Ministry of Public Health of Ukraine

National O.O.Bohomolets Medical University

Oncology Department

STUDY GUIDE

OF THE PRACTICAL COURSE

“ONCOLOGY”

Part I

For the students of medical faculties

Worked out by I.B.Shchepotin MD, PhD, DSci, Prof; G.A.Vakulenko MD, PhD,

DSci, Prof; V.E.Cheshuk MD, PhD, DSci; A.S.Zotov MD, PhD; O.I.Sidorchuk

MD, PhD; V.V.Zaychuk MD, PhD; L.V.Grivkova MD, PhD; O.E.Lobanova

MD; I.N.Motuzyuk MD; Y.V.Levchishin MD.

Kyiv - 2008

Ministry of Public Health of Ukraine

National O.O.Bohomolets Medical University

Oncology Department

“APPROVED”

Vice-Rector for Educational Affairs

Professor O. Yavorovskiy

______________

“___” __________ 2008

STUDY GUIDE

OF THE PRACTICAL COURSE

“ONCOLOGY”

Part I

For the students of medical faculties

Worked out by I.B.Shchepotin MD, PhD, DSci, Prof; G.A.Vakulenko MD, PhD,

DSci, Prof; V.E.Cheshuk MD, PhD, DSci; A.S.Zotov MD, PhD; O.I.Sidorchuk

MD, PhD; V.V.Zaychuk MD, PhD; L.V.Grivkova MD, PhD; O.E.Lobanova

MD; I.N.Motuzyuk MD; Y.V.Levchishin MD.

Kyiv - 2008

The texts of the lectures are approved by the methodical counsel

of Oncology Department.

Protocol № 19 « 17 » march 2008 .

CONTENTS

7. Tumors of the bones.

8. Tumors of the soft tissue.

9. Skin cancer. Melanoma.

10.Cervical cancer. Ovarian cancer. Uterine cancer.

7 . Tumors of the bones

Sarcomas can attack people without differentiating the age; however they occur

very rarely, accounting for just about a percentage all cases of cancers put together.

Although, close to a half of occurrences are in the limbs, generally sarcomas are

really unusual and that they can appear in any place of our bodies with a few

examples being muscle, skin, cartilage, bones, nerves and any of the internal organs

Primary skeletal neoplasms (bone tumors)

• account for only 1 - 1,5% of malignant tumors (0,2% of all human tumors),

(1–1,5 for 100.000 of population),

• metastatic disease is much more common.

Benignant bone tumors

• occur 2-3 times frequently than malignant ones.

Malignant skeletal tumors

• more common for men (1,5-2 times frequently, than for women)

• soft tissue-related counterparts outnumber bone tumors by a margin of

approximately 10:1.

• bone tumors are mostly of mesenchymal origin

• Ewing sarcoma, reticulosarcoma, etc. have neuroectodermal precursor cells.

bone tumors dispose in long tubular bones (40-70%)

• affect lower extremities 2-2,5 times more frequently than upper ones

• tumors, located in proximal parts of extremities are malignant

• few of the bone tumors affect small bones of feet and hands

• malignant bone tumors accounts for the age from 10 to 40 years

• primary bone tumors are more common for children.

The commonest benignant bone tumors, which affect children are:

• chondroblastoma

• bone fibroma

• osteoma

The commonest malignant bone tumors ones are:

• Ewing’s and osteogenic sarcomas.

After 40 years the commonest bone tumors are:

• chondrosarcoma,

• reticulosarcoma

• fibrosarcoma.

Because of their rarity, not much is known about the etiology and risk factors

of bone tumors.

• Radiation is associated with increased risk of soft tissue sarcomas.

Other factors that may increase risk of soft tissue sarcomas, :

• Vinyl chloride, used in making plastics

• Dioxin, an unwanted byproduct of incineration

• Herbicides that contain the chemical phenoxyacetic acid

The route of metastasis

• is usually hematogenous, and

• the lung (up for 80%) are the most frequent site of involvement.

• Lymphatic spread occurs less often (3-20%) and usually late in the course of

the disease.

Clinical presentation

Triad of symptoms are typical for bone tumors:

1. the presence of the tumor,

2. the pain &

3. malfunction of the defeated skeletal segment.

• In the beginning of the malignant process poor symptom data can be

discovered. The patient's general condition & preproduction testing data have

not remarkable changes.

• When the tumor is localized in the scull, vertebrae & near the big nerves,

neurological symptoms occur.

Diagnosis is made on:

1. the anamnesis data,

2. clinical presentation,

3. Rö-logical examination,

4. CT, MRI & angiography,

5. osteoscintigraphy (if it is necessary).

6. To evaluate the extend of soft-tissue defeating sonography, especially

dopplerography can be used.

7. The biopsy should be planned with the future surgical procedure in mind.

• Excisional biopsy is indicated for lesions less than 3cm in diameter,

• otherwise, incisional biopsy is indicated.

• Aspirate needle biopsy & trepan-biopsy are not descriptive.

Treatment of the bone tumors includes :

• surgery,

• radiotherapy &

• chemotherapy.

