1. Malignant disease of vulva Prepared by: Mrs Raheegeh Awni 12/02/2011

2. VULVAL MALIGNANCIES

3. Primary malignancies of the vulva account for about 3–4 per cent of
malignant tumours of the female genital tract.
They occur predominantly in elderly women, but there is a wide age range.
It is a highly curable disease in the early stages

4. Malignant tumors of the vulva are uncommon, representing about 4% of malignancies of the female genital tract.
Most tumors are squamous cell carcinomas, with melanomas, adenocarcinomas, basal cell carcinomas, and sarcomas occurring much less frequently.

6. Clinical presentation and symptoms
There is often a delay in presentation because of patient embarrassment,
or failure of the initial physician to adequately examine the
vulva. The patient most commonly complains of pruritus, bleeding
or a lump. Other symptoms may include pain, discharge or dysuria.

7. Physical examination
Red or white macule, papule or plaque
mass or ulcer
Nodule, lump or blue/black lesion of melanoma, predominantly
on labia majora and clitoris
Granular, red moist eczematous area of Paget’s disease, found predominantly on labia majora, but can extensively involve other areas too, including extension onto abdomen and thighs
Palpable inguinal or femoral lymph nodes may indicate metasis

8. Diagnosis
A tissue biopsy is required to confirm malignancy, and to identify the histological type of tumour.
Any pigmented skin lesion should be excised with a 1–2cm margin.
Punch biopsies should not be done for pigmented lesions
– if the lesion turns out to be a melanoma, it will be impossible to accurately determine the tumour thickness.
Post-biopsy wound repair changes will distort the lesion.

9. Lymph node drainage
The anterior labia majora and minora and clitoris drain into the
superficial and deep femoral nodes and inguinal nodes,
These eventually drain into the external iliac nodes.
Involvement of the pelvic nodes by vulval
malignancies is considered distant metastases in the staging
classification.
The midline vulval structures often drain bilaterally.
Anastomotic channels mean that there is some lymph drainage to contralateral pelvic nodes.

10. Pathology
As in the vagina and cervix, most of the tumours (about 90 per cent) are squamous cell carcinomas. Melanomas are the second most
common malignancy. Basal cell carcinomas and Paget’s disease
each account for about 2 per cent. Other tumours such as sarcomas and unusual subtypes of carcinomas are quite rare.

11. etiologic types of vulvar cancer
One type is seen mainly in younger patients,
is related to human papillomavirus infection
and smoking,
and is commonly associated with vulvar intraepithelial neoplasia (VIN) of the basaloid or warty type.

12. The more common other type is seen mainly in elderly women and is unrelated to smoking or human papillomavirus (HPV) infection; concurrent VIN is uncommon. When VIN is present, it is of the differentiated type. VIN III appears to carry a significant risk of progression to invasive cancer if left untreated.

13. VULVAR NEOPLASMS

14. 1- INTRAEPITHELIAL NEOPLASIA : The International Society for the Study of Vulvar Disease recognizes two varieties of intraepithelial neoplasia: squamous cell carcinoma in situ (Bowen's disease) or VIN III, and Paget's disease.

16. 2- Squamous cell carcinoma: of the vulva occurs mainly in postmenopausal women, and the mean age at diagnosis is 65 years.
A history of chronic vulvar itching is common

17. Squamous Cell Carcinoma In Situ: VIN III During the last 25 years, the incidence of VIN has increased.
Younger patients are being affected, and the mean age is approximately 45 years.

19. Clinical Features Itching
palpable or visible abnormalities of the vulva.
Approximately half of the patients are asymptomatic.
Most lesions are elevated, but the color may be white, red, pink, gray, or brown
"warty" appearance, and the lesions are multicentric.

