MINISTRY OF HEALTH OF UKRAINE

VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY

"CONFIRM"

at the methodical meeting

Department of Ray diagnostics,

Ray therapy and Oncology

Head of the department

As. of Prof., M.S.D. Kostyuk A.G.

______

"______" ______2013 year

METHODICAL GUIDELINES

For self-study for students in preparing for the practical (seminary) lessons

Subject of Study / Oncology
Module No / 1
Theme No / 19
Topic of Lesson / Cervical and Endometrial Cancer.
Distribution Risk factors, dysplasia. Classification by TNM. Methods of diagnosis. Clinics. Differential diagnosis. Treatment: surgery, radiotherapy, chemotherapy, combined.
Course / 5
Faculty / General Medicine

Cervical Cancer

1. Background.

The cervix is the lower third portion of the uterus (womb). It serves as a neck to connect the uterus to the vagina. The opening of the cervix, called the os , remains small and narrow, except during childbirth when it widens to allow a baby to pass from the uterus into the vagina.

Cervical cancer develops in the thin layer of cells called the epithelium , which cover the cervix. Cervical cancer usually begins slowly with precancerous abnormalities, and even if cancer develops, it generally progresses very gradually. Cervical cancer is the most preventable type of cancer and is very treatable in its early stages. Regular Pap tests and human papilloma virus (HPV) screening can help detect this disease early.

2. Specific goals.

1. To know the etiology of cervical cancer and the role of endocrine pathology in the development of these diseases, their prevalence among different groups of the female population, the overall results of a special treatment ( = I)

2. To know the main cause of cervical cancer, histologic classification and classification system for TNM, clinical manifestations, and cervical cancer, depending on the stage of the main methods of diagnosis and principles of radical and symptomatic treatment. ( = II)

3. To be able to examine patients with cervical cancer, to conduct a bimanual examination, the samples with dyes - Schiller and Tetrazolova, registering patients at the dispensary into the registration Form 30. (=III)

4. To be able to interpret the sonogram and hysterogram in patients with cervical cancer.

5. To be able to define a differentiated treatment policy in patients with different stages of cervical cancer and uterus. ( = III)

6. To acquire a deontological view when working with patients with cancer of the uterus and those who have complications which is the manifestation of the underlying disease

7. Develop a sense of responsibility for the timeliness proper medical diagnosis CIN and the correct choice of treatment tactics in this pathology.

3. Basic knowledge, skills, abilities, necessary for studying the topic(inter-disciplinary integration).

Preceding Subject / To know / To be able
Normal anatomy
Normal physiology
Biochemistry
Physiopathology
Morbid anatomy
Obstetrics and Gynecology
Operative Surgery and topographical anatomy / Operative surgery and topographic anatomy of the external and internal anatomy of female genital mutilation, the characteristic features of their structure, blood supply (both arterial and venous flow characteristics) innervation.
Menstrual cycle, its humoral and neuro-endocrine regulation. Features of oocyte maturation in the follicle.
The role of the lymphoid tissue of the pelvis was normal.
The major classes of female hormones, their synthesis and degradation.
Pathogenesis of endocrine disorders in patients with cervical cancer.
Macroscopic forms of tumors of the uterus. Histological classification of cervical cancer and
Methods of examination of patients with cervical cancer: a survey, physical and bimanual examination.
Additional studies: Ultrasound hysterography, hysteroscopy with biopsy.
The main types of surgery in patients with tumors of the body and cervix.
Diatherocoagulation, indications and techniques of conducting.
Total hysterectomy (TEM): indications, contraindications, technique execution.
TEM at Wertheim: indications, technique execution. Featuring a look uterus, ovaries, fallopian tubes / Featuring a look uterus, ovaries, fallopian tubes.
Determine the stage of cervical cancer and
according to the histological classification and classification TNM.
Conduct a focused and systematic collection of complaints and medical history of patients with suspected cervical cancer. Conduct physical and bimanual examination of the female genital organs.
Surgical approaches to define the line of the abdominal wall and above the vagina during gynecological cancer operations.
Interdisciplinary Intergation / Key diagnostic symptoms of diseases gynecological cancer field. / Identify specific manifestations in patients with cervical cancer, interpretable additional methods of examination in these diseases.