Surgical treatment includes:

1. both cripple operations –

• amputation or

• exarticulation of the extremity

2. & limb-sparing operations –

• excochleation,

• resection of the defeated bone,

• resection of the joint parts of the bones with the following substitution of this

defect by the plastic materials, bone transplants, polymers like hydroxilapatite),

• endoprosthesis of the big joints by modern prosthetic devices,

• distractive osteosynthesis.

• Sometimes cryotherapy can be used.

• Amputation & exarticulation are indicated when local resection cannot

be accomplished without jeopardizing of the function of the extremity

(i.e. involvement of major nerves or vessels occurs).

• If it is possible to remove the tumor completely, bone plastics or

endoprosthesis with the following radio- & chemotherapy are

accomplished even when solitary metastases are detected.

• radiotherapy

Bone sarcoma is a radioresistable tumor, that‘s why radiotherapy is applying

only as adjuvant for the surgery.

• chemotherapy

Endoarterial chemotherapy

is more effective then intravenous one. Treatment of the bone tumors, begins from

endoarterial chemotherapy during 4 days (2-6 courses with the 21-28 days intervals,

depending from the treatment effect) with the cisplatin, doxorubicin, metotrexat,

with the following radiotherapy (Σ dose 20-25Gy). Surgery after chemo- &

radiotherapy is developed.

System chemotherapy

After the operative treatment 5-6 courses of the system chemotherapy are usually

indicated:

• ifosfamid 3 mg/m2 & vincristin 1,4 mg/m2 during the 1 day, mesna 660

mg/m2 every 4 hours during 48 hours after the infusion of ifosfamid, cisplatin

100 mg/m2 during the 3 day.

• Or: doxorubicin 25 mg/m2 from the 1 to the 3 day, cisplatin 100 mg/m2

(prolonged infusion) during the 1 day. Cycles must be repeated every 3-4

weeks.

bone tumors treatment

• If the patient refuses to undergo the operation, radiotherapy (Σ dose 50-

60Gy) & system chemotherapy (6 courses) can be used.

• The possibility of the chemotherapy dose escalation with the

synchronous use of the haemopoetic grows factors (G-GSF –

granulocytostimulated grows factor, GM-CSF – granulocyto- &

macrofagostimulated grows factor) is investigated now .

• Metastatic lesions in the lungs can be resected if the primary tumor is

under good control and there is no evidence of other sites of involvement.

prognosis

• In the I-II stages 5-year survival achieves 70-80%.

• In the advanced cases (III-IV stages) 5-year survival is less than 30%.

• The more common reason of the death are the distant metastases (to the lungs,

bones, liver & brain).

Clinical presen-tation:Presence of the tumor, the pain &/or malfunction of the defeated skeletal segment

Diagnostics:Rö-graphia of the defeated skeletal segment (2 projections), CT, MRT osteoscintigraphy, angiography, sonography if it´snecessary, biopsy

Benignant bone tumors

Malignant bone tumors

Treatment:surgical: excochleation, resection of the defeated bone or exarticulation with the endoprosthesis of the joint.

Radical treatment (exceptchondrosarcoma, reticulosarcoma & Ewing´s sarcoma): neoadjuvantendoarterial & system chemotherapy withthe radiotherapy & the following operationresection of the defeated part of the bone (with the bone plastic or endoprosthetic),amputation or exarticulation of the limbwith the following chemo- & radiotherapy.

Palliative treatment (if the patient refuse to undergo the radical operation or/& if the radical treatment is impossible): radiotherapy & system chemotherapy are indicated

RECURRENCE

Radical treatment of the fibro- , chondrosarcomas: resection of the bone, if it´spossible, more common – high amputation or exarticulation of the limb.

Treatment of the reticulo- & Ewing´s sarcomas: radiotherapy & system chemotherapy

RECURRENCE

Treatment:surgical: resection of the defeated bone or exarticulation with the endoprosthesisof the joint, in exclusive cases –amputation of the limb .

Radical treatment: neoadjuvantendoarterial & system chemotherapywith the radiotherapy & the following operation reresection of the defeated part of the bone,amputation/reamputation or exarticulation of the limb with the following chemo- & radiotherapy.

bone tumors algorithm

1. The more common symptoms of the bone sarcomas are:

a. the presence of the tumor, appearance of the the pain and malfunction of

the nearest joint

b. the presence of the tumor, appearance of the the pain and high temperature

c. the presence of the tumor, bleeding and malfunction of the stomach

2. Diagnosis of the bone sarcoma may be proved by:

a. physical, Rő-logical examination, sonography

b. physical, Rő-logical examination, sonography, biopsy, CT, MRT

c. physical examination, sonography, ECG

3. Bone sarcomas often occur in the age of:

a. less than 20 years

b. from 20 to 45 years

c. elder than 50 years

4. Bone sarcomas are:

a. the rare tumors

b. common tumors

5. Treatment options for soft tissue sarcomas include:

a. surgery

b. radiation therapy

c. chemotherapy

d. all answers are correct

8. Tumors of the soft tissue

Connective (soft) tissues are are the ones that hold the body parts together and

connect one part to another. They are:

• muscle

• tendon

• ligament

• skin

• fat

• bone

• cartilage

• nerves

• blood vessels

• lymph vessels

Sarcoma starts in the body's connective tissues.

Cartilage tumors start in the bone, not in the joint.

