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Unfavourable clinical course
Malignant ovarian neoplasms
Adenocarcinoma of the fallopian tube
Cancer of external genital organs (vulvar cancer
Carcinoma of the vagina
Epidemiology. Cervical carcinoma is a common gynecologic malignancy. The average age of diagnosis for invasive cervical cancer is approximately 50. During the last years a tendency to increasing incidence of cervical carcinoma in young women is maked. Women relating to early sexual intercourse with multiple partners have this disease more frequent. Squamous cell carcinoma is practically never encountered in virgins. It is caused by the carcinogen or promoting factor that is sexually transmitted.
Etiology. Sexually-transmitted diseases are infected by herpes simplex viruses of 2-serotype (HSV-2) or by human papillomavirus (HPV-16/18, 29/31, 35), that can stay for a long time in the latent form. They are the causes of cervical cancer. The virus is inherited by sexual way through smegma. Pseudoerosions, leukoplakias, cervical polyps are the precursors for its development most frequently. Dysplasia of the epithelium belongs to precancer states. A carcinomatous process begins on the squamo-columnar junction.
Cervical carcinoma may be intraepithelial (preinvasive), microinvasive (growth of the process into stroma on the depth up to 0,5 cm beneath from basal membrane) and invasive one.
Histologically there have been distinguished:
Forms of tumor growth are: endophytic, exophytic, mixed.
At exophytic form a tumor grows into vagina, resembling a cauliflower and is able to fill into vagina. The endophytic form is characterized by tumor growing into the muscular layer of the cervix. As a result of this cervix enlarges and consolidates. During tumor disintegration a crater ulcer is formed. A mixed pattern of cervical carcinoma growth has signs of both endophytic and exophytic ones. Cervical carcinoma can be spread on the uterine body, parametrium and vagina.
Regional lymphatic nodes are situated around the cervix (obturator lymph nodes, general iliac, sacral, parasacral ones). Hematogenous metastasing of cervical carcinoma occurs rarely. Distant metastases to organs even in agonizing patients occur in less than 25-40 % cases.
Clinic. It depends on the process stage. The duration of preinvasive and microinvasive cancer is without any symptoms (preclinical stage). Serous or serous-bloody discharge, contact bleeding after sexual intercourse, vaginal examination, speculum examination may be used in the first stage. Pain in the hypogastrium and back, serous-purulent discharge, resembling meat slops with unpleasant smell (caused by lymph and blood effluence during tumor disintegration) on the second and third stage appears. Patients' general state is suffered. Fast tiredness and irritability can appear. The tumor can erode urinary bladder and rectum due to growing inside of them. Constipation and urinary disorders can occur in the result of this.
Diagnosis. The diagnosis is made after the speculum examination. The form of vaginal part of the cervix, its dimensions and anatomic state is determined. In the initial stages of cervical carcinoma one can see changes typical to pseudoerosion. Contact bleeding is an important symptom of cancer. If cancer is found only by cytological method, there can be no clinical signs. The bimanual vaginal examination in the initial stages of cancer is not informative. The cervix is dense or chondroid; crater and infiltration are available in patients with the expressed clinical process. Patients with suspicion of cervical carcinoma should be obligatory examined per rectum. These examinations are called as rectovaginal and rectoabdominal. It allows to estimate the state of lateral and back parametria and uterine cervix better.
The cytological examination of the cervical canal and uterine secretion is the method of early diagnosis of the cervical carcinoma. It provides rapid evalution of clinical state of the cervix, to diagnose preclinical forms of cervical cancer. Sampling of the material for cytological research is made before the bimanual examination of the patient. In healthy women the material is taken with a single-use wooden spatula from the vaginal part of the cervix and lateral fornices. Also one can use a brush to take the material from the cervical canal and squamo-columnar junction with a brush. Local sampling of material is performed in patients with suspicion on cervical cancer. Material is carried on the glass and thinly smeared on its surface.
Microscopic evaluation of smears is made by Papanicolau method (Pap smear screening) (see part IV):
This method of diagnosis cervical cancer is sufficiently exact, histological and cytological conclusion coincides in 95% of patients. Cytological diagnosis is not referred to the definitive one, because it does not determine the depth of invasion process.