20. Diagnosis Careful
Inspection of the vulva in a bright light, with the aid of a magnifying glass
Colposcopic examination

22. Management local superficial surgical excision, with primary closure.
The microscopic disease seldom extends significantly beyond the colposcopic lesion, so margins of about 5 mm are usually adequate.
For extensive lesions involving most of the vulva, a "skinning" vulvectomy, in which the vulvar skin is removed and replaced by a split-thickness skin graft, may be used.
Laser therapy is also effective, particularly for multiple small lesions, or for lesions involving the clitoris, labia minora, or perianal area
No specimen is available for histologic study after laser ablation, so a liberal number of biopsies must be taken before treatment to exclude invasive cancer.

23. PAGET'S DISEASE Paget's disease of the vulva predominantly affects postmenopausal white women.
Paget's disease also occurs in the nipple areas of the breast

24. INVASIVE VULVAR CANCER

25. SQUAMOUS CELL CARCINOMA
Squamous cell carcinoma accounts for about 90% of vulvar cancers.

26. Clinical Features vulvar lump, long-standing pruritus is common.
The lesions may be raised, ulcerated, pigmented, or warty in appearance,

27. definitive diagnosis
requires biopsy under local anesthesia. Most lesions occur on the labia majora; the labia minora are the next most common sites.
Less commonly, the clitoris or the perineum is involved
Approximately 5% of cases are multifocal.

28. Methods of Spread
Vulvar cancer spreads by direct extension to adjacent structures, such as the vagina, urethra, and anus; by lymphatic embolization to regional lymph nodes; and by hematogenous spread to distant sites, including the lungs, liver, and bone.
In most cases, the initial lymphatic metastases are to the inguinal lymph nodes
From these superficial nodes, spread occurs to the femoral nodes located medial to the femoral vein.

29. The incidence of lymph node metastases in vulvar cancer is approximately 30%. It is related to the size of the lesion
Approximately 5% of patients have metastases to pelvic lymph nodes.
Hematogenous spread usually occurs late in the disease and rarely occurs in the absence of lymphatic metastases.

30. Management
radical vulvectomy and bilateral inguinofemoral lymphadenectomy, with or without pelvic lymphadenectomy, has been considered the standard treatment for invasive vulvar cancer.
conservative approach has been used for the primary lesion, and the groin dissection has frequently been performed through a separate groin incision.

31. Staging In 1989, the International Federation of Gynecology and Obstetrics (FIGO) Cancer Committee introduced a surgical staging system for vulvar cancer.

32. Stage 0: Carcinoma in situ, intraepithelial carcinoma
StageI: Tumor confined to the vulva or perineum, or both, and 2 cm or less in greatest dimension; no nodal metastasis
  Stage Ia : As above with stromal invasion ≤1 mm 
 Stage IbAs: above with stromal invasion >1 mm

33. StageIITumor: confined to the vulva or perineum, or both, and more than 2 cm in greatest dimension; no nodal metastasis
StageIII: Tumor o fanysizewith:
Adjacent spread to the urethra and/or vagina, and/or the anus.
Unilateral regional lymph node metastasis, or a combination

34. Stage IVa: Tumor invades any of the following: upper urethra, bladder mucosa, rectal mucosa, pelvic bone or bilateral regional node metastasis, or a combination
  Stage IVb: Any distant metastasis including pelvic lymph nodes

35. Management In the past, en bloc radical vulvectomy and bilateral inguinofemoral lymphadenectomy, with or without pelvic lymphadenectomy, has been considered the standard treatment for invasive vulvar cancer. During the past 25 years a more conservative approach has been used for the primary lesion, and the groin dissection has frequently been performed through a separate groin incision.

36. MALIGNANT MELANOMA is the second most common type of vulvar cancer.
Melanomas may arise from a preexisting junctional or compound nevus.
They occur predominantly in postmenopausal white women and most commonly involve the labia minora or clitoris

38. Management
radical local excision alone, with margins of at least 1 cm, is adequate therapy.
For lesions with ≥1 mm invasion, radical local excision of the primary tumor is usually combined with at least inguinal-femoral lymphadenectomy.
Adjuvant therapy chemotherapeutic agents has been disappointing,

39. Prognosis
The overall 5-year survival rate for vulvar melanomas is approximately 30%,

40. BARTHOLIN'S GLAND CARCINOMA
Adenocarcinomas, squamous cell carcinomas, and rarely, transitional cell carcinomas may arise from the Bartholin's gland and its duct.