Soft tissue tumors are developed from the nonepitelial and extraskeletal

tissues (except CNS, internal organs & endocrine system).

• These neoplasm's constitute only 0,2-2,6% of the malignant tumors and

affect

• equal often men & women,

• more common in the age of 20-50 years.

• In 70% cases soft tissue sarcomas affect the extremities and in 30% - the

body & pelvis.

• The AIDS epidemic has introduced us to what was previously a very rare -

Kaposi's sarcoma. 

• Other soft tissue tumours may be associated with genetic syndromes such as

neurofibromatosis. 

• Roughly 20 different types have been described, each with a slightly different

tendency to metastasize or to invade locally.

Histological classification on the soft tissue tumors (WHO 1998)

• Grading of bone tumors is roughly based on the cellularity of the lesion

compared to the amount of extra cellular matrix, nuclear features, the presence

of mitotic figures and necrosis. Staging via the TNM system is normally not

used, because metastases in lymph nodes are not frequent in these lesions.

Therefore staging is based on degree of differentiation of the tumor tissue and

local and distant spread of the tumor.

• I. Tumors & tumor-like lesions of the fibrous tissue.

• А. Benignant: Fibromas: 1. Solid fibroma; 2. Soft fibroma (fibromyoma); 3.

Dermatofibroma (Fibrous histiocytoma ); 4. Elastofibroma of the back.

• B. Benignant: Fibromatosis : 1. Scar fibromatosis; 2. Keloid; 3. Fasciitis

nodular; 4. Radiation fibromatosis; 5. Juvenile hyaline fibromatosis ; 6.

Abdominal fibromatosis (abdominal desmoid); 7. Aggressive fibromatosis

(nonabdominal desmoid); 8. Congenital fibromatosis.

• C. Malignant: 1. Fibrosarcoma.

• II. Fat tissue tumors.

• А. Benignant: 1. Lipoma (including fibrolipoma, angiolipoma etc.); 2.

Intermuscular lipoma; 3. Hibernoma; 4. Angiomyolipoma; 5.

Lipoblastomatosis; 6. Diffuse lipomatosis.

• Б. Malignant: 1. Liposarcoma.

• histological classification on the soft tissue tumors (continuation)

• III. Muscular tissue tumors

• А. Smooth muscle tumors.

• 1. Benignant: а) Leiomyoma; б) angiomyoma; в) leiomyoblastoma.

• 2. Malignant: а) Leiomyosarcoma .

• B. Striated muscle tumors.

• 1. Benignant: а) Rhabdomyoma ;

• 2. Malignant: а) Rhabdomyosarcoma .

• IV. Blood vessels tumors.

• А. Benignant.

• 1. Hemangioma : а) hemangioendothelioma benignant; б) capillary

hemangioma; в) cavernous; г) venous.

• 2. Intermuscular hemangioma (capillary, cavernous, arterio-venous);

• 3. System hemangiomatosis;

• 4. Hemangiomatosis with/without congenital arterio-venous fistula;

• 5. Hemangiopericytoma benignant, б) glomus tumor.

• 7. Angiolipoma.

• В. Malignant.

• 1. Hemangioendothelioma malignant (angiosarcoma);

• 2. Hemangiopericytoma malignant.

• V. Lymphatic vessels tumors.

• А. Benignant.

• 1. lymphangioma: а) capillary; б) cavernous: в) cystic;

• 2. Lymphangiomyoma;

• 3. System lymphangiomyomatosis .

• B. Malignant.

• 1. Lymphangioendothelioma malignant (lymphangiosarcoma);

• VI. Synovial tissue tumors.

• А. Benignant.

• 1. Benignant synovioma.

• B. Malignant.

• 1. Synovial sarcoma.

• VII. Mesothelial tissue tumors .

• А. Benignant mesothelioma .

• B. Malignant mesothelioma .

• VIII. The tumors of the peripheral nerves.

• А. Benignant.

• 1. Traumatic neuroma;

• 2. Neurofibroma;

• 3. Neurilemmoma (schwannoma );

• 4. Neurofibromatosis.

• B. Malignant.

• 1. Malignant schwannoma (neurofibrosarcoma);

• 2. Primitive neuroectodermal tumor (peripheral neuroepitelioma PNET).

• IX. Tumors of the sympatic ganglia.

• А. Benignant. 1. Ganglioneuroma.

• B. Malignant. 1. Neuroblastoma, ganglioneuroblastoma.

• Х. Tumors of the paraganglious stuctures.

• А. Pheochromocytoma: 1. Benignant; 2. Malignant.

• B. Chemodectoma: 1. Benignant; 2. Malignant.

• C. Nonclassified paraganglioma.

• XI. Plurypotential mesenchymal tumors

• А. Benignant: mesenchymoma.

• B. Malignant : Malignant mesenchymoma.

• ХII. Tumors of the possible extragenital origin.

• А. Benignant. 1. Teratoblastoma.

• B. Malignant.

• 1. Teratocarcinoma;

• 2. Embrional carcinoma.

• XIII. Tumor with nonelucidated hystogenesis.

• А. Benignant.

• 1. Granular cell tumor ;

• 3. Soft tissue osteoma;

• 4. Myxoma.

• 2. Soft tissue chondroma;

• B. Malignant.

