Uterus Cancer

Vagina
Cancer
Ovarian Cancer GTT
Fibroid Endometriosis Endometrial Ca Cancer Cx Vulva
 Prophylactic
No gynecological Screening programs for………… Early detection

Prophylactic chemotherapy in certain cases of VM

manipulation [esp. HSG] Endometrial Ca Cancer Cx Cancer Vulva

Early detection by Follow up of every case of V.M

during menstruation Gonadectomy for
endometrial
CIN VIN dysgenetic gonads.
Hyperplasia
Early ttt of
cryptomenorrhea Immediate ttt of any
Proper ttt & follow up of ……………… ovarian swelling in
Care during surgery Endometrial Ca Cancer Cx Cancer Vulva postmenopausal lady
From endometrial endometrial
CIN VIN
implantation on the scar Hyperplasia

Encourage preg. & ttt of Prevention & ttt of PDF e.g ………………… ,…etc
hyperestrogenic state
Endometrial Ca Cancer Cx Cancer Vulva
remove estrogen -change sexual prevent
treatment

secreting Tm behavior chronic irritation

-stop smoking

 Curative
Factors affecting ttt Scheme of ttt of Ovarian Tm
Age ⓐEpithelial Tm ⓑSex cord Stromal Tm ⓒGCTs
Parity. As Epith Tm As Epith Tm
Severity of symptoms. But chemo& radiotherapy But
Size, Site & No  Staging  not recommend -Try to preserve fertility as you can
of myomas. See blow -Chemotherapy  different
Associated preg. -dysgrminoma  very radiosensitive
can be treated by chemotherapy
 Associated Mg [in metastatic cases]
 Uterus Cancer Ovarian

Vagina
GTT
Fibroid Endometriosis Endometrial Ca Cancer Cx Vulva Cancer
Scheme of ttt
Asymptomatic Endometriosis TAH & BSO then
ⓐEpithelial Tm

Hystero only in
+Follow Up β-HCG till 3 -ve rsults +Single Chemo
No ttt except associated pain after that A2 Staging

Hysterectomy
Not desired

Plecental Tm
certain cases [see later] Empirical Hormonal Ia G1,2 Ia1 IA Ia G1
Symptomatic ttt No postoperative Radio Wide Local Excision A2Fertility
<40 y & desiring Surgical ttt ttt Or Conization e' No groin Desired
Fertility (Main line of ttt) Ia G3 & Ib G1,2 or TAH +BSO dissection Unilat.
Ia2 & Ib IB

Radiotherapy [Main Line of ttt]

Myomectomy Excision of lesions ±

Chemo [ Single if faiied  Combin]

Vaginal cuff irrad. Oophorectomy
>40y or postoperative hormonal Ib G3 Radio Lateralized lesion Not desired

Stage I
<40 y & not ttt or Radical ttt Pelvic Or Radical Wide Local Excision TAH + BSO
desiring Fertility trechelectomy e' Ipsilat. groin
Irradiation Ia G2,3 & Ib &
Hysterectomy  Endometriosis Or Wertheim's dissection
Ic

(Chemo, radio, Surgery) then COCs for 1y'

Postmenopausal associated Infertility Centralized lesion

Fertility desired
Wide Local Excision TAH + BSO
+ Small Fibroid & Minimal or Mild
e' Bilat groin +Postoperative
mild symptoms Adheseolysis
dissection Combin Chemo
May be medical ttt & Excision of
Selected Cases
treatment

endometrioma
Alternative Surgical Moderate or Severe
IIa IIa

2ry Vaginal Local resection or selective

Pelvic
Maneuver ART ± May need -Modified radical
Irradiation  Radio

Lung local resection (lobectomy) +

Stage II

- Excision of Vulvectomy
Or Wertheim's IIb & IIc


endometrioma before

Multimodal
IIb e' Bilat. Groin Radical
-Course of Hormonal ttt dissection

All Stages of Cancer Cx 

 Radio Oophorectomy
before
+Postop.
Or Chemo or Radio

embolization of int. iliac

High Risk
-1ry Radiotherapy
IIIb & IIIc  Radio Debulking

1ry Combine Chemo 1ry Low Risk

Stage III

(Plan should be +
Extended Field tailored A2 Patient)

approach
Postoperative
Irradiation Combination
Chemotherapy
, Radiotherapy
IVa  Radio IVA