41. General principles of treatment of carcinomas
The standard treatments are surgery, often supplemented with external beam radiation therapy (EBRT) for advanced stages.
There is a trend towards vulval conservation,
Preoperative chemoradiation is evolving. FIGO has produced clinical guidelines for the management of vulval cancers.
A groin node dissection should be performed if the tumour is more than 1mm deep.
The status of the inguinal nodes will determine treatment to
the pelvis.

42. Sarcomas Sarcomas of the vulva are rare. They are smooth muscle tumour
leiomyosarcoma is the most common.
Wide resection is the treatment for most sarcomas.
Chemoradiation may play a role depending on tumour type.

43. VAGINAL MALIGNANCIES
Vaginal primary malignancies account for only 1–2 per cent of malignant tumours of the female genital tract.
Most tumours of the vagina are secondary, usually involving the vagina by direct extension from another site such as the cervix or vulva.

44. Clinical presentation and symptoms
An abnormal vaginal cytology smear may be the only indicator of vaginal disease.
Abnormal vaginal bleeding is the most common symptom of vaginal malignancy.
discharge, Dysuria, tenesmus and constipation may signal bladder or rectal
involvement.

45. Diagnosis A tissue biopsy
A cervical and vulval primary tumour should be ruled out. Multiple biopsies of the cervix are indicated
to rule out a primary tumour of that site which has extended into the vagina.

46. Management
Local excision is the best treatment in older women with unifocal disease.
Laser treatment has revolutionised the management of multifocal lesions in young women.
This avoids extensive and disfiguring surgery.

47. VULVAL CARCINOMA
An active approach to the diagnosis and management of vulval lesions may prevent development of cancer in women.

48. Treatment of VIN significantly reduces the risk of cancer development.
Superpotent topical corticosteroids may reduce the small
risk of cancer developing in lichen sclerosus.
VIN-related carcinoma
has increased significantly in young women recently.
a long history of antecedent symptoms such as pruritus
abnormal skin adjacent to a vulval malignancy, This, therefore, ought to be subject to biopsy.
Therefore if a visible lesion is present referral should be made to a specialist.

49. Women should be encouraged to self-examine the vulva with a
mirror.
In addition, symptoms of vulval disease of altered sensation
such as pruritus, irritation, rawness and soreness (vulval irritation)
should be taken note of and any aberrant skin appearances biopsied
Cigarette smoking and multiple lower genital tract neoplasia is
significantly more common in women younger than 50 years of age.

50. Vulvectomy
This is a historical operation except in the context of cancer
Women with vulval
carcinoma arising in VIN 3 should have radical local excision of the malignancy and a bilateral lymphadenectomy.
For a unilateral lesion a unilateral lymphadenectomy is performed.

51. Simple vulvectomy does not require a skin graft.
Normally in both conditions disease does not usually extend beyond
the midline of the labia majora. Very occasionally lichen sclerosus
can extend onto the inner thigh and buttocks.

52. CERVICAL MALIGNANCIES

53. The world’s most common malignancy in women is declining in incidence, as a result of cervical screening programmes.
Earlier detection and treatment of cervical cancer has reduced mortality by over 50 percent.

54. Clinical presentation and symptoms
An abnormal cervical cytology smear (Pap smear) may be the only
for the more common squamous lesions than glandular lesions.
Common early symptoms include:
Abnormal vaginal bleeding (postcoital, intermenstrual, postmenopausal
or menorrhagia)
Vaginal discharge, malodorous.
bleeding may result in anaemia.
Dysuria, severe and complete constipation and rectal bleeding may
signal bladder or rectal involvement.
Renal obstruction may cause pain and lead to and renal failure.
Abdominal or leg pain may be secondary to lymphadenopathy.