• 1. Alveolar soft part sarcoma ;

• 2. Malignant granular cell tumor ;

• 3. Chondrosarcoma extraskeletal;

• 4. Osteosarcoma extrasceletal;

• 5. Malignant giant cell tumor of soft tissue/soft parts;

• 6. Malignant fibroxanthoma;

• 7. Kaposi's sarcoma ;

• 8. Giant cell tumor of tendon sheath .

• ХIV. Nontumorous or tumor-like lesions of the soft tissue.

• А. Xanthomas.

• B. Ganglia.

• C. Myositis ossi´ficans.

• D. Proliferative myositis.

• ХV. Nonclassified tumors of the soft tissue.

• The route of metastasis is usually hematogenous, and the lung (60-80%)

are the most frequent site of involvement.

• Lymphatic metastasis occurs less often (<20%) and usually later then

hematogenous ones.

Not much is known about the etiology and risk factors of the soft tissue

tumors. Most of the authors consider, that the trauma (even chronic one), doesn't

leads to the soft tissue sarcomas. There are few reports about the viral origin of the

sarcomas. Sometimes sarcomas may occur after the chronic inflammatory process or

benignant tumors.

Clinical presentation

These tumors usually present as an enlarging mass, wich is frequently painless.

If they occur in deep location, such as retroperitoneum, they are often quite large at

the time of diagnosis. In the beginning of the malignant process poor symptom data

can be discovered. The patient's general condition & preproduction testing data have

not remarkable changes.

The more common symptoms of the soft tissue sarcomas are:

• the presence of the tumor,

• appearance of the pain &

• (sometimes) the malfunction of the nearest joint.

When the tumor squeezes the big nerves or/& vessels, neurological symptoms occur.

Diagnosis is made on the

1. anamnesis data,

2. clinical presentation,

3. sonography (especially dopplerography),

4. Rö-logical examination,

5. CT, MRI & angiography, osteoscintigraphy if it is necessary.

6. Biopsy :

• excisional biopsy is indicated for lesions less than 3cm in diameter: otherwise,

• incisional biopsy is indicated. The biopsy should be planned with the future

surgical procedure in mind.

• Aspirate needle biopsy & trepan-biopsy are not descriptive.

Treatment

These tumors are frequently treated inadequately because they often have a

pseudocapsule, which may lead the surgeon to assume falsely that all of the tumor

has been removed. In reality, these tumor extend along tissue planes well beyond

their apparent margins.

As a rule, the main method of the treatment of the soft tissue tumors is surgical

one. When the tumor is benignant, the local excision is indicated.

Radical operations:

• limb sparing surgery, which is indicated when wide local excision

(excision of the tumor together with the surrounding tissues, taking into

account fascial zones) can be accomplished without jeopardizing the function

of the extremity (i.e., when the process is without involvement of major nerves

&/or vessels) ;

• amputation or exarticulation of the extremity (with the endoprosthesis

of the joints, when it is possible). Sometimes cryotherapy can be used.

If the recurrence arises, reexcision must be accomplished.

soft tissue tumors treatment

Radiotherapy can be used for adjuvant or neoadjuvant reason.

• Adjuvant radiotherapy is realized in a classic regimen of the fractions

with Σ dose 30-60Gy.

• Neoadjuvant radiotherapy is conducted by the big fractions (5Gy) during

4-5 seances.

• As a single method, or together with the chemotherapy, radiotherapy is

possible in the tumor is inoperable or/& the patient refuses from the operation.

Chemotherapy

Endoarterial chemotherapy is more effective then intravenous one.

Treatment of the soft tissue tumors, begins from endoarterial chemotherapy

during 4 days (1-4 courses with the 21-28 days intervals, depending from the

treatment effect) with the cisplatin, doxorubicin, metotrexat.

System chemotherapy : are usually indicated 5-6 courses of the adjuvant system

chemotherapy:

• ifosfamid 2,5 mg/м2 & mesna 660 mg/m2 every 4 hours during 48 hours after

the infusion of ifosfamid during 3 days, cisplatin 100 mg/m2 during the 1 day.

Or: doxorubicin 50 mg/m2, cyclophosphan 750 mg/m2, vincristin 1,4 mg/m2,

bleomycin 5 mg/m2 during the 1 day, prednisolon 60 mg/m2 1-5 days. Or: cisplatin

100 mg/m2 (prolonged infusion) during the 1 day, doxorubicin 50 mg/m2 during 2-

4days, vincristin 1,5 mg/m2 at the 5 day, cyclophosphan 600 mg/m2 at the 6 day.

Cycles must be repeated every 3-4 weeks with the 21-28 days intervals.

The survival of the patients with the soft tissue sarcomas greatly depends on

• the staging of the disease &

• the grade of the differentiation of the cells.

In the I-II stages 5-year survival achieves 70-80%.

In the advanced cases (III-IV stages) 5-year survival is less than 30%.

The more common reason of the death are the distant metastases (to the lungs, bones,

liver & brain).

Clinical presenta-tion:•Tumor•Pain•Malfunction of the limb

Diagnosis:Sonography& Rö-graphy, CT or MRI,angiography, incisive or excisivebiopsy.