Colposcopy (simple and broadened) is used for the early diagnosis. But it is necessary to mention, that it is impossible to make a diagnosis of cervical carcinoma only thanks to colposcopic examination, because this method is additional and allows to choose the most altered cervical area for taking biopsy. A definitive diagnosis is made on the histological results of the material, which has been obtained during the biopsy. Biopsy in majority of cases allows also to determine the depth of the invasion.
Treatment is performed by oncogynecologysts according to the process' invasion. The intraepithelial and microinvasive cancer in young women undergo surgical treatment by cervical conization or its amputation. In the middle-aged or elderly women with uterine myoma, or ovarian cyst presence it is expedient to perform total hysterectomy with adnexa. The I-b - II stage of cancer are treated by combined (radiation + surgery) or combined-radical method (if contraindications for surgical intervention are present). Surgical intervention foresees the total hysterectomy or Wertheim's operation (removal of the uterus with its adnexa, the upper third of vagina and cellular tissue with regional lymphatic nodes). Treatment of cervical carcinoma at the III stage is performed by combined-radical method: distant irradiation of the initial focus and parametria followed by intracavitary curie-therapy. Patients with stage IV are treated individually, the therapy is usually symptomatic.
Sometimes the patients with cervical carcinoma require urgent care because of the presenting accident and rather considerable bleeding.
In such case it is necessary to perform speculum examination to inspect cervix for excluding the trauma of vagina and protruding myoma. If bleeding from crater ulcer or tumor which looks like a cauliflower is present, it is necessary to insert into vagina a hemostatic sponge. For its absence one should make a dense tamponade of vagina by gauze tampon, previously moistened by 10% calcium chloride solution, hydrogen peroxide or aminocapronic acid and to hospitalize the patient (transport by ambulance, in accompaniment of health care worker).
Prognosis depends on the process stage, histological structure and clinical form of tumor growth. A 5-year patients' survival at first stage of cervical carcinoma is observed in 75-85%, at Il-a stage — in 55-65%, at Ill-a stage — in 20-30% of cases.
Patients with cervical carcinoma period of treatment need special attendance, full-value balanced feeding. Individual treatment is a basic element of medical rehabilitation. Treatment of radical therapy complications (proctitis, cystitis and others) is especially hard. Instillations and microclysters with herbal infusions, sea-buckthorn oil are used. After the combined treatment the patients are considered to be able to work depending on profession: with mental activity — after 6-7 months, with physical work — after a year. If there are the expressed complications or treatment has proved to be ineffective, patients are transferred on the disablement.
Prevention. Diagnosis and treatment of diseases predisposing to cervical carcinoma, benign and precancer states are the main ones in the prevention of cervical carcinoma. Interm diagnosis and treatment of benign and precancerous cervical lesions are indicated. All women during all their life time should be regularly encouraged to avail themselves of annual health care checkups to include the Pap smear.
Endometrial carcinoma belongs to hormone-sensitive diseases.
Morphologically: adenocarcinoma, adenoacanthoma, clear cell mesonephroid adenocarcinoma, adenosquamous carcinoma, undifferentiated cancer are the subtypes.
According to International classification, adenocarcinoma is classified into well, moderate and poorly differentiated tumors. Advanced grade is associated with the higher risk of deep myometrial invasion and lymph node involvement.
Malignant tumor arises primarily in the area of uterine fundus and fallopian tubes angles, it is very difficult to determine primary tumor location during its growing. In most cases, there is an exophyte type of growing, sometimes they look like polyps. Endophyte type of growing is an exception, thus ulcerative-infiltrative type of endometrial carcinoma is rare.
Depth of the tumor invasion plays an important role for clinical duration of disease. It is absent in 8% of patients. Such tumors should be removed at uterine curettage.
Lymphogenous and hematogenous ways of metastases are common. At the beginning general iliac, external iliac and aortic lymph nodes involvement is common. Inguinal and supraclavicular lymph nodes invasion is present at the late stages. In 10 % of patients hematogenous way of metastases is present (lungs, liver, uterus, brain). Invasion of vagina may occur by lympho-hematogenous way or direct implantation.
