1. Precancer diseases of the female sexual organs. Female cancer.
N. Bahnij

2. Precancer cervical lesions
Cervical intraepithelial neoplasia (CIN)
Erythroplakia with atypia
Leukoplakia with atypia
Adenomatosis

3. Risk factors for cervical dysplasia
Human papillomavirus is a common virus that most women will be infected with at some time in their life.
smoking
multiple sexual partners
pregnancy before the age of 20
suffering from conditions that affect the immune system, like HIV

4. Layers of squamosus epithelium of cervix

5. CIN Classification
CIN I: Mild dysplasia; abnormal cells can be found in 1/3 of the lining of the cervix
CIN II: Moderate dysplasia; abnormal cells can be found in 2/3 of the lining of the cervix
CIN III: Severe dysplasia; abnormal cells can be found in more than 2/3 of the lining of the cervix and up to the full thickness of the lining

7. Diagnosis of cervical dysplasia
Speculum examination
PAP – smear
Processing of 3 % acetic acid of a cervix and revealing a white spot
Colposcopy
Cervical biopsy
Endocervical curettage
HPV - testing

8. Dysplasia is initially detected through a Pap smear

9. What is the thinnest and the more effected place of the cervix???

10. The smear should be taken from squamocolumnar junction – transition zone !

12. Types of PAP smears I – normal II a- inflammatory process
II b – mild dysplasia
III a - moderate dysplasia
III b – severe dysplasia
IV – carcinoma in situ
V – cancer
VI – smear is not informative

13. Frequency of Pap Smears
Begin no later than age 21.
If patient is sexually active - <21.
Once initiated, screening should be performed annually
After 30, for women who have had 3 consecutive, normal Pap smears, screening frequency may be reduced to every 3 years.
Screening may stop after total hysterectomy, >70 if the the patient is at low risk, and has had three consecutive normal Pap smears within the last 10 years.

14. Treatment for cervical dysplasia CIN1 – 70 % spontaneous regression
Treatment for cervical dysplasia CIN1 – 70 % spontaneous regression. CIN 2/3 lesions are usually surgically removed by: destruction (ablation) by carbon dioxide laser (photoablation) and cryocautery and removal (resection) by electrosurgical excision procedure (LEEP), cold knife conization.

15. 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

16. CERVICAL CARCINOMA 10 years from CIN III to cancer
Risk factors
Human Papillomavirus (HPV) Infection - (16, 18, 31, 33, 35 and 6 more)
Family History of Cervical Cancer
Age – 35-55
Sexual and Reproductive History
Socioeconomic Status
Smoking
HIV Infection
In Utero DES Exposure
Oral contraceptives
From initial infection to CIN III – 6 years

17. Types Squamous cell Carcinomas Cancer of flat epithelial cell
80% to 90%
Adenocarcinomas
Cancer from glandular
epithelium
10% - 20%
Mixed carcinoma
Features both types

18. Stages of Cervical Carcinoma

19. What are the symptoms of cervical cancer?
Abnormal bleeding
Between periods
With intercourse
After menopause
Unusual vaginal discharge
Other symptoms
Leg pain
Pelvic pain
Bleeding from the rectum or bladder
Some women have no symptoms
Usually women with cervical cancer have no symptoms, particularly if the cancer is small. The common symptoms of cervical cancer are:
Bleeding between periods
Bleeding or spotting after sexual intercourse
Bleeding or spotting in women who have already gone through menopause
Unusual, continuous, foul-smelling vaginal discharge
In women with more advanced cervical cancer additional symptoms may occur, such as:
Progressive and ultimately constant pelvic pain
One-sided leg pain caused by nerve involvement
A pelvic mass
Bleeding from the bladder or rectum.
It is not unusual for a woman with cervical cancer to have no symptoms. 19

20. Diagnosis Complaints Speculum examination. The cytological examination
HPV screening involves a Polymerase Chain Reaction (PCR)
Bimanual vaginal examination
Rectovaginal examination
Application of acetic acid and Colposcopy
Biopsy.

21. What should I do if I have just been diagnosed with cervical cancer?
Discuss treatment options
Conization
Hysterectomy
Radical trachelectomy
Surgical removal of the cervix and
upper vagina with the surrounding tissues.
uterine body remains
Radical hysterectomy
Radiation with chemotherapy
Ask about clinical trials (Gynecologic Oncology Group)
Other considerations
Preserve your fertility
Preserve your ovaries
There are many treatment options for cervical cancer. It all depends on how big it is, your medical history and your concerns for future fertility. You should discuss your treatment options with a gynecologic oncologist. 21

22. Cervical cancer: What is the chance of survival after treatment?
FIGO Stage
5-Year Survival
Stage I
81-96%
Stage II
65-87%
Stage III
35-50%
Stage IVA
15-20%
The survival rate five years after diagnosis varies depending upon the stage of cervical cancer. The risk increases with higher stages of disease. However, there are treatment options for everyone. 22

23. Vaccines

24. Who should get the vaccine?
The FDA has recommended the following groups of women get vaccinated:
Girls 11–12: Recommended Age Group (can be started as young as age 9).
Women 13–26: the benefit of the vaccine may be lower depending on prior HPV exposure.
The vaccine does not work to eliminate current HPV infections
The vaccine only prevents certain types of HPV infection 24

26. Endometrial cancer precursors
Endometrial hyperplasia - an overgrowth of the lining of the uterus, is a precursor to the development of cancer. Abnormal uterine bleeding is usually the first symptom