Benignant tumors

Malignant tumors

Treatment Surgical – local excision

Treatment: endoarterialchemotherapy & radiotherapy with the following surgery (wide local excision, amputation or exarticulation of the limb. Postoperative chemo- &/or radiotherapy

Recurrence

Treatment Surgical – local reexcision

Potent-ialmalig-nanttumors

Treatmemt - wide local excision with the radiotherapy, in the case of an extraabdominal localization, chemotherapy can be used

Recueeence

Recurrence

Treatmemt -wide local excision with the radiotherapy

soft tissue tumors algorithm

Treatment: endoarterialchemotherapy & radiotherapy with the following surgery (wide local reexcision, reamputation or exarticulation of the limb. Postoperative chemo-&/or radiotherapy

Treatment (if the tumor is inoperable or/& the patient refuses from the operation) chemo- radiotherapy is indicated

1. What are the soft tissue sarcomas?

a. malignant tumors that develop in connect, support, or surround tissues

b. benignant tumors that develop in connect, support, or surround tissues

c. malignant tumors that develop in epithelial tissues

d. benignant tumors that develop in epithelial tissues

2. The more common symptoms of the soft tissue sarcomas are:

a. the presence of the tumor, appearance of the the pain and malfunction of

the nearest joint

b. the presence of the tumor, appearance of the the pain and high temperature

c. the presence of the tumor, bleeding and malfunction of the stomach

3. Diagnosis of the soft tissue sarcoma may be proved by:

a. physical, Rő-logical examination, sonography

b. physical, Rő-logical examination, sonography, biopsy

c. physical examination, sonography, ECG

4. The most informative type of biopsy is:

a. excisional or incisional biopsy

b. core-needle biopsy

c. fine-needle aspiration

5. Treatment options for soft tissue sarcomas include:

a. surgery

b. radiation therapy

c. chemotherapy

d. all answers are correct

9. Skin cancer. Melanoma.

Skin cancer (Cancroid)

Etiology

• high isolation

• long-term contact with chemical carcinogens – the products of oil refining,

coal, shale oils, arsenic combinations

• ionizing radiation

• constant skin injuries ( mechanical injuries, burns).

Patamorphology

• basal-cells (basalioma)

• Squamous Cell Carcinoma ( keratinized and non-keratinized)

• Epidemiology

Bulgaria the sickness rate is 36 for 100.000 of inhabitants;

England it is 1.9 for 100.000 of inhabitants;

Ukraine – 35-38 of 100.000 inhabitants.

It is observed that countrymen are more likely to have the skin cancer than the

city dwellers.

Facultative precancerous forms:

• keratosis

• skin horn

• senile skin atrophy

• atheroma

• deep skin mycosis

• keratoachanthoma

• papilloma

• red flat herpes

Obligate precancerous

• Bouen tumor

• Xeroderma Pigmentosum

• Cair disease

International classification according to the TNM system

• T- primary tumor

• TX-there is no enough evidence for the primary tumor

• T0- the primary tumor is not identified

• Tis- Carsinoma in situ

• T1-the tumor is 2 cm in the maximum measurement

• T2- the tumor is more than 2 cm, but less than 5 cm in the maximum

measurement

• T3- the tumor is more than 5 cm in the maximum measurement

• T4- the tumor grows into the lower organs (cartilages, muscles, bones).

N – regional lymph nodes

• Nx- there is no enough evidence for the evaluation of the regional lymph

nodes

• N0- there is no evidence of the regional lymph nodes affection

• N1- the regional lymph nodes are affected

M – distant metastasis

• Mx- there is not enough evidence to identify distant metastasis

• M0- distant metastasis are not identified

• M1- there are distant metastasis

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

  T3 N0 M0

Stage III T4 N0 M0

  Any T N1 M0

Stage IV Any T Any N M1

Clinically forms of the skin cancer

• superficial

• infiltrative or deep-penetrative

• papillary

Diagnostics

• examination

• palpation

• dermatoscopy

• cytological analysis of the scrape, smear

• incisionary biopsy

• to diagnose the metastases in the regional lymph nodes it is common to use the

sonography

• of the distant metastases, the radiography of the pectoral cavity organs and the

ultrasonography of the abdominal cavity.

Differential diagnostics

• Red Lupus

• Tuberculosis

• Syphilitic gumma

• Actinomycosis

• melanoma

• Non-malignant skin growths

Treatment squamous cell carcinoma

• Surgery (Stage I,II) wide ablation of the tumor with the healthy skin area

around it (not less than 2 cm) together with the hypodermic cellular tissue and

fascia

• radiotherapy (Stage I,II) (closely-focused radiotherapy, total dose is 30-60

Gr).

• medicines (Stage III,IV) (chemotherapy)

• in the presence of the enlarged regional lymph nodes, on suspicion of having

metastasis, lymphadenectomia is performed at the same time with the excision.

Treatment basal-celled skin cancer

• electroexcision (the recovery takes place in 95 % of cases)

• closely-focused radiotherapy (the recovery takes place in 90 % of cases)

• excision (the recovery takes place in 95% of cases)

• cryotherapy

• the relapse is treated by the wide excision.

Prognosis

• In case of the regional lymph nodes metastases absence 5-years survival is

guaranteed in 75-80 % of cases, and when it is early diagnosed almost 80-100

% of patients completely recover and do not have relapses.

