Upload
scot-simon
View
220
Download
0
Embed Size (px)
Citation preview
Gynaecology Oncology
Ram AthavaleConsultant Gynaecological Oncology
University Hospitals Coventry & Warwickshire NHS Trust
Aims
A framework for main gynaecological cancers
To provide a foundation for further study
National Cancer Regfistrations UK 2004
Gynaecological malignancies
Cases Incidence/100,000
Lifetime risk
Ovary 5409 21.2 1:48
Uterus 5029 19.7 1:73
Cervix 2221 8.7 1:116
Vulva 824 3.3 1:350
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
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
Cancer Unit Diagnostic role
Rapid 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 index< 200Vulva- diagnostic excision of tumours less than 2 cms
Refer all other cases to the Cancer Centre
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
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
Treatment of cancer
Surgery
Chemotherapy Radiotherapy
Palliative care Supportive therapy
Multidisciplinary approach critical
Qs
Cervical cancer
Histology
Low grade disease HPV changes CIN I
High grade disease CIN II CIN III
Invasive cancer CGIN
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
Pathology
Peaks 35-44 and 75-85
Squamous (70%) Adenocarcinoma (12%) Adenosquamous (12%)
Direct spread - anatomical
Clinical features at presentation
Abnormal bleeding PCB,IMB,PMB
Abnormal smears
Advanced disease relatedoffensive PV dischargeneuropathic painrenal failureDVT
FIGO Staging
I – Confined to cervixIA Micro – invasive (<5mm 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 < 4 cms, IB2 > 4 cms
II – Beyond cervixIIA Upper 2/3 of vagina IIB Parametrium not reaching side wall
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
Clinical Staging +/- investigations
Visible tumour PV/PR to check spread to
parametrial/rectovaginal space EUA, cystoscopy +/- Sigmoidoscopy,proctoscopy MRI CXR FBC,U&E,LFT PET?
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
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
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
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
Palliative procedures
ExenterationAnterior or posterior or both
Radiotherapy
Tumour embolisation
Symptom control only
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%
Follow up
Clinical examination Reassurance Symptom relief – side effects of treatment HRT Psychosexual Early detection of recurrence
Vault smears limited role after radical surgeryNot recommended after radiotherapy
Qs
Ovarian cancer
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
Aetiology
Majority sporadic (90%) Genetic origin (up to 10%)
BRCA1 gene – 40-60 % riskBRCA2 – 10-30%Two or more 1st degree relatives affectedHNPCC
Increased risk in nullips, early menarche, late menopause, ovarian stimulation, abnormal ovarian development
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
Presentation
Asymptomatic Pelvic mass (diff. diagnosis) Pressure symptoms/abdominal
distension/GI symptoms Pain Abnormal bleeding Hormonal effects
Screening & Diagnosis
Clinical examination CA-125 & Transvaginal scan/Abd. Scan
Other tumour markers - CEA, CA 19-9 CT/MRI abdomen & pelvis FBC,U&E, LFT, CXR
Overlap between benign and malignant
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 3
M = menopausal statuspremenopausal= score 1postmenopausal=score 3
RMI score
RMI < 200more likely benignmanaged at Cancer Units
RMI > 200more likely malignantmanaged at Cancer Centre
FIGO Staging
Surgical/ pathological I – Confined to ovaries
with or without malignant ascites II – Confined to pelvis
includes 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
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
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
UKCTOCS trial
UK Collaborative trial for ovarian cancer screening
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
Qs
Endometrial / Uterine cancer
Endometrial cancer
Predominantly a disease of postmenopausal women
<5% risk under age 40
Numbers increasing, probably obesity related?Diet influence
Risk factors
Excessive endogenous oestrogensPCOperipheral conversion (adipose)
Unopposed oestrogensHRTTamoxifen
Breast cancer HNPCC
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
Pathology
Endometrioid adenocarcinoma 80%Grade 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’
Investigations
Examination Transvaginal scan
endometrial thickness > 4 mms (5 mms) considered significantendometrial biopsy required all cases
endometrial thickness < 4 mms
Endometrial biopsy Pipelle - outpatient Hysteroscopy OP/IP and curettage
CXR, (MRI)
FIGO stage and prognosis
Stage I Confined to body of uterus IA – Confined to endometrium IB – Invasion less than 50%myometrium IC – Invasion more than 50% myometrium
II – Cervix involvedA glands onlyB stromal invasion
III – Serosa of uterus, peritoneal washings+ve lymph nodes (IIIC)IV – Local/distant mets
Grade Histological type Lymphovascular space invasion
Treatment
SurgicalTAH +BSO, peritoneal washings / LAVH BSO
ASTEC trial – lymph nodes or not Surgery alone sufficient endometrioid type,
invasion<50% 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 stages
research ongoing for benefit in lower and higher stages
Prognosis
5 year survival I - 75% II – 58% III – 30% IV – 10%
Qs
Vulvar intraepithelial neoplasia (VIN)
Vulvar Intraepithelial Neoplasia
Most in postmenopausal 41% cases in premenopausal Vulval skin is part of anogenital
epithelium
HPV thought to be involved
Pathology VIN 2 or 3 grouped together- VIN
VIN 1 not recognised (ISSVD)
Undifferentiated (usual) VINHPV associatedBowenoidgenerally good prognosismultifocality – main problem
Differentiated VINassociated with lichen sclerosus/ squamous hyperplasiarelatively older women
Presentation
Pruritus Asymptomatic During investigations for CIN/ VaIN
Lesions may be
raised/flat/sing/multiple/diffuse/discrete Investigation by vulvoscopy +/- acetic acid Adequate biopsies
8 mm punch
Treatment
Multifocal Discomfort/mutilation VIN 3 may progress to cancer
life time risk up to 9% Single lesions excised Multiple lesions – excision or
individualised depending upon location Photodynamic therapy- research HPV vaccine / Topical Imiquimod
Follow up
Vulvoscopy every 6 months until 2 years then individualised
Colposcopy and smears as routine (unless CIN identified)
Vulvar cancer
Vulval cancer
Uncommon Elderly >65 years 90% squamous Other types - more aggressive Associated with smoking, cervical
neoplasia, immunosupression
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 lesion< 2 cms)
Spread & staging
Lymphatic (groin nodes) and local
CXR cervical cytology where appropriate
If multicentric – local inspection of cervix, vagina
FIGO (clinical +surgical) Staging
FIGO stage
I - tumours less than 2 cmsIA up to 1 mm depth of invasionIB more than 1 mm
II Tumour > 2 cms irrespective of depth
III Spread to lower third vagina, unilateral groin nodes
Bilateral groin nodes, bladder/ rectum, distant spread
Treatment
Surgery Wide excision with good margins Vulvectomy and groin incisions for
nodes Sentinel nodes – research
Radiotherapy Node positive Insufficient margins
Chemotherapy/chemoradiotherapy
Morbidity
50% wound breakdown Lymphoedema Lymphocyst formation Rectocele & cystocele Sexual dysfunction
Follow up
Detect early recurrencemore visible
Poor outcome for recurrenceand node positive cases
Five year survivalStage I – 90- 97%Stage II – 85%Stage III – 74%Stage IV – 30%
Qs