56. Physical examination
Pelvic examination may show an obvious cervical abnormality, such as ulceration or exophytic mass.
Extensive involvement of the endocervix may result in an enlarged barrel-shaped cervix.
A pelvic mass may be palpated.
General examination may reveal evidence of metastases, perhaps as an abdominal mass due to para-aortic lymphadenopathy,
There may be signs of uraemia, anaemia or jaundice.

57. Diagnosis
A tissue biopsy is required to confirm malignancy (even though a cervical smear may show malignant cells), and to identify the histological type of tumour.
Endocervical curettage (ECC) should be
done as well, to detect any lesions that may be in the endocervical canal.

58. Pathology
Most cervical cancers are squamous cell carcinomas (over 80 percent), but adenocarcinomas are increasing in incidence cent).
Non-epithelial tumours such as sarcomas
( connective tissue) , melanomas and lymphomas are rare.

59. 1- Squamous (epidermoid) neoplasias
Squamous cancers arise from dysplastic squamous epithelium
Over 85 per cent of cervical squamous cancers are caused by
sexually transmitted virus human papillomavirus (HPV).
The three major associated risk factors are:
1- early age at first intercourse,
2- multiple sexual partners,
3- a male partner with multiple previous sexual partners.

60. Other Factors as:
oral contraceptive use, cigarette smoking, parity,
family history, and associated genital infections .
Immunosuppressed patients (e.g. transplant or AIDS patients) are also at increased
Risk in invasive carcinoma,

61. The lesion has acquired the potential to metastasise and is
regarded as malignant.
The tumour may be microinvasive (superficially invasive) or frankly invasive.
Microinvasive tumours occur in a younger age group than the
frankly invasive tumours (43 versus 51 years old),
Colposcopically the lesion resembles a squamous intraepithelial lesion (SIL).
The tumour may qualify as microinvasive if:
The tumour is not clinically apparent.
Using FIGO rules, the maximum depth is no greater than 5mm, and the maximum width is no greater than 7mm.

62. The entire tumour must be removed before accurate measurements can be made;
If microinvasion is diagnosed in a cone,
then the margins must be clear of high grade squamous intraepithelial lesion (HSIL) as well as invasive tumour.
Lymph node metastasis, tumour recurrence and death all correlate directly with depth of invasion.

63. 2- Glandular neoplasias
Adenocarcinoma in situ
Adenocarcinoma in situ (AIS) is the precursor to most invasive
adenocarcinomas.
Skip lesions are not uncommon, and a negative resection margin of a cone does not assure removal of the lesion.
Over one third of these patients with a negative margin may have
residual AIS or invasive adenocarcinoma.
However, Goldstein and Mani in a study of 61 patients found that if the resection margin in a cone was clear of AIS by at least 10 mm, then none of the patients had residual AIS in the subsequent hysterectomy specimen.

65. 1- Invasive adenocarcinoma
Most adenocarcinomas arise from the endocervical glands.
There is a high frequency (over 80 per cent) of HPV infection (types
18 as well as 16)
Most recent studies indicate that prognosis for typical adenocarcinomas
is no worse than for squamous cancer.
Types of invasive adenocarcinoma are:
(1) Mucinous adenocarcinoma
(a) Endocervical type – most common
(b) Also signet ring and intestinal types
(2) Endometrioid adenocarcinoma
(a) May be even more common than the endocervical type
(b) Located higher up in the endocervical canal
(3) Clear cell carcinoma – most have been in young women with

66. 2- Adenosquamous
This has both adenocarcinoma and squamous carcinoma components.
It is often associated with pregnancy.
Some but not all investigators have believed it has a worse prognosis.