• 5-years survival with the regional lymph nodes -metastases and growing

through the close organs and tissues is only 24%.

Non-malignant skin tumors of the conjunctive tissue-like origin.

• fibroma ( soft and hard)

• dermatofibroma

• lipoma

• angioma

• gemangioendotelioma

• neurofibroma

The treatment used here is surgical.

Skin sarcomas (histological classification)

• The tumors of formed dense conjunctive fibrous tissue ( fibrosarcoma and

dermatosarcoma Darie).

• The tumors of the fat base ( liposarcoma)

• The tumors of muscle tissue ( miosarcoma)

• The tumors of the blood and lymphatic vessels

(angiosarcoma, angioendotelioma, Caposhy sarcoma, lymphangiosarcoma).

• The tumors of the undifferentiated cells (undifferentiated sarcoma,

mixosarcoma).

The treatment of the skin sarcoma

• surgical

• closely-focused radiotherapy with corticosteroids.

• in cases of the generalized forms of Kaposhy sarcomas the cytostatic therapy

is used – the combination of doxorubicin, vinblastin and bleomicin, and also

monochemotherapy with the prospidin.

• as the biotherapy they use intron A.

Skin melanoma

Etiology

The exogenous risk factors

• Physical factors: ultra-violet radiation from the sun, ionizing radiation,

electromagnetic radiation, fluorescence illumination, nevus traumatism.

• Chemical factors: harmful chemical agents used in the petrochemical, chemical

( in particularly producing nitric acid), producing rubber plants, in the

production of vinyl chloride, polyvinyl chloride, plastic, benzol, pesticides.

• Biological factors: the nutrition quality ( high level of daily protein and adipose

consumption), medical products (exogenous estrogens).

The endogenous risk factors

Biological constitution features, which presence raises the risk of the

melanoma development: racial and ethnic predisposition, the level of the body

pigmentation, hereditary ( family) factors, anthropometric indexes, immune failings,

endocrine factors, reproductive women’ factors.

Predecessors of the melanoma, that is such pathological skin changes , which

can have the probability of the malignant mutation: pigmentary parchment-skin,

Dubrei melanosis, nevuses

Melanoma pathomorphology

• Epithelial

• spindle-celled

• mixed

• small-celled

International classification according to the TNM system

• T- primary tumor

• Tis- melanoma in situ

• T1-the tumor is less than 1mm thick; a) without ulceration and the invasion

level is II/III b)with ulceration or invasion level is IV/V.

• T2- the tumor is 1,01-2.0 mm thick, a) without ulceration b)with ulceration

• T3- the tumor is 2,01-4,0 mm thick; a) without ulceration b)with ulceration

• T4- the tumor is more than 4 mm thick a) without ulceration b)with ulceration

N- regional lymph nodes

• N1- metastases in 1 gland a)micrometastases 1; b)macrometastases 2

• N2-metastases in 2-3 lymph nodes a) micrometastases1; b)macrometastases2

c)transitional metastases/satellites without metastatic lymph nodes

• N3-4 and more metastatic lymph nodes or the conglomeration of lymph nodes,

or transitional metastases/satellites with metastatic lymph nodes

• 1-micrometastases are diagnosed after the observation or selective

lymphodenectomia.

• 2.- macrometastases - are clinically found metastases in the lymph nodes,

confirmed by the therapeutical lymphodenectomia or extracapsular spreading

of metastases in the lymph nodes.

M-distant metastases

• M1a- there are distant metastasis on the skin, hypodermic or in the lymph

nodes.

• M1b – metastases in the lungs.

• M1c – other visceral or any distant metastases.

  Clinical stages TNM Morphological stages pTNM

0 Tis N0 M0 Tis N0 M0

IA T1a N0 M0 T1a N0 M0

IB T1b N0 M0 T1b N0 M0

  T2a N0 M0 T2a N0 M0

IIA T2b N0 M0 T2b N0 M0

  T3a N0 M0 T3a N0 M0

IIB T3b N0 M0 T3b N0 M0

  T4a N0 M0 T4a N0 M0

IIC T4b N0 M0 T4b N0 M0

III Any T N1 M0      

    N2 M0      

    N3 M0      

IIIA       T1-4a N1a M0

        T1-4a N2a M0

             

IIIB       T1-4b N1a M0

        T1-4b N2a M0

        T1-4a N1b M0

        T1-4a N2b M0

        T1-4a/b N2c M0

IIIC       T1-4b N1b M0

        T1-4b N2b M0

        Any T N3 M0

IV Any T Any N Any M 1 Any T Any N Any M1

The main signs of nevuses malignisation

• Disappearing of the skin pattern on the nevus surface;

• appearance of the shiny, glossy nevus surface;

• appearance of the asymmetry or contours irregularity (scalloped) contours of

nevus, that is changes of its shape;

• Horizontal nevus growth;

• Appearance of the subjective heat sensation, itching or pain in the nevus area;

• Appearance of the single nodules ( satellites) around nevus;

• Appearance single nodules on the surface of the nevus without its visual

growth

• Peeling of the nevus surface with the formation of the withered “scabs”;

• Absence of hair or shedding of the hair on the nevus surface

• Partial (irregular) or complete color change of nevus –melanoma ( melanoma)

– appearance of the areas of so called bound depigmentation;

• Vertical growth of nevus- melanoma above the surrounding areas.