2ry Brain intrathecal

Liver Local resection or
, Immunotherapy

local chemo or Selective

Pelvic Irrad. Or Pelvic

embolization of Hepatic Ar
, Palliative ttt
Stage IV

IVb Exenteration IVB

Chemo or radio
Whole abd. Systemic
Irrad. Chemotherapy &
Locoregional ttt e'
or H. ttt or
palliative intent
Chemotherapy
 Uterus Cancer Ovarian

Vagina
Cancer
GTT
Fibroid Endometriosis Endometrial Ca Cancer Cx Vulva Cancer
Main Line of ttt is ………………………
Surgery Surgery
Surgery Radiotherapy Surgery Surgery Chemotherapy
&Hormonal ttt
Lines of ttt
No ttt Fibroid Fibroid Tm ‫ هو‬No ttt ‫الوحيد اللى عنده‬
e' follow up every 6m'
in Asymptomatic Case No ttt & Myomectomy ‫ ⬅ كالهما موانع لل‬Mg & Cx
(No SymptomsNo ttt)
Except
ⓐLarge myoma > 12 wk
(liable to degeneration)
ⓑRapidly growing myoma
(suspicion of Mg)

ⓒ Large interstitial cervical fibroid

treatment

 (to avoid ureteric compression)

ⓓ Pedunculated subserous myoma
(liable to torsion)
ⓔ Submucous myoma in nullipara
 (to avoid infertility or abortion)

Medical ttt (Hormonal ttt)  Fibroid , Endometriosis & Endometrial Carcinoma

Symptomatic ttt Ⓐ Expectant ttt Anti-estrogens
 GnRH agonists
Indication Young women è Mild pelvic pain
Indicated in:
+ Endometriosis is apparent on laparoscopy  GnRH agonists
1-Patients near menopause è small
+ no immediate interest in pregnancy
myoma & slight menorrhagia.
Methods  Analgesics (NSAIDs)
2- Patients unfit for surgery.  Gestagens
3- Preoperative period Ⓑ Hormonal ttt
to shrink myoma. Indication  Young infertile woman è stage 1 & 2 Endometriosis  Tamoxifen
 Gestagens Principle 
Can be used instead of GnRH agonists Ectopic endometrium (like normal endometrium) responds to hormonal regulation
so, the objective of ttt is to cause atrophy of ectopic endometrium
 Progesterone Rc Modulators
by pseudo-pregnancy state Causes decidualization, necrosis, resorption of
Under Research
Implants or pseudo-menopause state
Management during Pregnancy
Methods  See Below
See Obstetrics
 Pseudo-pregnancy State Pseudo-menopause State
COCs Gestagens only GnRH analogue (agonists) Danazol
Pituitary down regulation & -- of pituitary gonadotropins

Action
desensitization to endogenous GnRH → -- of ovarian steroidogenesis
state of HH* (Medical oophorectomy)
(Medical hypophysectomy)

1-4 tablets/d' MPA (10-30 mg/d) or Goserlin (Zoladex) 600-800 mg/d'

Dose

e' out rest DMPA (150 mg/3 m' IM) 3.6 mg/m' SC for at least 6-9 m'
[Continuous Manner] [Continuous Manner]
for at least 6-9 m'
Cheap & effective 50% Symptomatic relief after 6m' Most effective approved drug for ttt
Results

50% pain relief 80% Regression of endometriotic of endometriosis

25-50% pregnancy lesions
40% Recurrence 25% Recurrence
 Initial flare up of endometriotic symptoms
in 1st wks after ttt
See Contraception
S/E

d2 flare up before down regulation Virilizing symptoms

Menopausal symptoms & osteoporosis

*HH Standard abbreviation for hypogonadotropic hypogonadism

Gestagens  Oral MPA [Provera]
Injection  DMPA [Depo MPA or Depo Provera]
Danazol  Oral synthetic 3-isoxazole derivative of 17α-ethinyl testosterone
 Uterus Cancer

