConservaRvetreatmentMonitoring:•  repeatdilataRonandcurefageauer3monthsoftherapy

•  Noresponseauer3monthsoftherapy=treatmentfailure

•  maintenancetreatmentwithoralcontracepRvepills(OCPs),cyclicprogesRns,depotmedroxyprogesteroneacetate(DMPA),orLNG-IUSunRlpregnancyisdesired

•  Ifpregnancyisdesired,afemptsshouldbemadeauer3monthsfromreversionofthecancer.

OVARIANCANCER

OvarianCancer

•  2ndmostcommongynecologiccancerandmostcommoncauseofcancerdeathintheU.S

•  Incidenceincreaseswithage(beyond50years)-epithelialtumor

2010PhilippineCancerFactsandEsRmates

0 2000 4000 6000 8000 10000 12000 14000

StomachThyroid

LeukemiaCorpusLiverOvary

Colon/rectumLung

CervixBreast

Es#matedleadingnewcancercases,females

2010PhilippineCancerFactsandEsRmatesEsRmatedLeadingNewCancerDeaths,females

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Brain/NS

Corpus

Stomach

Leukemia

Colon/rectum

Cervix

Breast

Pathogenesis

A.AccumulaRonofgeneRcaberraRon-Rasfamilyofoncogenes-p53

B.InheritedgenemutaRon-BRCAmutaRon&LynchSyndrome

C.DeNovoproliferaRon-incessantovulaRon-PIDandEndometriosisassociatedtumors

Pa0ernofSpread:

•  TranscoelomicdisseminaRonordirectextension

•  LymphaRc•  Hematogenous

PresentaRons

•  Non-specific(earlysaRety,epigastricpain,bloatedness,weightloss)

•  Abdominalenlargement•  Pelvicmass•  Vaginalbleeding

DIAGNOSIS•  Ultrasoundremainstobethemosthelpfulimaging

examinaRonforovariancancerdiagnosiswiththehighestsensiRvity

•  CA125andHE4(morespecifictumormarkerforovarian

cancer)

*However,ROUTINEscreeningforaverage-riskwomenusingTVUTS,CA125andpelvicexamisnotrecommended

SuggesRveofOvarianmalignancy

•  complexmasswithbothsolidandcysRccomponents

•  papillaryexcrescencesandprojecRons•  internalechoesandseptaRons•  Ascites•  peritonealmetastasis

RiskFactors•  Nodefinitecause

Factorsthatincreaserisk:•  Nulliparity•  MenstrualirregulariRes•  Hxofbreastorendometrialcancer

FactorsthatcouldbeprotecRve:•  Pregnancy•  OralcontracepRves

PoorSurvivalRatedueto:

•  Latediagnosis•  Noreliablescreeningmethods•  Nodefiniteriskfactors•  NoknowneRology•  Noprecursorlesions•  Non-specificsymptomsandsigns

ContrastofSurgicalFindingsBenign Malignant

Surface papillae Rare Very common Intracytic papillae Uncommon Very common

Solid areas Rare Very common Bilaterality Rare Common Adhesions Uncommon Common

Ascites (>100 ml) Rare Common Necrosis Rare Common

Peritoneal implants

Rare Common

Capsule intact Common Infrequent Totally cystic Common Rare

FIGO1988 FIGO2014

FIGOGuidelinesCommifee:

RevisethestagingsystemtoimproveuRlityandreproducibility

Ovarian,Fallopiantubeandprimary

peritonealcancer:samestagingsystembecauseofcommonhistology:Seroustype

FIGO STAGE 1 NEW STAGING OLD STAGING

I Tumor confined to ovaries or fallopian tube(s)

Tumor limited to the ovaries (one or both)

IA Tumor limited to one ovary (capsule intact) or fallopian tube No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings

Tumor limited to one ovary; capsule intact No tumor on ovarian surface No malignant cells in ascites or peritoneal washings

IB Tumor limited to both ovaries (capsules intact) or fallopian tubes No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings

Tumor limited to both ovaries; capsule intact No tumor on ovarian surface No malignant cells in ascites or peritoneal washings

I Tumor confined to ovaries or fallopian tube(s)

Tumor limited to the ovaries (one or both)

Tumor limited to one or both ovaries or fallopian tubes with any of the following: Surgical spill intraoperatively Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface Malignant cells in the ascites or peritoneal washings

Tumor limited to one or both ovaries with any of the following:

Capsule ruptured, tumor on ovarian surface, malignant cells in ascites or peritoneal washings

II Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or primary peritoneal cancer

Tumor involves one or both ovaries with pelvic extension

IIA Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries

Extension and/or implants on uterus and/or tube(s); no malignant cells in ascites or peritoneal washings

IIB Extension to other pelvic intraperitoneal tissues

Extension to other pelvic tissues No malignant cells in ascites or peritoneal washings

IIC Pelvic extension (IIa or IIb) with malignant cells In ascites or peritoneal washings

FIGO STAGE 3

NEW STAGING OLD STAGING

III Tumorinvolvesoneorbothovaries,fallopiantubes,orprimaryperitonealcancer,withcytologicallyorhistologicallyconfirmedspreadtotheperitoneumoutsidethepelvisand/ormetastasistotheretroperitoneallymphnodes

Tumorinvolvesoneorbothovarieswithmicroscopicallyconfirmedperitonealmetastasisoutsidethepelvisand/orregionallymphnodemetastasis

FIGO STAGE 3

IIIA1PosiRveretroperitoneallymphnodesonly(cytologicallyorhistologicallyproven)(i)Metastasis<10mmingreatestdimension(ii)Metastasis>10mmingreatestdimensionIIIA2Microscopicextrapelvic(abovethepelvicbrim)peritonealinvolvementwithorwithoutposiRveretroperitoneallymphnodes

Microscopicperitonealmetastasisbeyondpelvis

FIGO STAGE 3

IIIB Macroscopicperitonealmetastasisbeyondthepelvisupto2cmingreatestdimension,withorwithoutmetastasistotheretroperitoneallymphnodes

Macroscopicperitonealmetastasisbeyondthepelvis,2cmorlessingreatestdimension

FIGO STAGE 3

NEW STAGING OLD STAGING IIIC

Macroscopicperitonealmetastasisbeyondthepelvismorethan2cmingreatestdimension,withorwithoutmetastasistotheretro-peritoneallymphnodes(includesextensionoftumortocapsuleofliverandspleenwithoutparenchymalinvolvementofeitherorgan)

Peritonealmetastasisbeyondpelvis,morethan2cmingreatestdimensionand/orregionallymphnodemetastasis

FIGO STAGE 4

IV Distantmetastasisexcluding

peritonealmetastasesIVA:PleuraleffusionwithposiRvecytology

IVB:Parenchymalmetastasesandmetastasestoextra-abdominalorgans(includinginguinallymphnodesandlymphnodesoutsidetheabdominalcavity)

Growthinvolvingoneorbothovarieswithdistantmetastases.Ifpleuraleffusionispresent,theremustbeposiRvecytologytoallotacasetoStageIV.ParenchymallivermetastasisequalsStageIV

Borderlinetumor/LowMalignantPotenRal

•  10to15%ofepithelialovariancancers•  Mostcommon:earlystage•  Rarelymetastasizeinlymphnodes•  Nuclearatypia,straRficaRonoftheepithelium,formaRonofmicroscopicpapillaryprojecRons,cellularpleomorphism,andmitoRcacRvity

•  ABSENCEofstromalinvasion•  Recurrenceispossible(usuallylate)

Pathology:SerousCA

•  >50%ofovariancancerareseroushistology•  PredominantlycysRcwiththinfluidwithinwithpapillaryexcresences/muralnodule

•  Resemblesthefallopiantubeepithelium•  Pathognomonic:PSAMMOMABODIES•  CA-125:mostusefultumormarker

Pathology:SerousCA

Pathology:Endometrioid

•  About15to20percentofepithelialovariancancers

•  Histology:similartotheendometrialglands•  MixtureofcysRcandsolidmass.•  AssociatedwithEndometriosisandPID•  CA-125alsouseful

This can be cystic with smooth surface and variable amounts of intracystic soft or solid masses or papillae. This can sometimes have necrosis and hemorrhage.