Clinic. Abnormal uterine bleeding is the most important symptom of endometrial cancer. Women in menopause may have abnormal bleeding or watery discharge (lymphorhea) from vagina. Pain is the late symptom of endometrial cancer. At first it is the result of excretions accumulation in the uterine cavity. It is dull in case of peritoneal, adjacent organs or nervous nodes involvement. If the pathological process is extended into adjacent organs following symptoms would be present: revealing of mucus and blood in the feces, coprostasis — in case of rectal tumor; hematuria — in case of urinary bladder involvement; hydronephrosis as a result of uterher's compression.
There are three types of cancer clinical course.
Slow, rather favourable clinical course. This form is observed in patients with significant hyperestrogenemia and lipids and carbohydrates dysmetabolism impairment. Continuous uterine bleeding as a result of endometrial hyperplasia is the most common symptom. Lymphatic way of metastasing is absent. Histolo-gycally, it is well-differentiated cancer with superficial invasion of the myometrium.
^ . Metabolism disorder is absent The course of the disease is rather short Endometrial carcinoma involves all layers of myometrium, extends to cervix, parametrium and vagina It is a poorly differentiated tumor
Acute, extremely unfavourable clinical course. It is characterised by unfavourable factors combination, such as deep extension of tumor, lymph nodes and peritoneal metastases "Ovarian" type of metastases would be present It is characterised by ascitis and omentum metastases.
Diagnosis is made basing on history, clinics, physical and pelvic examination.
Other additional examinations should be performed, including ultrasonography, cytological sampling of the endometrial cavity, hysteroscopy, hysterography, fractional curettage with the cytological examination
In history it is very important to pay attention to reproductive period duration, menstrual dysfunction, especially to presence of acyclic uterine bleeding, climacterium and menopausal course peculiarities
The overall accuracy of cytological sampling research of the endometrial cavity approaches 90 % . Hysterocervicography or hysteroscopy gives a possibility to reveal tumor location, extension of invasion
Combination of hysterography and gases pelvigraphy is the best method for diagnosis of the depth of endometrial carcinoma invasion — tumor extension into myometrium and out of uterine borders These methods help to make a special management of patient's treatment that is accompanied by clinical and morhological signs
Biopsy curettage of the endometrial cavity after hysterocervicography should be performed. Histological structure peculianties and level of tumor differentiation should be revealed Fractional curettage should be performed.
Ultrasound examination of female internal organs is indicated for diagnosis of metastases.
Investigation of adjacent organs, such as cystoscopy, chromocystoscopy, excretory urography, rectoromanoscopy, colonoscopy is recommended. Plain film of breast and X-ray examination of skeleton is indicated in case of distant metastases. Patient's examination is finished by radioizotope lymphography which can reveal lymph nodes metastases. Combination with hysterocervicography gives a possibility to reveal the level of tumor extension.
Treatment. Surgical, combined treatment, combining of radiation and hormones should be used.
^ is the method of choice in the patients with tumor localized near uterine fundus without deep invasion, without lymph nodes involvement, mainly at the first pathogenetical type of tumor. Vertgeum-Gubarev operation is the cornerstone of surgical treatment. Total abdominal hysterectomy with bilateral salpingoophorectomy is performed, but it is contraindicated for the patients with concomitant extragenital pathology. Therefore, J.V.Bochman (1964) has offered his modification.
Difference between these two operations is that the author abstains from the removal of the upper third part of vagina, wide excision of transverse and sacrouterine ligaments, paravaginal fat, that let to avoid separation of ureters. Such variant of operation is possible in case when tumor doesn't reach the internal cervical ostium and when the ability of its growing into vagina and parametrium is insignificant.
^ (operation+radiation, operation+hormones, opera-tions+radiation+hormones) should be recommended for the patient with deeply invasive cancer, those with cervical involvement, poorly differentiated tumors with regional lymph node metastases or for the patients with the second pathoge-netical type of endometrial carcinoma (without hormonal, carbohydrates and lipids dysmethabolism).