67. 3- Small cell undifferentiated carcinoma
This is a neuroendocrine tumour, not to be confused with the
small cell type of squamous cancer; similar to oat cell carcinoma of
the lung.
Neuroendocrine tumor refers to the type of cell that a tumor grows from rather than where that tumor is located
HPV 18 is present in most.
It is an infiltrative lesion.
It is very aggressive, producing distant metastases in 80–90 per cent.
It is very radiosensitive and chemosensitive.
Staging should include a bone marrow biopsy.

68. Spread and metastasis
Cervical cancers spread directly into the vaginal fornix, up
into uterus, parametrial and paracervical tissues, the pelvic wall,
and then to other pelvic structures such as the bladder or
rectum.
Lymphatic spread involves hypogastric, external iliac and sacral
nodes, and then common iliac, inguinal and para-aortic nodes.
Haematogenous spread is uncommon, and occurs late in the
course of the disease.
This is usually to lung, liver and bone.

69. General principles of treating cervical cancer
Surgery and radiation therapy are equally effective in treating early stage, small volume tumours.
Surgery is the treatment of choice for younger fit patients, if there is a low risk of nodal metastases
Surgical staging is the most accurate way of determining disease extent.
Surgery alone, without radiation, maintains vaginal anatomy and sexual function.

70. Postoperative radiotherapy after radical hysterectomy is indicated for those at high risk of local recurrence:
Lymphovascular space invasion
Deep cervical invasion to outer third
Positive or close (<3mm) surgical resection margins
Parametrial involvement
Positive pelvic or para-aortic lymph node metastases.

71. Radical hysterectomy and bilateral or Radical radiotherapy with 75–80% pelvic lymphadenectomy (plus platinum-based chemotherapy
postoperative radical radiotherapy as primary treatment if high risk factors for recurrence present.

72. OVARIAN MALIGNANCIES

73. OVARIAN MALIGNANCIES
The incidence of ovarian cancer is 9–17 per women per year.
The incidence is highest in industrialised countries except for Japan.

74. Ovarian cancer is the fifth most common cancer among females in the United States, accounting for one-fourth of all gynecologic cancers.
It is the leading cause of death from gynecologic cancer because it is difficult to detect before it disseminates
Most women with ovarian cancer are in the fifth or sixth decade of life.

75. Breast–ovarian cancer syndrome, linked to an inherited mutation
in the BRCA1 gene( ABNORMALBRCA1 BReast CAncer gene one)
Carriers of BRCA1 have a 50 per cent lifetime
risk of ovarian cancer.
(2) Site-specific ovarian cancer syndrome.
(3) Hereditary non-polyposis colorectal cancer (HNPCC) syndrome
(type II Lynch syndrome), which can include colon, breast, endometrial and prostate cancer in affected individuals and which is usually associated with a history of malignancy appearing before the age of 30.

76. Screening
No effective screening programme for the general population for the
identification of ovarian cancer has been established.
a combination of
the tumour marker CA125,
pelvic abdominal ultrasound
and pelvic examination have not produced an acceptable
Patients with a strong family history of ovarian,
endometrial, breast and colon cancers
Patients with these inherited cancers usually present about 10 years
earlier than the previous generation.
They may benefit from earlier screening, using CA125 markers and transvaginal ultrasound on a yearly basis,

77. Clinical presentation and symptoms
present late, at stage 3 or 4 at diagnosis.
Abdominal distention may be due to the tumour, ascites or both.
Respiratory symptoms may result from the increased intraabdominal pressure or transudation of fluid into the pleural cavity.
Abdominal discomfort.
Feeling of pressure in the pelvis.
Urinary or gastrointestinal tract symptoms.
Abnormal vaginal bleeding may be present, particularly if the
tumour has functional stroma.

78. stromal tumours. The most common oestrogen-associated tumours are mucinous and endometrioid carcinomas, and metastatic colorectalcancer.
Androgenic tumours are most commonly metastatic
Acute pain may result from torsion or rupture.
Rupture.

