SKDI

Tumor dan Keganasan pada Organ Genital

• Karsinoma serviks 2
• Karsinoma endometrium 1
• Karsinoma ovarium 1
• Teratoma ovarium (kista dermoid) 2
• Kista ovarium 2
• Koriokarsinoma 1
• Adenomiosis, mioma 1
 Cervical cancer

Dr.dr. Asep Sukohar, M.Kes

Department of Pharmacology and Therapy
Medical Faculty of Lampung university
 Introduction
• Cancer of the cervix is the most common
female genital cancer in developing countries
every year about 500,000 women , acquire
the disease and 75% are from frame
developing countries.
• About 300,000 women also die from the
disease annually and of these 75% are from
developing countries
• Finland which has an advanced population
based screening program has one of the
lowest rates in the world.
 Incidence
• 4-6 % of female genital cancers.

Age
• 40-50 years old
 Risk factors and aetiology
 Coitus at young age: <16 years old increased risk by 50%
 Number of sexual partners: 6 sexual partners or more increase risk by 14.2
folds.
 Smoking for> 12 years increase the risk by 12.7 folds.
 Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
 Poor uptake of screening program.
 Long term use of the contraceptive pill increase the risk due to increasing
exposure to seminal fluids.
 Barrier method decrease the risk (condan)
 Immuno suppresion risk increased with immuno suppressed renal transplant
patients and in HIV positive women.
 HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
 Low socioecomic class of
 Type of patient:

• Multiparous.
• Low socioeconomic class.
• Poor hygiene.
• Prostitutes.
• Low incidence in Muslims and Jews.
 Predisposing factors:
• Cervical dysplasia.
• (Cervical intraepithelial neoplasia)
• CIN III / CARCINOMA IN SITU
• THE LESION PROCEEDS THE INVASION BY 10-
12 YEARS
 Symptoms:
Early symptoms Late symptoms
- None. - Pain, leg oedema.
- Thin, watery, blood tinged - Urinary and rectal
vaginal discharge frequently symptoms
goes unrecognized by the dysuria
patient. haematuria
- Abnormal vaginal bleeding rectal bleeding
Intermenstrual constipation
Postcoital haemorrhoids
Perimenopausal - Uraemia
Postmenopausal
- Blood stained foul vaginal
discharge.
 Pathology type
• Squamous cell carcinoma- 90%.
• Adenocarcinoma- 10%.
 Types of growth
• Exophytic: is like cauliflower filling up the
vaginal vualt.
• Endophytic: it appears as hard mass with a
good deal of induration.
• Ulcerative: an ulcer in the cervix.
 DIAGNOSIS
1- History.
• Many women are a symptomatic .
• Presented with abnormal routine cx smear
• Complain of abnormal vaginal bleeding
• post coital bleeding
• perimenopausal bleeding
• postmenopausal bleeding
• blood stain vaginal discharge
2- Examination:
• Mainly vaginal examination using cuscu’s
speculem nothing is found in early stage .
• Mass ,ulcerating fungating in the cervix
• P/V P/R is very helful.
Cytology Histology

calposcopy
 Preoperative evaluation
• Review her history.
• General examination:
o Anaemia.
o Lymphadenopathy-Supraclavicular LN.
o Renal area.
o Liver or any palpable mass.
o Oedema.
• Laboratory tests:
o CBC, LFT, RFT, Urine analysis.
o Tumour markers.
o Chest X- ray, abdominal X- ray, IVU.
o CAT, MRI, if necessary.
o Ultrasound.
o Lymphography, if necessary.
 Staging
Best to follow FIGO system.
• Examination under anaesthesia.
• Bimanual palpation.
• P/V, P/R.
• Cervical biopsy, uterine biopsy.
• Cystoscopy, Proctoscopy, if necessary.
 STAGES OF CANCER CERVIX

• Once cancer cervix is found (diagnosed), more

tests will be done to find out if the cancer cells
have spread to other parts of the body. This
testing is called staging.
• TO PLAN TREATMENT, A DOCTOR NEEDS TO
KNOW THE STAGE OF THE DISEASE.
cervical intraepithelial neoplasia ( CIN)
 SPREAD:
Direct Lymphatic Dissemination
(late)
- Uteruq. A- primary node: - parametrial spread
- Vagina. parametrial. causes obstruction of the
- Parametrium. Paracervical. ureters, many deaths occur
due to uraemia.
- Bladder and rectum. Vesicovaginal.
- Obstruction to the
Rectovaginal. cervical canal results in
Hypogastric. pyometria.
Obturator and external iliac