4. Tasks for independent work in preparation for the occupation.

4.1. Theoretical issues to employment:

1. The spread of cancer of the uterus, cervical cancer.

2. Histological classification and TNM classification system and cervical cancer.

3. Mandatory and special methods of examination.

4. Differential diagnosis of cervical cancer and other diseases.

5. Surgical treatment of cervical cancer and uterus.

6. Indications and contraindications for surgery.

7. Technique of radical surgery in patients with cervical cancer.

8. Palliative surgery.

9. Preoperative preparation of patients, post-operative treatment and postoperative complications.

10. Long-term results of treatment of cervical cancer and uterus.

11. Combined treatment of cervical cancer and uterus. Forecast.

12. Question dispensary patients on cervical cancer.

4.2. Practical work (jobs) that need to perform in class:

1. Carefully collect history. Determine the history of symptoms of cervical cancer;

2. Physical examination the patient: palpation and assessment of lymph nodes, including regional, palpation of the abdomen, liver, detection of ascites balloting and percussion of abdomen;

3. Conduct vaginal, rectal, recto-abdominal and recto-vaginal examination;

4. Determine the methods of investigation: Ultrasound, cytology of exudatesfrom peritoneal cavities, chest radiography, laboratory tests of blood and urine, laparoscopy if indicated, X-ray of the stomach, Irrigoscopy, fibrogastroscopy, colonoscopy and sigmoidoscopy;

5. Determine the stage of disease in patients with cervical cancer of the uterus;

6. Identify complications of cervical cancer;

7. The indications for surgery, chemotherapy and combined treatments;

8. Assess the condition of the patient in the early postoperative period.

4.3. Content of the topic

Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb) that opens at the top of the vagina.

Causes

Worldwide, cervical cancer is the third most common type of cancer in women. It is much less common in the United States because of the routine use of Pap smears.

Cervical cancers start in the cells on the surface of the cervix. There are two types of cells on the cervix's surface: squamous and columnar. Most cervical cancers are from squamous cells.

Cervical cancer usually develops very slowly. It starts as a precancerous condition called dysplasia. This precancerous condition can be detected by a Pap smear and is 100% treatable. It can take years for precancerous changes to turn into cervical cancer. Most women who are diagnosed with cervical cancer today have not had regular Pap smears or they have not followed up on abnormal Pap smear results.

Almost all cervical cancers are caused by HPV (human papilloma virus). HPV is a common virus that is spread through sexual intercourse. There are many different types of HPV. Some strains lead to cervical cancer. (Other strains may cause genital warts, while others do not cause any problems at all.)

A woman's sexual habits and patterns can increase her risk for cervical cancer. Risky sexual practices include having sex at an early age, having multiple sexual partners, and having multiple partners or partners who participate in high-risk sexual activities.

Risk factors for cervical cancer include:

  • Not getting the HPV vaccine
  • Poor economic status
  • Women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1960s to prevent miscarriage
  • Weakened immune system

Symptoms

Most of the time, early cervical cancer has no symptoms. Symptoms that may occur can include:

  • Abnormal vaginal bleeding between periods, after intercourse, or after menopause
  • Continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling
  • Periods become heavier and last longer than usual

Cervical cancer may spread to the bladder, intestines, lungs, and liver. Patients with cervical cancer do not usually have problems until the cancer is advanced and has spread. Symptoms of advanced cervical cancer may include:

  • Back pain
  • Bone pain or fractures
  • Fatigue
  • Leaking of urine or feces from the vagina
  • Leg pain
  • Loss of appetite
  • Pelvic pain
  • Single swollen leg
  • Weight loss

Exams and Tests

Precancerous changes of the cervix and cervical cancer cannot be seen with the naked eye. Special tests and tools are needed to spot such conditions.