Vagina
Cancer
Ovarian Cancer GTT
Fibroid Endometriosis Endometrial Ca Cancer Cx Vulva
 Surgical ttt
Hysterectomy  Conservative  TAH + BSO Indications  Radical  Unilateral
Indication ttt Indication C/I of radiation vulvectomy oophorectomy

Hysterectomy. Surgical excision of isolated metastasis

[Bassett's
C/I of Myomectomy Lines Standard operation [As Radio is Main Line of ttt]
operation]
Indication Ia G1
Advantages 1-Adhesiolysis nowadays Surgical Modalities Technique +desiring fertility
1- avoids anatomical 2-Surgical excision of -Radical operations  Conization of Cx
butterfly incision…….
recurrence. endometriomas [Wertheim's] + follow up ‫وتشرح بالتفصيل من الجدول التالي‬ [TAH + BSO done
2- less mortality than 3-Electrocoagulation give no better results Indication Stage Ia1 Indication immediately after
myomectomy or Laser evaporation & morbidity wishing to preserve fertility No Place nowadays completion of family]
of Implants -Then after that  Radical  Radical

Not ttt of Choice as it doesn't preserve Fertility

Types  Modified
1-Total hysterectomy 4-LUNA to relief pain A2 Staging trachelectomy radical oophorectomy
LUNA Laparoscopic
2-Subtotal
Uterosacral n ablation
Postoperative ttt Indication  Ia2, Ib vulvectomy Indication 
[Mainly irradiation]
hysterectomy
Indications
wishing to preserve fertility Technique IIb & IIc
Ovaries removed if  Vaginal
Infertility & Pain hysterectomy
Principles [3 incisions] Technique
1- They are
 Radical ttt
-Remove cx only (leaving 1 vulval incision  TAH + BSO
Pathological Indications corpus) per vagina For vulvectomy
Lines +Removal of pelvic
2-Family Hx of e' extreme obesity -Pelvic lymphadenectomy 2 groin incisions  peritoneum
ovarian cancer. TAH + BSO + HRT or prolapse by laparoscopy. For groin dissection +Removal of bladder or
3-Patient is > 45 y Indications Disadvantages  Werthiem 's rectum if affected
1-Recurrent dse.
Indication
4-Injured during BSO &exploration are hysterectomy the routine  Debulking
2-Severe
operation difficult Indication I – IIa operation nowadays operation
 Myomectomy endometriosis  Laparscopic [Cytoreductive surgery]
Principles  Wide Local
See Later 3-No response to assisted vag.
[Abd. Radical hysterectomy] excision e' Indication III & IV
medical ttt hysterectomy
Alternatives TAH + BSO+ ……… safety margin Technique
4- Patient completed -Established in certain ‫وتشرح بالتفصيل من الجدول التالي‬
UAE [Uterine ar ‫وتشرح بالتفصيل من الجدول التالي‬ Technique
her family centers e' needed
Embolization]  Pelvic exenteration Local excision e'
experience  2nd look
Indication Stage IVa safety margin
By Material Gel Foam
Combined Surgery 1cm laterally laparotomy

Local uterine resection.

Relatively effective but Types
need experience &have & Hormonal therapy & down to inferior Indication
long term S/E -Make Surgery Ant. Post. Total fascia in depth If No clinical evidence of
Easier Wertheim's operation dse & -ve Tm markers
Laparoscopic
-Control residual ‫وتشرح بالتفصيل من الجدول التالي‬ after Completion of
occlusion of lesions
Indication
 Schauta operation chemotherapy
Uterine ar -Improve Results Stage I
By Staples or Clips Indications Technique
using Laparoscope cancer Cx +prolapse -Laparotomy
Relatively effective but -Laparoscopy
Principles
need more research
vaginal Radical hysterectomy
`
 Operations
Radical Debulking
Werthiem 's hysterectomy Pelvic exenteration Vulvectomy operation
[Bassett's operation] [Cytoreductive surgery]
Indicati