In case of combining radiative therapy intrauterine radiation with a-radiation should be applied. Application of cobalt inside uterine cavity is also recommended.
Hormonotherapy is the method of choice in the patients with contraindications to operative and radiative treatment. Oxyprogesterone acetate should be prescribed for these patients in a dose of 250 mg every day during 4 month, every second day during the next 4 months, then — every week in a dose of 500 mg during lifetime.
The efficiency of this treatment is considerably increased in case of its combination with chemotherapeutic agents, such as Ftoruracil, Cyclophospan and Adriamycin.
^ (prognosis). Patient with endometrial tumor that doesn't invade the myometrium has 95% 5-year survival rate, whereas patient with a poorly differentiated tumour with deep myometrial invasia may have 5-year survival rate only 20%.
Prevention. Interm treatment of endometrial hyperplasia and menstrual dysfunction.
All not epithelial malignant tumors belong to sarcomas. Presence of uterine myoma in pre- and postmenopausal women, especially during its fast growing belong to the risk factors of uterine sarcomas. There are four histological types of uterine sarcomas:
Clinical findings. Uterine bleeding and pelvic pain are the most common presenting symptoms.
General weakness, weight loss, subfebril temperature for a long period of time are the symptoms of uterine sarcoma presence for a long period of time.
Metastasis. The preferential way of spread is via the bloodstream. Other less frequent ways of spread are via the lymph nodes and by contiguity.
Diagnosis. In many cases, the diagnosis is an unexpected finding at the time of hysterectomy done for other indications. Sampling research of the endometrial cavity either by biopsy and curettage can assist in diagnosis less than 50% of cases owing to the fact that many of these tumors are intramural and thus without endometrial extension. Hysterography or hysterocervicography should be performed. Investigation of the adjacent organs should be recommended in all types of uterine sarcomas.
Plain film of breast, liver and X-ray examination of skeleton should be prescribed for diagnostics of distant metastases.
Treatment. The preferred treatment is total abdominal hysterectomy and bilateral salpingo-oophorectomy. Careful intraperitoneal and retroperitoneal revision is performed. Radiation therapy and chemotherapy are indicated for palliation of patients with distant metastases or recurrences. Adriamycin and Karminozine are used.
Most of the malignant neoplasms that arise in the ovary fall into three categories: primary cancer (neoplasms derived from the ovarian surface epithelium, i.e. epithelial tumors), secondary (neoplasms derived from papillary or pseudomucinous cystadenomas), metastatic (intestinal and breasts' metastasis).
Etiology. Ovarian tumors belong to hormonal active tumors. Epidemiologic and experimental investigations of ovarian cancer reveal impairment of menstrual function in these tumors.
The certain epidemiologic factors associated with the development of ovarian cancer include low parity, decreased fertility and delayed childbearing. All of these factors lead to hormonal disbalance in the organism.
Recently, demonstration of the genetic inheritance of ovarian cancer has revealed an important information regarding the possible etiology of the disease.
The relationship between the benign ovarian neoplasm and its malignant counterpart is clinically important. If the benign counterpart is found in the patient the removal of both ovaries is necessary, because of the possibility of future malignant transformation in the remaining ovary. The decision concerning the removal of one or both ovaries, however, must be individual and is based on the age, type of tumor, and future risks. Some investigators have suggested that a bilateral oophorectomy in the patients over 40 years should be performed. It gives a possibility to decrease the ovarian cancer development. There is a connection between breast cancer and ovarian tumors. The incidence of ovarian cancer in these women is in 10 times higher than in healthy women. There is dependence between endometrial hyperplastic processes and ovarian cancer.
One should remember that unblastomatic unproliferative processes (follicle, luteal cysts) are the results of pituitary and ovarian hormones disbalance. The observation that patients with breast cancer have a two fold increase in the risk of developing of ovarian cancer supports the concept that hormones play an important role in the cause of ovarian cancer.