• The consistence change of the nevus-melanoma, which is defined with

palpation, that is its softening;

• Ulceration of the epidermis above the nevus-melanoma;

• Inflammation in the area of the nevus-melanoma and surrounding tissues;

• Weeping of the nevus-melanoma surface

• Bleeding of the nevus-melanoma.

Clinical-anatomical forms of the melanoma

• Superficial (70%)

• Nodule-like ( nodous, nodular) (15%)

• Acral lentigous and mucous melanoma ( 10%).

• Lentigo maligna melanoma (melanoma-like freckles)

Melanoma diagnostics

• studying anamnesis

• previous skin changes

• external tumor shape

• the state of the lymph nodes system

• dermatoscopy

• echography

• tumor thermography

• cytological analysis of the smears – the tumor prints, a sentinel node biopsy

• radioisotope scanning with the help of radio-active 32 P (300%)

Differential diagnostics of melanoma

• Youth melanoma ( Spits nevus)

• Blue nevus

• Galo-nevus

• Displastic nevuses

• Cavernous thrombotic gemangioma

• Non-malignant skin tumors

• Malignant skin tumors

• underungual, and underepidermal haematoma

• onihomikosis

• extrasexual chancre

• metastases of the other histogenesis tumors into the skin

Skin melanoma treatment

• The incision of the skin should be performed within the distance of 3-5 cm

from the tumor, in this case it is necessary to step back in the direction of the

regional lympho-outflow.

• It is necessary to ablate in one block the skin, hypodermic cellular tissue and

fascia.

• The surgery should be necessarily performed with the general anesthesia.

• When there is a suspicion of regional lymph nodes having metastases the

regional lymphadenectomy should be performed at the same time.

Stage I treatment

• The standard treatment in case of IA and IB stages - is wide excision of the

tumor at the distance of 2 cm from the tumor borders.

Stage II treatment

• The standard excision is at the distance of 3 cm from the tumor borders.

• Besides the tumor excision it is possible to perform immunotherapy using

interferon a-2b 3 ml ME/m2 of hypodermic injection 3 times per week during

3 years or until the relapse and melanoma metastases.

Stage III treatment

• The medical standard is wide excision of the primary tumor within 3 cm and

more combined with the regional lymphodenectomia.

• Chemotherapy ( chemoimmunotherapy), immunotherapy ( interferon a-2b,

BCG), polychemotherapy should be performed in usual or modified

( hyperthermia, hyperglycemia etc) conditions. As polychemotherapy

dacarbasin is used combined with the medications of platinum ( cisplatin),

alkaloids of periwinkle ( vinblastin), the medications of urea nitromesil group

(lomustin).

Stage IV treatment

• standard of this tumor treatment is systemic chemotherapy

• The surgical treatment of IV stage melanoma can be performed in the

presence of the single metastases in the lungs, gastrointestinal tract, bones or

brain. Palliative resections are done, which in some cases are very effective

and significantly prolong life.

• palliative radiotherapy can relieve the patients state

• in addition to melanoma treatment main schemes it is common to use

antiestrogens ( tamoksifen).

Prognosis

• in case of the localized process 5-years survival is possible in 75-86 %, 10-

years – 47%

• in case of the regional metastases - 33-52% and 13% accordingly

• in case of the distant metastasis 5-years survival does not exceeds 5-12%.

1. 45 years old patient has a star-shaped scar on the back of the right hand. This scar

appeared after the professional trauma 8 years ago. Recently the scar began to seal

and then ulcerated in the center. Biopsy showed the squamous cell carcinoma.

Regional lymph nodes did not change. Treatment tactics?

a. radiotherapy

b. chemotherapy

c. surgery

d. surgery and radiotherapy

e. surgery and polychemotherapy

2. An oncologist was approached by the 55 years old patient. A year ago the cancer

of the lower lip was diagnosed. After a course of shortfocused X-ray therapy his

ulcer healed. A month ago the ulcer appeared once again in the same area as well

an enlarged solid lymph node submaxillary. Treatment tactics?

a. chemotherapy and radiotherapy

b. surgery and polychemotherapy

c. surgery

d. polychemotherapy

e. radiotherapy

3. 25 years old man complained of the tumor in the area of the left arm-pit and the

dark birth-mark on his shoulder-blade. He was born with this birth-mark but

during the last half of the year (six months) it increased noticeably. 2 weeks ago a

tumor appeared in the left armpit and consist of several painless nodes. The skin –

remains unchanged. Treatment tactics?

a. polychemotherapy

b. immunotherapy

c. radiotherapy

d. radiotherapy and chemotherapy

e. surgery and polychemotherapy

4. 28 years old women has a problem with her birthmark in the area of the small of

the back that extends over the skin for 2-3 mm, and which she traumatized

several times with her girdle. Regional nodes are not increased. By way isotope

diagnostics radioactive phosphorus is accumulating nevus in amount of 180%.

Diagnosis?

a. basal-cells (basalioma)

b. squamous cell carcinoma

c. skin melanoma

d. displastic nevuses

e. cavernous thrombotic gemangioma

5. 48 years old women complains of the dark intumescences on the sole of her right

foot. Objective: in the area of the arch of the right foot there is a pigmental

formation 1*2 sm, it extends over the skin fjr 1-2 mm, and it is covered with

the thin blood – crust. Regional nodes are not increased.