B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Inguinal.
 DIFFERENTIAL DIAGNOSIS
• Cervical ectropion.
• Cervical tuberculosis.
• Cervical syphilis, Schistosomiasis, and
Choriocarcinoma are rare causes.
 TREATMENT
• Surgical.
• Radiotherapy.
• Radiotherapy & Surgery.
• Radiotherapy and Chemotherapy followed by
Surgery.
• Palliative treatment.
Drugs Approved to Prevent Cervical Cancer
Cervarix (Recombinant HPV Bivalent Vaccine)
Gardasil (Recombinant HPV Quadrivalent Vaccine)
Gardasil 9 (Recombinant HPV Nonavalent Vaccine)
Recombinant Human Papillomavirus (HPV) Bivalent Vaccine
Recombinant Human Papillomavirus (HPV) Nonavalent Vaccine
Recombinant Human Papillomavirus (HPV) Quadrivalent Vaccine
Drugs Approved to Treat Cervical Cancer
Avastin (Bevacizumab)
Bevacizumab
Blenoxane (Bleomycin)
Bleomycin
Cisplatin
Hycamtin (Topotecan Hydrochloride)
Platinol (Cisplatin)
Platinol-AQ (Cisplatin)
Topotecan Hydrochloride
Drug Combinations Used in Cervical Cancer
Gemcitabine-Cisplatin

NCI (National Cancer Institute)

 The choice of treatment will depend on

• Fitness of the patients

• Age of the patients
• Stage of disease.
• Type of lesion
• Experience and the resources avalible.
 Surgical procedure
• The classic surgical procedure is the
wertheim’s hystrectomy for stage Ib,IIa, and
some cases of IIb in young and fat patient
 Werthemeim’s hystrectomy
• Total abdominal hystrectomy including the
parametrium.
• Pelvic lymphadenectomy
• 3 cm vaginal cuff
• The original operation conserved the ovaries
,since squamouss cell carcinoma does not
spread dirctly to the ovaries.
• Oophorectomy should be performed in cases
of adenocarcinoma as there is 5-10% of
ovarian metastosis
 Surgery offers several advantage
• It allows presentation of the ovaries
(radiotherapy will destroythem).
• There is better chance of preserving sexual
function.
• vaginal stonosis occur in up 85% of irradiates.
• Psychological feeling of removing the disease
from the body .
• More accute staging and prognsis
 COMPLICATIONS OF SURGERY
• Haemorrhage: primary or secondary.
• Injury to the bladder, uerters.
• Bladder dysfunction.
• Fistula.
• Lymphocele.
• Shortening of the vagina.
INDICATIONS OF P/O XRT FOLLOWING
WERTHEIM’S HYSTERECTOMY (STAGE I , IIa):
• Positive pelvic lymph nodes.
• Tumour close to resection margins and/or
parametrial extension.
 Radiotherapy
• Stage IIb and III
• Radical Radiotherapy
• External irradiation (Teletherapy).
• Intracavitary radiation (Brachytherapy).
• In some cases of stage IIa or b radio and
chemotherapy to be given then followed by
simple hysterectomy -------
 Palliative therapy
• For stage IV – individualized therapy.
• Some suitable for extensive surgery.
• Some suitable for chemotherapy.
• Good nursing care.
• Analgesia-must be used in sufficient amount to ----- pain (Codein
sulfate, Pethidine, Morphine, Diamorphine).
• Antiemetic if necessary.
• IV drip, entral, and parentral feeding.
• Urinary Catheterization.
• Other measures for symptom relief.
 PROGNOSIS
Depends on:
• Age of the patient.
• Fitness of the patient.
• Stage of the disease.
• Type of the tumour.
• Adequacy of treatment.
THE OVERALL 5 YEARS SURVIVAL FOLLOWING
THERAPY:
• Stage I -------80%
• Stage II-------50-60%
• Stage III-------30-40%
• Stage IV-------4%
 Follow up policy
• No hysterectomy- Cycloprogyn 1mg daily.
• The patient to be seen 1/12 post-treatment.
• 3 monthly for 2 years.
• 4 monthly for 3rd year.
• 6 monthly until 5years.
• Then yearly all her life.
• Patients with stage I and II disease treated with radical
radiotherapy will be assessed by EUA approximately 3
months after completing treatment.
Endometrial Cancer
Dr.dr. Asep Sukohar, M.Kes
GENERAL OVERVIEW OF GYNECOLOGIC
CANCERS

• 79,480 new cases/yr of female genital system

cancers in the U.S.
• 28,910 deaths in U.S. from genital system cancers
in 2005
• Diet, exercise and lifestyle choices play important
roles in the prevention of cancer
• Knowledge of family history also increases
prevention and early diagnosis rates
• Regular screening and self-examinations for
appropriate cancers  early detection early
intervention & therapy
 Endometrial Cancer

• Strong association with excess

weight
 Adipose tissue: Consequences of Obesity
on Cancer Development
Obesity has been implicated in the development of
• Type 2 diabetes
• Heart disease
• Stroke
• Hypertension
• Gallbladder disease
• Osteoarthritis
• Sleep apnea
• Asthma
• Psychological disorders or difficulties
• Some cancers, including ovarian, cervical, breast,
and endometrial
• Dyslipidemia
• Complications of pregnancy
• Hirsuitism
• Menstrual abnormalities
• Stress incontinence
• Increased surgical risk
 ENDOMETRIAL CANCER