Malignant ovarian neoplasms are usually categorized according to the origin of the cell and are similar to their deign counterparts:
There are malignant tumors with inside and outside growing. Mixed tumors are also common.
Epithelial cell ovarian carcinoma may reach both small and large sizes, they are typically multiloculated and often have external excrescencies on otherwise smooth capsular surface. The walls of malignant cysts have different thickness, and, as a rule, have papillary injections on the inner surface. Epithelial tumors haven't cysts, they are soft. They are small in sizes, with smooth surface and grow in the direction of the adjacent organs.
Sometimes the metastatic cancer can appear in the ovaries. The term Krukenberg tumor describes the ovarian tumor that is metastatic from other sites such as the gastrointestinal tract (80% from stomach, remainder from colon, breast, and endometrium). Most of these tumors are characterized as infiltrative, mucinous carcinoma of predominantly signet-ring cell type and as bilateral and associated with the widespread metastatic disease.
Ways of spread of ovarian cancer. Ovarian cancer can spread by means of several pathways The neoplasm can directly invade adjacent organs such as the small intestine, rectosigmoid, colon, peritoneum, omentum, uterus, fallopian tubes, and broad ligament Spread can occur by means of the peritoneal fluid and malignant cells can be implanted throughout the pelvis and abdominal cavity, including the omentum, posterior cul-de-sac, infundibulopelvic ligaments, paracolic gutters, right diaphragm and capsule of the liver. Ascites can often develop with peritoneal metastases.
Dissemination may also occur through lymphatics to the uterine tube, uterus, pelvic and paraaortic lymph nodes. Metastases occasionally are detected in distal sites such as the supraclavicular or inguinal lymph nodes.
The least common way of spread is hematogenous dissemination. Hematogenous metastases occur in the liver parenchyma, skin, and lungs.
Clinic. Early diagnosis of ovarian cancer is difficult, because symptoms are often absent or vague until the neoplasm has attained a large size and metastasized Even large tumors usually produce nonspecific symptoms Early symptoms include vague sensations of pelvic or abdominal discomfort, urinary frequency, and alterations in gastrointestinal function When the neoplasm attains a diameter of about 15 cm, it rises into abdominal cavity, which leads to feelings of abdominal fullness or distension and early safety Abdominal enlargement can also be secondary to ascites General weakness, weight loss, continuos dull pain in the lower part of abdomen are common. In 15% of patients they experience abnormal vaginal bleeding.
Hemorrhage into the tumor or torsion of the ovary containing neoplasm can produce sudden pain and other symptoms of acute abdomen
The physical findings in patients with ovarian neoplasms in early stages are similar to benign ovanan cystadenomas. Usually, they are of small sizes, painless, movable, with firm consistency. They are palpated on the back from the uterus. The tumor may be palpated by means of rectal examination. One can feel the mass within the cul-de-sac. The tumor may be fixed because it can fill the available space in the pelvis or because the pedicle is very short (it looks like uterine myoma). The tumor reaches large sizes and rises out of the pelvis It is palpated in the abdomen The surface of tumor is nodular There may be irregularities or even solid portions It is immobile There is a high temperature as a result of products' disintegration absorption in the case of tumor destruction Anemia, leukocytosis and increased ESR are common symptoms m early stages of tumor. If the tumor reaches large sizes the symptoms of intestinal obstruction may be present. The dyspnoe may be present at ascites. Bilaterahty or fixation arouse the suspicion of malignancy.
Diagnosis. Pelvic examination is the main one in diagnostics of ovarian cancer neoplasms. Physical findings in patients are absent if a tumor is of small sizes. Bilateral tumors may be palpated on the sides of the pelvis, sometimes in the back of the uterus. Malignant ovarian tumors are similarly irregular with nodular surface and have the firm consistency. Ultrasonography should determine tumor location, its internal surface. Ultrasonography is especially useful for uncertain physical findings in case of obesity.
Percutaneous fine-needle aspiration is an accurate method of diagnosing of the variety of tumors. It should not be used for the initial diagnosis of the ovarian tumor, because the neoplasm should be treated by surgical excision. There is some risk that a cystic neoplasm may rupture when aspirated.