Cancer Cx Ovarian Cancer

ons

No place nowadays Stage III & IV

Stage I & IIa Stage IVa
TAH + BSO Types Butterfly incision Technique
+ removal of upper 1/3 of vagina remove whole vulva TAH + BSO
+ removal of parametrium Anterior Posterior Total e' wide safety margin +remove as much
Principle

+ pelvic lymphadenectomy Wertheim's operation

as you can from
+Cystectomy +removal of +Cystectomy +bilat. Groin dissection* affected organ
+Urinary rectum +removal of + mons veneris [omentectomy
diversion +colostomy. rectum + ant. part of perineum +remove rectum,
+wet colon, bladder, ….]
colostomy *Inguinal & femoral lymphadenectomy Optimal debulking
Tm residual ≤ 2 cm
1- Blood loss Complications
2- Febrile morbidity (infection) Early
Hge (1ry or reactionary)
3- Ureteric stricture Groin Wound infection & UTI Aims (benefits)
4- Fistula formation Necrosis & breakdown  response to
Complications

[Vesicovaginal & Ureterovaginal] Seroma formation postoperative chemo

Late & radio therapy
5- Pulmonary embolism Fistula formation giving best results
6- Intestinal obstruction (adhesions) Stress incontinence [Palliative surgery]
7- Bladder dysfunction (denervation) Chronic Leg Edema
Recurrent leg lymphangitis ↓ risk of infection
Disadvantages
 Relieve intestinal
Leaves Wide raw surface w' is
obst.
not closed & very Liable to
 Improve bladder
infection  High Morbidity &
& rectal functions
Mortality
Myomectomy for Myoma [Fibroid Tm]
Indications Types and Routes
Young patients (< 40 y) desiring pregnancy ⓐAbdominal
C/I
 Abdominal incision→
1-Patients > age 40
Pfannenstiel or midline sub umbilical (if myoma is large).
2- Large No of fibroids [So that leaving behind useless uterus]
 Temporary hemostasis
3-Suspicion of Mg
1- Temporary occlusion of Uterine Ar at level of internal os By
4-Cx fibroid
-Rubber tourniquet (less traumatic) or
Advantages -Bonney's myomectomy clamp (more traumatic)
only the myoma is removed  So uterus is preserved 2- Myometrial injection of Pitressin
Disadvantages  Uterine incision:
1-Higher mortality than Hysterectomy 1- Vertical, midline & in anterior uterine wall.
d2 Higher risk of bleeding 2- Allows removal of maximum No of myomas by tunneling technique.
2-Pelvic adhesions esp. in Post. Wall incision  Infertility
 Removal of myomas followed by obliteration of Tm bed
3- Rupture of uterine scar in subsequent pregnancy
Posterior wall myoma is removed by:
4- Recurrent fibroid
1- Bonney's Hood operation
Timing Transverse fundal incision  enucleate myoma flap is pulled forward & sutured
1-Postmenstrual [to bleeding] anteriorly.
2-Postpartum by 6 m' 2- Transcavitary incision.
Preoperative preparation 3- Posterior wall incision (better avoided as it causes adhesions)
Preoperative investigation e.g. CBC …..etc If submucous myoma is suspected  Uterine cavity is opened
ttt of anemia before surgery ⓑVaginal For fibroid in portiovaginalis of Cx
+ Blood should be available for transfusion
A written consent for hysterectomy 1- Polypectomy  For small cervical fibroid polyp.
If Uncontrollable bleeding occur 2- Morcellation (piece meal removal)  For large cervical fibroid polyp.
Preoperative 3- Enculeation  For interstitial fibroid in portiovaginalis
-GnRH analogues to  size of Myoma by 50% ⓒLaparoscopic myomectomy For subserous or Interstitial fibroid
-Rectal misoprostol to  intraoperative bleeding ⓓHysteroscopic Myomectomy For small submucous fibroid

How to  Blood loss during Myomectomy??