There is irregular, infiltrative proliferation of glandular type epithelium resembling proliferative type endometrium with cytologically malignant nuclear features.

Pathology:Mucinous

•  5to10percentoftrueepithelialovariancancers•  MulRloculated,mulRcysRcmasswiththickmaterialwithin

•  Resemblesmucin-secreRngadenocarcinomasofintesRnalorendocervicalorigin

•  Associatedwithappendicealtumorandpseudomyxomaperitonei

•  CA-19-9(tumormarkerformucin-producingcellslikeappendix,pancreas,intesRne)

Pathology:Mucinous

ClearcellcarcinomaoftheOvary

•  5to10percentofepithelialovariancancers•  CysRcmasswithsolidcomponent•  mostfrequentlyassociatedwithpelvicendometriosisandPID

•  PresenceofclearcellandHOBNAILcells

ClearcellcarcinomaoftheOvary

Management:Ovariancancer

Surgery– ExploratoryLaparotomy(midlineverRcal)– Peritonealwashing(diaphragm,rightandleuhemi-abdomen,pelvis)

– CarefulinspecRonandpalpaRonofallperitonealsurfaces

– BiopsyandresecRonofanysuspiciouslesions,masses,andadhesions

– Totalabdominalhysterectomy+bilateralsalpingo-oophorectomy(THBSO)

•  Surgery– (USO)withfrozensecRon(FS)ispermifedforyoungpaRentswithstageI

– Infracolicomentectomyorinfragastricomentectomy

– Randomperitonealbiopsies(undersurfaceoftherighthemidiaphragm,bladderreflecRon,cul-de-sac,rightandleuparacolicrecessesandpelvicsidewalls)

– PelvicandparaaorRclymphnodesampling– Appendectomyformucinoustumors

– ParacentesisininiRalmanagementofovarianmassisnotrecommended

– Pfannensteilincisionalsonotadvised

– **Tumordebulkingforadvancedstage

– Chemotherapyasadjuvanttherapy

• CarboplaRn-Paclitaxel

IndicaRonsfor“E”operaRon:

•  Anyadnexalmassauermenopauseorbeforepuberty

•  solidadnexalmassatanyage•  cysRcmass>8cm•  cysRcmassbet5-8cm,

–  persistent>8wks•  (+)complicaRons

GermCelltumors

•  mostcommonovarianmalignanciesdiagnosedduringchildhoodandadolescence

•  Symptomsaresimilartotheepithelialcounterpart

•  Massdoesnotgrowasbigastheepithelialtumors

Dysgerminoma•  Mostcommonmalignantovariangermcelltumor•  Mostcommonovarianmalignancydetectedduringpregnancy

•  theonlygermcellmalignancywithasignificantrateofbilateralovarianinvolvement(15-20%)

•  Ingeneral:Solid,cream-coloredtumor•  large,rounded,polyhedralclearcellsthatarerichincytoplasmicglycogenwithlymphocyteinfiltraRon

•  LactateDehydrogenase(LDH)-animpt.tumormarker•  5%-(+)HCG

YolkSactumor

•  PreviouslycalledEndodermalsinustumor•  Solid,yellowishtumor•  Schiller-Duvalbodiesarepathognomonicwhenpresent

•  Alpha-Fetoprotein(AFP)astumormarker

IMMATURETERATOMA

•  3rdmostcommonmalignantgermcelltumor•  Gross:solidw/cysRcspaces•  Micro:immatureRssuederivedfrom3germlayers

•  usuallyfromendodermal,e.g.neuroepithelium

•  Tumormarker:AFP

This typically has a smooth surface and is cystic. Cut section demonstrates greasy yellow sebaceous material and hair. Often there is a thickening of the cyst wall (Rokitansky's protuberance) from which hair and sometimes teeth and bone arise.