Laparoscopy with diagnostic purposes should be indicated for the patients for revealing external peculiarities of the tumor, presence of dissemination and metastases. It is contrindicated for the patients that were previously operated, with excessive weight, with large tumors.
Sometimes diagnostic laparotomy is necessary in the evaluation of ovarian cancer. After skin incision a detailed inspection of pelvis and abdominal cavity must be held. Smears for cytologic evaluation and biopsy should be performed. The final diagnosis is made after cytologic and hystologic investigation.
Radiographic examination is valuable in the diagnosis of chest and abdominal cavity revealing. X-ray examination of stomach and intestine is obligatory for exception of metastatic ovarian cancer. Fibrogastroscopy and biopsy, pneumo-pelviog -aphy may be useful for diagnosis.
Lymphography is of value in the diagnosis of dysgerminoma when lymphogenic way of spread is the main one. In 30% of patients sacral metastases are present.
Treatment. All histologic types of ovarian carcinoma are threated in the same way. The standard surgical procedure for carcinoma of the ovary is total abdominal hysterectomy and bilateral salpingoophorectomy. A partial or complete omentectomy should be performed, and in the advanced disease, an attempt should be made to resect as much metastatic tumor as possible. The contralateral ovary and fallopian tube are removed unless the conservation of fertility is important. The contralateral ovary is resected because it has been shown to contain an occult metastasis or primary carcinoma in 5% of patients.
It is a radical method of treatment for the patients with ovarian carcinoma in the I-II stages. In the cases of advanced cancer (III-IV stages) the surgeon must determine the appropriate treatment after exploring the patient's abdomen. Some patients have unrespectable cancer. In this case the surgeon should attempt to establish the diagnosis by excising the involved ovary. If this is not feasible, a biopsy should be obtained from the ovary or metastases. Several studies have revealed that survival of the patients with stage III-IV ovarian cancer is improved Radiation therapy is uneffective when there are large residual tumor masses, and treatment with many chemotherapeutic regimens is also the most successful when residual tumor volume is minimized This type of surgery is referred to as cytore-ductive surgery
The patient whose neoplasm has spread beyond the ovary is initially a candidate for chemotherapy even if all tumor has been resected. Chemotherapy is usually advocated for women with all stages of disease. A variety of drugs are active against the ovarian cancer. Such of them as Methotrexate, Cyclophosphan, Sarcolizine are emerhed as drugs for chemotherapy. Combination chemotherapy may be more effective than single-agent chemotherapy in patients with bulky residual tumor, but it is also more toxic. Combination of such agents as Cyclopho-sphane+Phtoruracil; Cyclophosphane+Methotrexate+Phtoruracil; Cyclophos-phane+Adriablastine+Cisplatin should be prescribed. Tiotef and Cisplatin should be administrated intraperitoneally.
There is no difference between single-agent and combination therapy in the cases of advanced cancer. You should remember that Cisplatin has Nephrotoxic effects, and Adryamicin and Phtoruracil have cardiotoxic effects.
Prognosis. The overall survival rate for stage IA is 90-98%; for stage IB — it is less than 68%, for stage II — 50%, for stage III — 10-15%. The overall survival rate for ovarian cancer at 5 years is 28-30%.
Dysgerminoma is the most common malignant germ cell tumor which is arising from undifferenting gonades that are present in the ovarian sinus.
Clinic. The tumor is common in the infantile patients of 30 years of age. Patients generally can observe pelvic or abdominal mass, abdominal enlargement or pain. The duration of symptoms ranges from 1 month to 2 years with a median of 4 months. The metastases are present in lungs.
Diagnosis is difficult and it is based on the results of clinical findings, laparo-scopy and histologic investigation results.
Treatment is surgical with the following radiation therapy and chemotherapy.
Ovarian teratoblastoma is a rare malignant tumor which is found in childhood in juvenile period.
Clinic. Pain in the lower part of the abdomen and general weakness are common. In the advanced cases ascites is present. Metastatses anse very quickly.
Diagnosis is based on the histologic results.