27. Risk Indicators for Endometrial Cancer and Precursors
  Age   60 years
Obesity (with upper body fat pattern)a
  Estrogen-only replacement therapy
Previous breast cancer
  Tamoxifen therapy for breast cancer
Chronic liver disease
Infertility
  Low parity
  Chronic anovulation (Polycystic ovarian disease, estrogen-secreting ovarian stroma or tumors)

28. WHO Classification and Diagnostic Criteria of Endometrial Hyperplasia
  Simple Hyperplasia Without Cytologic Atypia
  Increased number of glands relative to stroma   Dilated glands with irregular outlines   Crowded, clustered glands   Tall, columnar epithelium with nuclear pseudostratification   Complex Hyperplasia Without Cytologic Atypia
  Increased number of glands relative to stroma   Back-to-back glands (crowded glands with little or no intervening stroma)   Hyperplasia With Cytologic Atypia
  Variation of size and shape of nuclei   Nuclear enlargement   Loss of polarity   Coarse chromatin clumping   Prominent nucleoli   Hyperchromatism

29. Endometrial hyperplasia
Cystic hyperplasia
Simple hyperplasia

30. Endometrial hyperplasia
Atypical hyperplasia
Simple hyperplasia

32. Endometrial biopsy

33. Diagnosis and treatment
Intramuscular progesterone therapy. MPA (500mg)therapy for 3 months;
Micronized progesterone -cyclic natural micronized progesterone for 3 to 6 months;
Levonorgestrel intrauterine device
GnRH analogue for 6 months with sampling every 3 months is a reasonable option in patients without atypia.

36. Staging
According to the U.S. Gynecologic Oncology Group histologic grading system,1
grade 1, well-differentiated carcinoma, consists of a neoplasm with less than 5% of solid cancer
grade 2, moderately differentiated carcinoma, contains between 6% and 50% solid cancer
grade 3, poorly differentiated carcinoma, is made up of more than 50% of solid tumor.

37. Modified WHO classification
endometrioid adenocarcinoma
serous carcinoma
clear cell carcinoma
mucinous carcinoma
mixed types of carcinoma
undifferentiated carcinoma

38. Staging

39. Clinical signs
Irregular vaginal bleeding, intermenstrual or post menopausal
Watery vaginal discharge may be present in postmenopausal women
Mass in late stages

40. Endometrial cancer: investigations
T.V.S. and biopsy
Hysteroscopy and biopsy
? M.R.I. Or C.T. scan

41. Endometrial cancer: investigations

42. Endometrial cancer: treatment
Operative: total abdominal hysterectomy and Bilateral Salpengo-oophorectomy +/_ lymph node dissection is the operation of choice.
Adjuvant Radiotherapy for >1b
Chemotherapy ineffective
Hormonal therapy, progestogens, in early or recurrent cases

43. 5 – year survival rate for endometrial cancer

44. Ovarian Cancer The 2nd most common gynecologic malignancy
27% of gynecologic cancers
The most frequent cause of death from gynecologic cancers
Due to advanced stage at the time of diagnosis
53% of all deaths from gynecologic cancers
Incidence increases with age, most marked beyond 50 years, with increase continuing to age 70 years, and decrease after age 80 years

45. Risk factors Family history of cancer
Personal history of cancer: Women who have had cancer of the breast, uterus, colon, or rectum have a higher risk of ovarian cancer
Age over 55
Never pregnant:
Menopausal hormone therapy: estrogen taking

46. OVARIAN CANCER
primary (neoplasms derived from the ovarian surface epithelium, i.e. epithelial tumors),
secondary (neoplasms derived from papillary or pseudomucinous cystadenomas)
metastatic (intestinal and breasts’ metastasis).

47. Classification 1.Surface epithelial – 65-70%: 2. Stromal – 15-20%:
Serous (tubal)
Mucinous (endocx & intestinal)
Endometrioid
Transitional cell - Brenners.
Clear cell
2. Stromal – 15-20%:
Granulosa-cell tumor
Thecoma
Fibroma
Sertoli-Leydig cell tumors
3.Germ cell tumors – 5-10%:
Teratoma –
Benign cystic (dermoid cysts)
Solid immature
Monodermal – struma ovarii, carcinoid
Dysgerminoma
Yolk sac tumor Choricarcinoma
Mixed germ cell tumor
4.Metastatic tumors – 5%

48. Serous Cystadenoma

49. Papillary serous cystadenoma (solid/cystic)-borderline

50. Papillary cystadenoma (bor)

51. Thecoma Solid tumor with variegated yellow - orange appearance.
Produces estrogens

52. Krukenberg Tumor

53. FIGO classification

54. Ovarian cancer - “silent killer”
Bloating
Pelvic or abdominal pain
Pain in the back or legs
Diarrhea, gas, nausea, constipation, indigestion
Difficulty eating or feeling full quickly
Urinary symptoms (urgency or frequency)
Pain during sex
Abnormal vaginal bleeding
Trouble breathing

55. 55

56. Diagnosis Physical examination Pelvic examination
Rectovaginal examination
Ultrasound
Magnetic resonance imaging
CA-125 high false-positive rate
HE4 marker more sensitive than CA125
Laparoscopy, microscopy
The combination of HE4 and CA 125 was more sensitive than either marker alone - Risk of Ovarian Malignancy Algorithm (ROMA) is calculated

57. Treatment

58. Prognosis
The five-year survival rate for all stages of ovarian cancer is 45.5%.
For cases where a diagnosis is made early in the disease, when the cancer is still confined to the primary site, the five-year survival rate is 92.7%.

59. Thanks for attention