• Cancer of the uterine endometrial lining

• Most common female reproductive cancer
– 40,000 new cases/year
– 7,000 deaths/year
• Most of these malignancies are
adenocarcinoma
 Incidence and Prevalence
• Most common gynecologic cancer
• 4th most common in women (US)
• 2nd most common in women (UK)
• 5th most common in women (worldwide)
• Western developed > Southeast Asia
• Increase in the 1970’s
– Increased use of menopausal estrogen therapy
 RISK FACTORS FOR ENDOMETRIAL
CANCER
• Early menarche
(<age 12)
• Late menopause
(>age 52)
• Infertility or nulliparous
• Obesity
• Treatment with tamoxifen
for breast cancer
• Estrogen replacement
therapy (ERT) after
menopause
• Diet high in animal fat
• Diabetes
• Age greater than 40
• Caucasian women
• Family history of
endometrial cancer or
hereditary nonpolyposis
colon cancer (HNPCC)
• Personal history of breast
or ovarian cancer
• Prior radiation therapy for
pelvic cancer
 Endometrial Carcinoma
Etiology
• Unnoposed estrogen
hypothesis: exposure to
unopposed estrogens
Pathology
• Spreads through uterus,
fallopian tubes, ovaries and
out into peritoneal cavity
– Metastasizes via blood and
lymphatic system
 SYMPTOMS OF
ENDOMETRIAL CANCER
• Symptoms
– Non-menstrual bleeding or discharge
• Especially post-menopausal bleeding
– Heavy bleeding
– Dysuria
– Pain during intercourse
– Pain and/or mass in pelvic area
– Weight loss
– Back pain
 ENDOMETRIAL CANCER

• Diagnosis • Treatment
– Pelvic examination – Surgery
– Pap smear (detect cancer spread • Hysterectomy
to cervix)
• Salpingo-oophorectomy
– Endometrial biopsy
• Pelvic lymph node
– Dilation and curettage dissection
– Transvaginal ultrasound • Laparoscopic lymph node
sampling
– Radiation therapy
– Chemotherapy
– Hormone therapy
• Progesterone
• Tamoxifen
 Endometrial hyperplasia
• Overgrowth of the glandular epithelium of the
endometrial lining
• Usually occurs when a patient is exposed to
unopposed estrogen, either estrogenically or
because of anovulation
• Rates of neoplasm
– simple hyperplasia: 1%.
– complex hyperplasia with atypia: 30%
 Endometrial Hyperplasia
• Complex hyperplasia with atypia
– One study found incidence of concomitant
endometrial cancer in 40% of cases
– Hysterectomy or high dose progestin tx
• Simple
– Often regress spontaneously
– Progestin treatment used for treating bleeding
may help in treating hyperplasia as well
• Estrogen dependent disease
– Prolonged exposure without the balancing effects
of progesterone
• Premalignant potential
– Endometrial hyperplasia
– Simple => 1%
– Complex => 3%
– Simple with atypia => 8%
– Complex with atypia => 29%
 Reduced Risk
• Oral Contraceptives
– Combined OC => 50% reduced rate
– Actual reduction number small because uncommon in
women of child bearing age
– Long term offers protection
– Reduced risk presumably => progesterone
• Tobacco Smoking
– Some evidence that it reduces the rate
– Smokers have lower levels of estrogen and lower rate
of obesity
 Prevention and Survival
• Early detection is best prevention
• Treating precancerous hyperplasia
– Hormones (progestin)
– Hysterectomy
– 10 ~ 30% untreated develop into cancer
• Average 5 year survival
– Stage I => 72 ~ 90%
– Stage II=> 56 ~ 60%
– Stage III => 32 ~ 40%
– Stage IV => 5 ~ 11%
 Potentially modifiable risk factors

Dietary factors
Isoflavones:
Phytoestrogens that have
properties similar to
selective estrogen
receptor modulators

Soy, beans, chick peas…

 Dietary fiber
Increases estrogen
excretion and decreases
estrogen reuptake:
whole grains,
vegetables, fruits, and
seaweeds
 Treatment
Hyperplasia without atypia
• Cyclic gestagen treatment is recommended for pre -
menopausal women who have hyperplasia without
atypia.
• For postmenopausal women who have hyperplasia
without atypia, surgical extirpation with
hysterectomy and bilateral adnexal removal can be
considered, in the light of the patient’s estimated
individual risk
 Hyperplasia with atypia
• For women who have hyperplasia with atypia
and are postmenopausal, or are
premenopausal but do not plan to bear any
more children, hysterectomy with adnexal
removal is urgentl recommended, in view of
these patients’ estimated 30% risk of
developing an invasive carcinoma.
 Invasive carcinoma

• Even some women with invasive carcinoma can

be offered the option of a trial of conservative
treatment, if they are premenopausal and still
wish to bear children, and if the histological
finding is of a well-differentiated carcinoma
(grade I) without suspicion of myometrial
invasion
 Surgical treatment
• Patients with tumor stage IA and grade 1 or 2
are unlikely to have lymph node involvement,
and their prognosis is usually very good
 Summary points
• Endometrial cancer is one of the leading
gynecological cancers in the US
• Obesity is one of the key factors involved in
Endometrial cancer development
• More research is needed to explore
modifiable risk factors in endometrial cancer
development