  • Pap smears screen for precancers and cancer, but do not make a final diagnosis.
  • If abnormal changes are found, the cervix is usually examined under magnification. This is called colposcopy. Pieces of tissue are surgically removed (biopsied) during this procedure and sent to a laboratory for examination.
  • Cone biopsy may also be done.

If the woman is diagnosed with cervical cancer, the health care provider will order more tests to determine how far the cancer has spread. This is called staging. Tests may include:

  • Chest x-ray
  • CT scan of the pelvis
  • Cystoscopy
  • Intravenous pyelogram (IVP)
  • MRI of the pelvis

Treatment

Treatment of cervical cancer depends on:

  • The stage of the cancer
  • The size and shape of the tumor
  • The woman's age and general health
  • Her desire to have children in the future

Early cervical cancer can be cured by removing or destroying the precancerous or cancerous tissue. There are various surgical ways to do this without removing the uterus or damaging the cervix, so that a woman can still have children in the future.

Types of surgery for early cervical cancer include:

  • Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue
  • Cryotherapy -- freezes abnormal cells
  • Laser therapy -- uses light to burn abnormal tissue

A hysterectomy (removal of the uterus but not the ovaries) is not often performed for cervical cancer that has not spread. It may be done in women who have repeated LEEP procedures.

Treatment for more advanced cervical cancer may include:

  • Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina.
  • Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed.

Radiation may be used to treat cancer that has spread beyond the pelvis, or cancer that has returned. Radiation therapy is either external or internal.

  • Internal radiation therapy uses a device filled with radioactive material, which is placed inside the woman's vagina next to the cervical cancer. The device is removed when she goes home.
  • External radiation therapy beams radiation from a large machine onto the body where the cancer is located. It is similar to an x-ray.

Chemotherapy uses drugs to kill cancer. Some of the drugs used for cervical cancer chemotherapy include 5-FU, cisplatin, carboplatin, ifosfamide, paclitaxel, and cyclophosphamide. Sometimes radiation and chemotherapy are used before or after surgery.

Outlook (Prognosis)

How well the patient does depends on many things, including:

  • The type of cancer
  • The stage of the disease
  • The woman's age and general physical condition
  • If the cancer comes back after treatment

Pre-cancerous conditions are completely curable when followed up and treated properly. The chance of being alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area is 92%.

The 5-year survival rate falls steadily as the cancer spreads into other areas.

Possible Complications

  • Some types of cervical cancer do not respond well to treatment.
  • The cancer may come back (recur) after treatment.
  • Women who have treatment to save the uterus have a high risk of the cancer coming back (recurrence).
  • Surgery and radiation can cause problems withsexual, bowel, and bladderfunction.

When to Contact a Medical Professional

Call your health care provider ifyou:

  • Have not had regularPap smears
  • Have abnormal vaginal bleeding or discharge

Prevention

A vaccine to prevent cervical cancer is now available. In June 2006, the U.S. Food and Drug Administration approved the vaccine called Gardasil, which prevents infection against the two types of HPV responsible for most cervical cancer cases.

Studies have shown that the vaccine appears to prevent early-stage cervical cancer and precancerous lesions. Gardasil is the first approved vaccine targeted specifically to prevent any type of cancer.

Practicing safe sex (using condoms) also reduces your risk of HPV and other sexually transmitted diseases. HPV infection causes genital warts. These may be barely visible or several inches wide. If a woman sees warts on her partner's genitals, she should avoid intercourse with that person.

To further reduce the risk of cervical cancer, women should limit their number of sexual partners and avoid partners who participate in high-risk sexual activities.

Getting regular Pap smears can help detect precancerous changes, which can be treated before they turn into cervical cancer. Pap smears effectively spot such changes, but they must be done regularly. Annual pelvic examinations, including a pap smear, should start when a woman becomes sexually active, or by the age of 20 in a nonsexually active woman.

If you smoke, quit. Cigarette smoking is associated with an increased risk of cervical cancer.