This cystic structure is lined predominantly by skin and cutaneous adnexal structures, usually with abundant sebaceous and sweat glands. Hair is almost always present. Other components include cartilage, bone, bronchial or gastrointestinal epithelium and mature glial tissue. If only skin and adnexal structures are present it can be termed dermoid cyst.

Sebaceous land

Immature Glands Immature Neural Tissue

Immature Cartilage

The diagnosis of this tumor requires the presence of immature elements derived from any of the three germ layers: skin elements, mature neural tissue, connective tissue, cartilage, bone, gastrointestinal or bronchial epithelium.

IMMATURETERATOMA

Choriocarcinoma

•  HighB-HCG•  SyncyRotrophoblastandcytotrophoblastwithnodilatedvilli

•  Lesscommongermcelltumors:– Polyembryona– Embryonalcarcinoma–  Immatureteratoma

GermCellTumors

Germ Cell Tumor Tumor Marker Histology

1. Dysgerminoma – MC

LDH Lymphocytic stromal infiltration

2. Endodermal sinus tumor – 2MC

AFP Schiller – Duvall Bodies

3. Teratoma, immature – 3MC

Carcinoid Struma ovarii

Neuroectodermal

4. Embryonal Carcinoma

HCG, AFP Syncytio

5. Polyembryoma HCG

6. Choriocarcinoma HCG Syncytio / cyto

ManagementofGermcelltumor

ConservaRvesurgicalmanagement(USO)maybeanopRonformalignantgermcelltumorifthepaRentisyoungordesirousofpregnancyduetohighresponsetochemotherapy

Sex-Cordtumor:Granulosa-celltumor

•  Mostcommon•  Feminizing•  Symptomsareage-determined•  Pre-puberty-isosexualprecociouspuberty•  ReproducRve-Abnormalmenstrualcycles•  Postmenopause-postmenopausalbleeding

Sex-Cordtumor:Granulosa-celltumor

•  Gross:maybesolidorcysRc•  Micro:Call-ExnerBodies-rosefelikearrangementofgranulosacells

•  ComplicaRons:endometrialhyperplasiaoradenocarcinoma

•  RadiosensiRve•  Bilaterality:5%

Granulosa-celltumor

•  AdultGranulosacelltumor– diagnosedauerage30,withtheaverageagebeing52years

– menometrorrhagiaandpostmenopausalbleedingarecommon

–  inhibinA,inhibinB,andserumestradiol

Granulosa-celltumor

•  JuvenileGranulosacelltumor– childrenandyoungadults,andhalfarediagnosedbeforepuberty.Themeanageatdiagnosisis13years

–  isosexualperipheralprecociouspuberty– Moreaggressive

ManagementofGranulosacelltumor

Chemotherapyasadjuvanttherapy(Bleomycin,EtoposideCisplaRn)

MetastaRccanceroftheovary

•  Krukenbergtumor•  Primarycanceroriginatedfromcolon,stomach,smallintesRne,appendix

•  Solidmass•  Commonlybilateral•  Signet-ringcells

This tumor typically has rounded, firm, white masses that may be bosselated, yellow or white on cut section. Fleshy, gelatinous or spongy areas are common.

Presence of mucin-laden, signet-ring cells strewn individually and in small clusters within a hypercellular ovarian stroma (occasionally with storiform pattern). The cytoplasm occasionally is granular and eosinophilic rather than pale and vacuolated (sometimes has bull's-eye appearance, containing large vacuole with central eosinophilic body).