79. SIGNS The disease is frequently misdiagnosed
A solid, irregular, fixed pelvic mass is suggestive of ovarian cancer,
upper abdominal mass,
ascites,
or both, the diagnosis is almost certain.

80. STAGING (FIGO) Stage I : Growth limited to the ovaries.
  Stage Ia : Growth limited to one ovary; no ascites. No tumor on the external surface; capsule intact. 
 Stage Ib: Growth limited to both ovaries; no ascites. No tumor on the external surfaces; capsules intact. 
 Stage Ic: Tumor either stage Ia or Ib but with tumor on the surface of one or both ovaries or with capsule ruptured or with ascites present containing malignant cells or with positive peritoneal washings.

81. Stage II: Growth involving one or both ovaries with pelvic extension.
Stage IIa: Extension or metastases, or both, to the uterus or tubes, or both.  
Stage IIb: Extension to other pelvic tissues.
 Stage IIc: Tumor either stage IIa or IIb but with tumor on the surface of one or both ovaries or with capsule or capsules ruptured or with ascites present containing malignant cells or with positive peritoneal washings. 81

82. Stage III: Tumor involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal nodes, or both.
Superficial liver metastasis equals stage III.
Tumor is limited to the true pelvis, but with histologically proven malignant extension to small bowel or omentum

83.  Stage IIIa: Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces. 
 Stage IIIb: Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Nodes negative for disease. 
 Stage IIIc: Abdominal implants >2 cm in diameter or positive retroperitoneal or inguinal nodes, or both.

84. Stage IV: Growth involving one or both ovaries with distant metastasis
Stage IV: Growth involving one or both ovaries with distant metastasis. If pleural effusion is present, Parenchymal liver metastasis equals stage IV.

85. Management of early stage ovarian cancer
Patients with stage 1A grade tumours have a high rate of cure with surgery alone and do not require further adjuvant
therapy.
Patients with stages 1A and 1B or 1C tumours, as
well as those with clear cell tumours, should have adjuvant postoperative chemotherapy.
a platinum analogue, alone or in combination with paclitaxel.
radiotherapy

86. Management of advanced ovarian cancer
Seventy-five per cent of all women affected by epithelial ovarian
cancer are diagnosed at stage 3 or 4.
Medically fit women should have as much of the tumour removed as possible at laparotomy.
Maximal cytoreductive surgery.
The amount of residual disease at completion of primary surgery influences prognosis.
Postoperative chemotherapy,

87. Prognosis of ovarian carcinomas
Features that are independently associated with reduced survival are:
Advanced stage
High grade
Large volume of residual tumour after cytoreduction
Ascites
Rupture
Dense adhesion of tumour
High serum CA125 preoperatively and/or postoperatively.

88. CLASSIFICATION
These lesions fall into four categories according to their tissue of origin. Most ovarian neoplasms (80% to 85%) are derived from coelomic epithelium and are called epithelial carcinomas.
Less common tumors are derived from primitive germ cells, eg. gonadal stroma, or nonspecific mesenchyme.
In addition, the ovary can be the site of metastatic carcinomas, most often from the gastrointestinal tract or the breast.

89. 1- EPITHELIAL OVARIAN CARCINOMAS
subtypes of epithelial carcinomas are serous (about 40%), mucinous (about 25%), endometrioid (about 20%), and clear cell (about 5%).
Serous tumors resemble fallopian tube epithelium histologically
About 30% of patients with stage I and stage IIa disease have bilateral involvement.
On gross examination, serous carcinomas have an irregular and multilocular appearance

90. 2- GERM CELL TUMORS
Germ cell tumors of the ovary account for only about 2% to 3% of all ovarian malignancies.
They occur in young patients and frequently produce either human chorionic gonadotropin (hCG) or α-fetoprotein (AFP), which serve as tumor markers.

91. The most common germ cell tumors are the dysgerminoma and immature teratoma.
Endodermal sinus tumors, embryonal tumors, and nongestational choriocarcinomas are less common.
Mixed germ cell tumors are not uncommon.