Preoperative
-Choice of time
-Correction of Anemia
-GnRH analogues
-Rectal misoprostol
Operative
-Temporary occlusion of Uterine Ar
-Myometrial injection of Pitressin
-Uterine incision should be vertical & Midline
Endometrial Ca Ovarian Cancer GTT
 Chemotherapy
a) For epithelial Tm ttt of choice as it preserves fertility
 Adriamycin
Single agent chemotherapy Single agent chemotherapy
 Cisplatin D.O.C  Melphalan [Alkylating agent]
0.2mg/kg/day for 5 d' /28 days  Methotrexate [MTX] MC used
Others  Mech. of Action
 Carboplatin Cisplatin, carboplatin, paclitaxel, doxorubicin, Folic acid antagonists -- DHF* reductase enz.
Cyclophosphamide Required for conversion folic acid into folinic acid
arrested synthesis of DNA, RNA & protein
Combination chemotherapy Dose
PT (cisplatin +paclitaxel) -1mg/kg body wt for 5 d' course
-Courses are repeated every other wk
P Platinol [Trade Name] =Cisplatin [Repeat courses till hCG is –ve and then add 3 courses
T Taxol [Trade Name] = paclitaxel after -ve titre]
S/E
CT (carboplatin +paclitaxel) Alopecia
PAC (cisplatin +doxorubicin +Cyclophosphamide) BM suppression  [ PLt, WBCs, RBCs]
Hepatoxicity &Nephrotoxicity
b) For germ cell Tm Ulcerations of mouth & GIT Nausea vomiting &
BEP (Bleomycin + Etoposide + cisplatin) diarrhea
VBP (vinblastine + bleomycin + cisplatin) [stop drug if WBCs < 3000, PLts < 100x103, impaired
VAC (Vincristine +actinomycin D, liver & kidney functions]
Cyclophosphamide) * dihydrofolate
 Actinomycin-D
ABx that intercalates DNA strands
Effective as a single agent in non-metastatic GTT
 Other Chemotherapeutics
Cyclophosphamide, Vincristine, etoposide
Combined regimens:
 M-EA MTX + Etoposide or Actinomycin-D
 EMA-C  Etoposide + MTX + Actinomycin-D +
Cyclophosphamide or Vincristine.
 Uterus Cancer
Ovarian Cancer
Endometrial Ca Cancer Cx Vulva
 Radiotherapy
 Vaginal cuff irradiation Indications 
6000-7000 cGY
Main Line of ttt
In Stage II to shrink
-Indications Stage Ia G3 or Ib G1,2 Mech. of action Tm To facilitate surgery
 Whole pelvic irradiation
-Cytolethal action  kill resting cells [to prevent sphincteric
-arrest the mitotic cell  disintegration disruption]
5000-5500 cGY
-Sloughing & endarteritis obliterans in Tm bed
-Indications  Stage Ib G3, II & IVa Bl supply
 Extended field irradiation Postoperative in case
Advantages of residual Tm
4500-5000 cGY
Easy & non-invasive (or surgery) Immunotherapy
-Indications  Stage IIIb & IIIc Higher 5y survival than surgery
 Whole abdominal irradiation Nonspecific →
The only line in advanced cases or when surgery  Recurrent Tm
3000 cGY -BCG or
is C/I [Surgery is preferred]
-Indications  Stage IVb -Corynebacterium
Indications 
parvum.
All stages [whether alone or preoperative or Any +ve LN >5mm or α-INF
postoperative] Extracapsular spread [SC or intraperitoneal]
C/I 
Young patient palliative ttt
[artificial menopause + narrow vagina]
Radioresistant Tm e.g, adenocarcinoma
Available surgery with good 5y survival rate
>radiotherapy
Complicated cases e.g, pyometra
Advanced cases to UB & rectum
Recurrent cases
Associated pelvic pathology e.g,
PID, prolapsed, fibroid & ovarian cyst
 Cancer
Ovarian Cancer
Endometrial Ca Cancer Cx Vulva
Complications
1-Ovaries  artificial menopause
2-Vagina  narrowing
3-Pelvis  adhesions
4-Necrosis of:
GIT radiation sickness [persistent vomiting &diarrhea]
UB Hematuria & Vesico-vaginal fistula
Rectum  Bleeding/rectum
5-Others:
BM depression, pyrexia, erythema, scaly dermatitis & flaring up of
infection
Methods & dose of Radiotherapy:
Teletherapy [External irradiation]
To treat the regional LNs & to shrink Tm
5000 Rad in 5 w
Brachytherapy [Intracavitary or internal irradiation]
Affect the central Tm
-Techniques
Paris Single small dose for long time [5 d']  (not used now)
Stockholm High dose for short time [22-30 h']  (not used now)
Manchester at 2 points  (the best)
Extended field radiotherapy
Field extended to para-aortic LNs
Chemoradiation
Chemical substance making Mg cells more radiosensitive
Example Cisplatin [Become more popular Nowadays]