Krukenbergtumor

PrimaryFallopianTubeCancer

•  Incidence(US):0.41per100,000women(‘0.14-1.8%’)

•  Age:60-79y/ohighestincidencerates•  Incidence(Phil):0.1%-0.5%ofallgynecologiccancers

•  Age:40-65years,mean=52years

Criteriatodiagnoseprimarytubalcancer:

1.Gross :maintumorinthefallopiantube2.Micro :mucosashouldbemainlyinvolved :TransiRonbetweenbenign& malignantdemonstrated

The oviducts, or fallopian tubes, vary from 8 - 14 cm in length and are covered by peritoneum. It is divided into the following potions: interstitium (a), isthmus (b), ampulla (c), and infundibulum (d).

b b a a

NomalFallopianTube

This is composed of fine branching papillae (Arrow) covered by one or more layers of epithelium with enlarged pleomorphic hyperchromatic nuclei (inset). There is increased and abnormal mitoses. In poorly differentiated areas, the tumor may grow in solid sheets of cells with small or large foci of necrosis.

InvasiveAdenocarcinomaOfFallopianTube

Pathology•  Themajority(88%)ofPFTCswereadenocarcinomas;

–  Serous 44%–  Endometrioid19%.–  Mixed 3.9–16.7%–  UndifferenRated 7.8–11.3%–  Mucinous3–7.6%

•  TumorGrade–  GradeI 15–20%–  GradeII 20–30%–  GradeIII 50–65%

•  Laterality–  Unilateral 89%–  Bilateral 11%

•  Stageatdiagnosiswasfairlyevenlydistributed–  localized(36%)–  regional(30%)–  distant(32%) Stewart et al,

ClinicalFeaturesClinical Features Percentage Vaginal bleeding or spotting 50%–60%

Abdominal pain, colicky or dull 30%–49%

Abdominal or pelvic mass 60% (range, 12%–84%)

Ascites 15%

Rare presentations (acute abdomen, palpable inguinal node, umbilical-bone cerebral metastases, cerebellar degeneration, asymptomatic)

[38–41]

Postmenopausal bleeding or spotting with negative Pap smear

Pectasides et al, 2009

LATZKO’STRIADAsyndromewhichconsistsof:1)  profusewateryorhoney-coloredvaginal

discharge,2)  apelvicmass,and3)  colickypelvicpainthatessenRallygoes

awayuponsuddendisappearanceofthemass

AlthoughthistriadisrarelyfoundinpracRce,

it’saclassicdiagnosRcsyndromeforfallopiantubedisease.

Sotto & Manalo, 1994

Diagnosis

•  Imagingstudies– Ultrasound– CTScan– MRI

•  CA-125level•  Cytology•  Pathology

STAGING:SameasovariancancerTREATMENT:1.Surgery

ConservaRve:StIA&desirousofpregnancyComplete:>StIB

2.Chemotherapy-adjuvant

Agents:sameasinovarianca3.Radiotherapy-rolecontroversial

PROGNOSIS:Poor5-yearSurvivvalRateStageI 60%II 40%III10%IV0%

PrimaryPeritonealCarcinoma•  Upto15percentoftypicalepithelialovariancancersare

actuallyprimaryperitonealcarcinomas•  Serousisthemostcommonhistology

ThankYou

Malignancy of the endometrium, ov, ft

Health & Medicine

Kanker endometrium

ACP CA Endometrium

endometrium 2

CAP Cancer Protocol Endometrium · Web viewClinical History Colon carcinoma is the most common malignancy in hereditary nonpolyposis colon cancer (HNPCC; Lynch syndrome (LS)). However,

endometrium hyperplasy

Carcinoma endometrium

Straight tubules of proliferative endometrium Early secretory endometrium with subnuclear vacuoles

ca endometrium

Malignancy Types

POSTMENOPAUSAL ENDOMETRIUM

reseotivitas endometrium

Thyroid malignancy

Thin Endometrium

48 the endometrium

KARSINOMA ENDOMETRIUM

BAB II TINJAUAN PUSTAKA 2.1 Endometrium pada Siklus Menstruasi Normal Endometrium

Endometrium Hyperplastic Processes

Tumor endometrium

MANAGEMENT OF MALIGNANCY · MANAGEMENT OF MALIGNANCY GEMENT OF MALIGNANCY MANAGEMENT OF MALIGNANCY INTRODUCTION Key points The system is failing patients with a cancer, particularly

Gynecologic Malignancy