92. 3- DYSGERMINOMAS
Dysgerminomas occur in children and young women. About 10% are bilateral.
These tumors are seen in patients with gonadal dysgenesis or the testicular feminization syndrome.
In such patients, the dysgerminoma may arise in a gonadoblastoma. In about two-thirds of patients, the disease is confined to the ovaries at the time of diagnosis.
About 10% of dysgerminomas are associated with other germ cell malignancies.

94. Prognosis
The 5-year survival rate for patients with stage Ia pure dysgerminoma treated with unilateral oophorectomy is about 95%, whereas it is 80% for stage II and 60% to 70% for stage III disease. Recurrences following conservative surgery have at least an 80% 5-year survival rate.

95. 4- IMMATURE TERATOMAS
Immature teratomas are the second most common malignant ovarian germ cell tumor.
About 75% of malignant teratomas are encountered during the first two decades of life.
Bilateral lesions are rare, although the other ovary may contain a benign dermoid cyst in about 5% of cases.
Like other germ cell tumors, immature teratomas grow fairly rapidly, cause pain

96. Pure immature teratomas do not produce hCG or AFP.
Neural elements are most frequently seen, but cartilage and epithelial tissues are also common.

97. Treatment The primary tumor should be removed.
In young patients, the uterus and contralateral ovary should be preserved to maintain fertility.
postoperative chemotherapy using bleomycin, etoposide, and cisplatin.
Prognosis Survival correlates with grade and stage of disease.
The 5-year survival rate for patients with grade 1 immature teratomas is about 95%,

98. FALLOPIAN TUBE MALIGNANCIES
Fallopian tube malignancies account for less than 0.3 per cent of
gynaecological malignancies.
The mean age of patients is 57 years.
The most common presenting symptoms are abnormal vaginal
bleeding and abdominal pain.
’Hydrops tubae profluens’ is a symptom complex occurring in
about 10 per cent.
It is characterised by intermittent colicky pain, relieved by a sudden vaginal discharge of watery fluid.
CA125 levels are often elevated.

100. The carcinomas affecting the tube are similar to those of the ovary.
Serous carcinoma is the most common (70 per cent), followed by endometrioid and transitional
These tumours are surgically staged
These tumours spread to the peritoneum, adjacent organs and para-aortic and pelvic lymph nodes.
Distant metastases are present
Treatment is as for ovarian cancers.

101. ENDOMETRIAL CARCINOMAS
Primary malignancies of the endometrium are the most common gynaecological malignancies, and account for 13 per cent of cancers
Almost one third of cases occur in premenopausal women, but most patients are over 40 years old.

102. Clinical presentation and symptoms
abnormal or postmenopausal vaginal bleeding
The risk of malignancy associated with bleeding increases with age
(asymptomatic women may present with abnormal endometrial cells on a cervical smear.

103. Diagnosis
Women with high risk factors such as abnormal uterine bleeding
over the age of 40,
massive obesity,
history of endometrial hyperplasia,
oestrogen or tamoxifen use may benefit from a variety of investigations

104. DX
Cervical smear
Transvaginal ultrasound – the cut-off for maximal normal endometrial thickness is 5 mm.
It is very rare for a malignancy to be thinner than 5mm, so this can be useful in ruling out malignancy
Biopsy obtained (D&C)
Hysteroscopy.

105. Spread and metastases
Invasion is into the myometrium, through serosa into parametria,
and late into the bladder or rectum.
There is lymphatic drainage into the pelvic and then the paraaortic
nodes.
There are pelvic metastases to the ovaries and vagina.
Spread downward into the cervix (stage 2 disease) is predictive of distant metastases.
Pulmonary metastases are seen as a late event.

106. Treatment of endometrial carcinomas
Abdominal hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy is the basic treatment for all stages.
Postoperative radiotherapy, no survival benefit was achieved when compared with
surgery alone.

107. Thank you