Treatment is surgical with the following radiation therapy.
Adenocarcinoma of the fallopian tube is one of the rarest malignancies of the female genital tract It may developed primarily (from utenne tube) secondary, or metastatically (from lesions arising in the adjacent organs such as uterus and ovanes). Primarily the disease affects the older women. The average age is 40-55 years that had chronic tubal inflammation for a long period of time. The process is always unilateral.
Adenocarcinoma of the fallopian tube has pappilary, glandular-papillarty, papillary-solid and solid structure. The process can quickly metastase inside the pelvis. Ascites is a rare associated finding. Distant metastases are relatively more important for tubal carcinoma than for ovanan carcinoma. More than 50% of the recurrences with tubal carcinoma appear outside the pentoneal cavity, although they usually associated with intrapentoneal metastases.
Clinic. Most patients with tubal carcinoma are asymptomatic, and diagnosis is made only after the patient has undergone surgical exploration for a pelvic mass A few patients have symptoms such as vaginal bleeding or discharge, lower abdominal pain, abdominal distension and pressure. In many cases these symptoms are vague and nonspecific Postmenopausal bleeding or discharge may be a symptom. The most common finding at examination is a pelvic or abdominal mass.
Diagnosis. Ultrasonography and laparoscopy, cytologic investigation of the uterine aspirate can prove the diagnosis.
Treatment is surgical. Total abdominal hysterectomy and bilateral salpingo-ophorectomy with the following radiation and chemotherapy are used.
Cancer of external genital organs is a malignant epithelial tumor, that appears in women during menopause and looks like infiltration, dense nodes or papilar formations. Ulceration is possible . Precancer diseases come before the appearing of neoplasm. Late puberty, early menopause and high fertility are typical for the patients with vulvar carcinoma. Frequently vulvar carcinoma is combined with obesity and diabetes mellitus.
Exophytic, nodular, ulcerous and infiltrative forms of the tumor are distinguished.
^ . The main symptoms are itching, burning, pain, purulent-hemorrhagic discharge. Pain of tumors is usually localized in the region of clitoris. Hemorragic discharge can appear at tumor disintegration.
Final diagnosis is made basing on the histological research.
Metastasing happens into nodes of inguinal-femoral collector.
Treatment is surgical. Vulvectomy and bilateral inguinal lymphadenectomy (Ducken's operation), combined treatment (vulvectomy and radiotherapy) are used. Radiotherapy is performed before the operation, and then after it they irradiate the regions of primary lesion and regional metastasing.
Regular medical check-up of patients must be made by the end of their life.
Carcinoma of the vagina can be primary and metastatic. More frequently women can have cancer in climacteric period and after menopause. Cancer canappear in the aged women with long-termed decubital ulcer due to its infecting and traumatizing. Exophytic (as cauliflower) or endophytic infiltrative growth is observed. Histologically carcinoma of the vagina is divided into the squamous cell keratinizing carcinoma, non-keratinizing and adenocarcinoma.
^ . The purulent-hemorrhagic discharge, pain, disturbance of urination, signs of general intoxication are common unexpectable. Bleeding can occur at disintegration of the tumor. Nerves are pressed, ruined and patients feel pain if a tumor spreads to the underlying tissues, paravaginal cellular tissue. Neoplastic process can be spread on the adjacent organs like urinary bladder and rectum. Disintegration of the tumor can cause formation of bladder-vaginal and recto-vaginal fistulas. Hydro- and pyonephrosis, and later—uraemia can develop on condition that the ureters are compressed.
One should differ carcinoma from decubitus, syphilitic and tuberculosis ulcers, condilomas, endometriosis, chorioepithelioma, metastases of cervical and uterine cancer into vagina.
Lymphatic cancer spread is more common: from upper one-third into iliac and hypogastric lymph modes; from middle one-third into the sacral ones; from the lower one-third into the inguinal lymphatic nodes.
Final diagnosis is made after biopsy.
Treatment. Carcinoma of the vagina is treated by the combined radiotherapy. X-ray or gamma-ray telethepary with insertion of radioactive preparations into vagina are used.