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on the conference of the Department

of Obstetrics and Gynecology with the Course

of Infant and Adolescent Gynecology

“____” _____________200 p.

protocol No

T.a.The Head of the department, Professor


Methodological instruction

on the themes singled out for independent study

Malignant tumors of female genitalia”


For 5 year students of

medical faculty

2 academic hours

Developed by assistant, PhD

Oksana Bakun

Chernivtsi, 2008

I. Scientific and methodical grounds of the theme

Early and active diagnosis of benign tumors and precancerous diseases of female genitalia, their timely and correct treatment are the pledge for solution of cancer problems.

II. Aim:

A student must know:

1. Methods of examination for diagnosis of cervical carcinoma.

2. What is the method of early diagnosis of cervical carcinoma used?

3. Modern diagnostic methods of malignant diseases of female genitalia.

4. Modern therapeutic methods of malignant diseases of female genitalia.

A student should be able to:

1. Diagnose malignant tumors of uterus and adnexa.

2. Carry out a vaginal speculum-examination, vaginal examination, put up primary diagnosis.

III. Recommendations to the student


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. 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:

  • squamous cell keratinous carcinoma

  • squamous cell nonkeratinous carcinoma

  • adenocarcinoma

  • clear cell adenocarcinoma

  • dimorphic adeno-squamous cell carcinoma

Highly-differentiated, moderate-differentiated and low- differentiated (or undifferentiated) cancers have been distinguished according to the potential malignancy.

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.

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. 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.

Microscopic evaluation of smears is made by Papanicolau method (Pap smear screening):

  • I type — unaltered epithelium

  • II-a type — inflammatory process

  • II-b type — proliferation, metaplasia, hyperkeratosis, (at suitable clinical picture they are interpreted as polyp, simple leuloplakia, endocervicosis)

  • III-a type — mild, moderate dyplasia on the background of benign process and unaltered epithelium

  • III-b type — severe dysplasia of squamosus epithelium on the background of benign process and in the region of unaltered epithelium

  • IV type — suspicion of malignization intraepithelial cancer

  • V type — cancer

  • VI type — the smear is uninformative (the material was taken wrongly)

For the patients with III-V types of smears for confirmation of diagnosis simple and broadened colposcopy, and histological research must be held. Patients with III type of smears undergo regular medical monitoring. Colposcopy (simple and broadened) is used for the early diagnosis.

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.


Endometrial carcinoma belongs to hormone-sensitive diseases. Continuously increased estrogen production leads to excessive endometrial proliferation with trans formation -into malignant tumor. Immune status of organism, virus infection, genetic disorders play an important role in the development of this disease. Obesity, diabetes mellitus are classically associated with endometrial carcinoma and, therefore, qualified as risk factors.

Morphologically: adenocarcinoma, adenoacanthoma, clear cell meso-nephroid adenocarcinoma, adenosquamous carcinoma, undifferentiated cancer are the subtypes.

According to International classification, adenocarcinoma is classified into well, moderate and poorly differentiated tumors.

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. Histologycally, it is well-differentiated cancer with superficial invasion of the myometrium.

^ Unfavourable clinical course. 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

Treatment. Surgical, combined treatment, combining of radiation and hormones should be used.


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:

  • leiomyosarcoma

  • endometrial stromal sarcoma

  • carcinosarcoma (malignant mixed homologous mesodermal tumor)

  • mixed heterologous mesodermal tumor

  • other types of 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.


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. 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:

  • malignant epithelial cell tumors, which are the most common type, 46-48%

  • malignant germ cell tumors, 10-14%

  • malignant stromal cell tumors, 4,7%

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, mfundibulopelvic ligaments, paracolic gutters, right diaphragm and capsule of the liver. Ascites can often develop with peritoneal metasteses.

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. 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).

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.

Laparoscopy with diagnostic purposes should be indicated for the patients for revealing external peculiarities of the tumor, presence of dissemination and metastases. Sometimes diagnostic laparotomy is necessary in the evaluation of ovarian cancer.

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 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.


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

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 arise 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 pnmanly (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 penod 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.

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.

Diagnosis. Ultrasonography and laparoscopy, cytologic investigation of the uterine aspirate can prove the diagnosis.

Treatment is surgical.


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.

^ Clinical manifestations. 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.


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.

^ Clinical manifestations. 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.

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.

^ IV. Control questions and tasks

1. What is the Papanicolau method?

2. What are the forms of cervical carcinoma growth?

3. Diagnostic methods of vagina cancer.

4. Morphologically classification of endometrial carcinoma.

5. What kind the treatment should be used for endometrial carcinoma?

6. Stages of Primary Carcinoma of the ovary

7. What treatment is used for adenocarcinoma of the fallopian tube?

8. Stages of uterus cervix cancer.

9. Stages of uterus body cancer.

10. Classification of ovary cancer.

11. Methods of treatment.

V. List of recommended literature

1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.959-1121

2. Gynecology.-Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.-P.244-313

3. Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.-2000.-P.174-178;230-233

Approved on Session of Department of Obstetrics and Gynecology with course of Infant and Adolescent Gynecology_________________ protocol No___

T.a.The Head of Department:_______________O.A.Andriiets’


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On the conference of the Department iconM. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Rickets

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