 Combined surgery & radiotherapy

As postoperative radiotherapy for patients e' LN mets & Paracervical
spread

 palliative ttt
e.g Painkiller, Hemostatic dose of radiotherapy, ….etc
 Endometrial Ca Cancer Vulva Ovarian Cancer GTT
● Schedule: ● Schedule: → ● Methods:
Every 3 m' for 1y then Every 6 m' for 2-3 y' then 1) Serum β-HCG
every 6 m' for 2y' then annually after that. every 1m' for 6m' then
every y' for 4 & 5y' ● Recurrent cancer vulva every 2 m' for another 6 m'
In Each visit High risk cases for recurrence then twice yearly.
-Symptoms analysis 1) Cases è multifocal or 2) X-ray chest
-Signs by Vaginal, Rectal preinvasive dse Every 3 m' for 1 y' then twice yearly
Follow Up

& speculum examination 2) Cases è LNs mets 3) No Pregnancy

-if Finding are +ve Types For at least 1y' after 3 successive –ve
[US, CT & MRI]  Local recurrence HCG results
Repeat radical wide excision is often
successful
 Clinical recurrence in groin
 Distant recurrence
Usually treated e'
Empiric chemotherapy
Survival Rate by FIGO 5 y' survival Prognostic Scoring System
Classification: Stage I & II 80-100 %. (WHO 2000)
Stage 0 100 % Stage III a 30-40 %.
Stage I 90% Stage III b 20 %. Item 0 1 2 3
Stage II 80% Stage III c & IV 5% Age <39 >39
Stage III 50% Prognostic Factors
Bl gp A or B AB / B
Stage IV 15% Age
Duration 4-6 7-12 >12
younger women have better prognosis
Since last
<4
Carcinoma in Clitoris is Very Stage [Most important factor] preg m'
bad prognosis Histologic type:
Prognosis

Type of V. abortion Term

because …………. Clear cell carcinoma worse pregnancy Mole Preg.

prognosis HCG level <103 103-104 104-105 >105

Histologic grade No 0 1-3 4-8 >8
Biologic factor: Site Lung Spleen GIT CNS

Mets
Kidney Liver
Diploid Tm have longer survival rate Size 3-5cm
than aneuploid Tm <3 >5
Tm residual 5 y survival in Prior Single 2 or
Chemo More
-Microscopic residual 40-75 %
-Optimal debulking  30-40%
Score 0-6 = Low risk
-Suboptimal debulking < 5%
Score > 6 = High risk
Surgical performance
Ascites
 Fibroid
Recurrent Fibroid Classification ‫اكتبها هناك في‬
● Incidence: Metastatic GTT subdivided into
Commoner when myomectomy is done before 30 y' Low risk (good prognosis)
● Types: e' No any risk factor
 Anatomical recurrence  Symptomatic recurrence
Recurrence

(recurrent menorrhagia) High risk (poor prognosis) 

Incidence 5-10%
Causes 1-Growth of new fibroids
2-Incompelete removal
3-Missed submucous fibroid
during myomectomy
4-Missed small seedling fibroids.
3-5% Presence of any of the following risk factors
-Long duration: → Last pregnancy from > 4m'
1-Associated endometrial -Last pregnancy was term pregnancy.
hyperplasia -High pre-ttt HCG level
2-Subinvolution after [Serum β-HCG level > 40000 mIU/ml]
myomectomy -Liver or brain Mets.
-Significant prior chemotherapy.