5. Tests for self evaluation.

A. Tests for self evaluation (test problem)

1. What is the most common histological form of cancer of the uterus:

1) adenocarcinoma

2) squamous cell carcinoma

3) undifferentiated carcinoma

4) anaplastic carcinoma

5) clear cell carcinoma

Correct answer: 1.

2. Radical surgery in cancer of the uterus:

1) hysterectomy

2) resection of the uterine

3) total hysterectomy

4) ovariohysterectomy

5) hysterectomy

Correct answer: 3.

3. The first symptom of cervical cancer:

1) spotting

2) weakness

3) pain in the genitals

4) watery discharge

5) pain during intercourse

Correct answer: 4.

4. Immature morphological variant of cervical cancer:

1) G2

2) G1

3) G4

4) G3

5) G0

Correct answer: 4.

5. T2 cervical cancer are:

1) The tumor extends beyond the uterus

2) The tumor extends to the pelvic wall

3) tumor limited to the cervix

4) The tumor extends to the vagina

5) the tumor grows into the surrounding tissue

Correct answer: 1.

B.Situation tasks for self-control:

1. Patient K., 44 years old, seeking antenatal care with complaints of vaginal bleeding after sex. Vaginally: cervix hypertrophied. The front lip of the cervix - a tumor in the form of cauliflower 2x2 cm, which is bleeding in contact palpation. Uterus of normal size andempty inside. Rectal: supra-cervical portion of the cervix is ​​sealed, but not increased. Formulate a complete diagnosis.

Correct answer: Cervical cancer stage I.

2. In patient M., 62 - years old, after 14 years of menopause, there spotting for a month. Withbimanual study bleeding from the genital tract increased, uterus large, painless, appendages on both sides are not increased, their site is painless. The neck when viewed in the mirror clean. What kind of pathology in this case, is it?

Correct answer: Uterine cancer.

3. In the gynecological ward admissions M., 65. Complaints of pain in the left hip area, especially at night. The urine and feces appeared blood. For the first time a doctor asked 3 months ago. Vaginally: - narrow vagina infiltrated cancer, cervix look impossible. Rectal: vaginal wall and rectum also infiltrated cancer. The body of the uterus increased to 11 weeks of pregnancy, is dense. In the parameters of both sides palpable infiltration that reach the walls of the pelvis. What is your diagnosis? What do you associate pain at the site of the leftThigh? How does blood appear in the urine and feces? Which is your treatment strategy?

Correct answer: Uterine cancer stage IV. Stretching of n.pudenda by the mass-irradiation in the thigh, the spread of cancer into the bladder - blood in the urine; into rectum - blood in the stool. Symptomatic treatment:Analgesics, including narcotic drugs and haemostatic therapy.

6. Literature.

Basic.

1. SorcinV, Popovich A, DumanskiyYu, et al.Clinical oncology. Simferopol, 2008; 192 p.

2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.

Additional.

1. National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Cervical Cancer Screening. v. 2012.

2. Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2010;60(2):99-119.

3. Pham H, Geraci SA, Burton MJ; CDC Advisory Committee on Immunization Practices. Adult immunizations: update on recommendations. Am J Med. 2011;124(8):698-701.

4. Kahn JA. HPV vaccination for the prevention of cervical intraepithelial neoplasia. N Engl J Med. 2009 16;361(3):271-8.

5. Noller KL. Intraepithelial neoplasia of the lower genital tract (cervix, vulva): Etiology, screening, diagnostic techniques, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 28.

Endometrial Cancer

1. Background.

The uterus is the pelvic organ that holds the pregnancy and that bleeds each menstrual period. The cervix is that part of the uterus fixed at the top of the vagina. The normal size of the uterus is about that of a lemon. The uterus is divided into three parts. The great bulk of the uterus is composed of smooth muscle and forms a thick uterine wall. The inside of the uterus is lined with a glandular epithelium which is supported by the endometrial stroma. Together, the glandular lining and the endometrial stroma are referred to as the endometrium of the uterus. The endometrium is hormonally sensitive and changes throughout the menstrual cycle and during pregnancy.