Diagnosis?

a. displastic nevuses

b. cavernous thrombotic gemangioma

c. basal-cells (basalioma)

d. squamous cell carcinoma

e. skin melanoma

10. Cervical Cancer. Uterine cancer. Ovarian cancer.

Cervical Cancer

EPIDEMIOLOGY

Cervical cancer is the 2nd most common cancer in women (after breast cancer)

and is the 3rd leading killer (behind breast and lung cancer).

It affects about 16 per 100,000 women per year and causes death in about 9

per 100,000 per year.

In the Ukraine, howeever, cervical cancer is the 3rd most common cancer of

women. About 12,800 women in the Ukraine are diagnosed with cervical

cancer and about 4,800 die each year.

Among gynecological cancers it ranks behind endometrial cancer and ovarian

cancer.

HISTORY

1. Cervical cancer was common in female sex workers.

2. It was rare in nuns, except for those who had been sexually active before entering

the convent.

3. It was more common in the second wives of men whose first wives had died from

cervical cancer.

4. It was rare in Jewish women.

5. In 1935, Syverton and Berry discovered a relationship between HPV and skin

cancer in rabbits.

ETIOLOGY

1. The main cause of development of cervical cancer is human papillomavirus

(HPV) infection which responsible for more than 90% of the cases of cervical

cancer.

2. There are 230 types of HPV but only 7 common types of HPV which cause of

the cervical cancer: 16, 18, 31, 33, 42, 52 and 58.

3. Types 16 and 18 are the most dangerous in development of the cancer

Infect by HVP in world

Argentina & Honduras - 40%

USA – 26%;

Canada – 22%;

Sweden – 12,8%;

Denmark – 15,4%;

Japan – 10,7%

Spain – 5%.

RISK FACTORS

Human papillomavirus infection

Smoking

HIV infection

Chlamydia infection

Dietary factors

Oral contraceptives

Multiple pregnancies

Use of the hormonal drug diethylstilbestrol (DES)

Family history of cervical cancer

PATHOPHYSIOLOGY

HPV subtypes 16 and 18 introduce two genes called E6 and E7 which code for

proteins that inhibit p53 and Rb, which are two important tumor suppressor

genes in humans.

The p53 gene product is involved in regulation of apoptosis (cell suicide), and

Rb is responsible for halting the cell cycle at the G1-phase.

HISTOLOGY

Types of malignant cervical tumors include the following:

squamous cell carcinoma (about 80-85%) (Fig.3-7)

adenocarcinoma

adenosquamous carcinomas

small cell carcinoma

neuroendocrine carcinoma

melanoma

lymphoma

STAGING

Cervical cancer is staged by the FIGO staging system which is based on

clinical examination, rather than surgical findings.

For premalignant dysplastic changes, the CIN (cervical intraepithelial

neoplasia) grading is used.

The TNM staging system

Stage 0 - full-thickness involvement of the epithelium without invasion into the

stroma (carcinoma in situ)

Stage I - limited to the uterus (Fig.6)

– IA - diagnosed only by microscopy; no visible lesions

IA1 - stromal invasion less than 3 mm in depth and 7 mm or less

in horizontal spread

IA2 - stromal invasion between 3 and 5 mm with horizontal

spread of 7 mm or less

Treatment consists of surgery (including local excision) in early stages

– IB - visible lesion or a microscopic lesion with more than 5 mm of depth

or horizontal spread of more than 7 mm

IB1 - visible lesion 4 cm or less in greatest dimension

IB2 - visible lesion more than 4 cm

Stage II - invades beyond uterus

– IIA - without parametrial invasion

– IB - visible lesion or a microscopic lesion with more than 5 mm of depth

or horizontal spread of more than 7 mm

IB1 - visible lesion 4 cm or less in greatest dimension

IB2 - visible lesion more than 4 cm

Stage II - invades beyond uterus

– IIA - without parametrial invasion

Treatment consists of surgery and radiotherapy in advanced stages of the

disease

IIB - with parametrial invasion

Stage III - extends to pelvic wall or lower ⅓ of the vagina

– IIIA - involves lower ⅓ of vagina

– IIIB - extends to pelvic wall and/or causes hydronephrosis or non-

functioning kidney

IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis

IVB - distant metastasis

Treatment consists of chemotherapy and radiotherapy

Clinical presentation

1. Vaginal bleeding

2. Contact bleeding or (rarely) a vaginal mass.

3. Moderate pain during sexual intercourse

4. Vaginal discharge

Symptoms of advanced cervical cancer may include:

Heavy bleeding from the vagina

Loss of appetite

Weight loss

Fatigue

Pelvic pain

Back pain

Leg pain

Single swollen leg

Leaking of urine or feces from the vagina

Bone fractures

DIAGNOSIS

• Palpation

• Visual inspection of the cervix aided by using an acetic acid (e.g. vinegar)

solution to highlight abnormal cells on the surface of the cervix

• Colposcopy

• Endocervical curettage is made by doing a biopsy of the cervix

• Hysteroscopy

• Cystoscopy

• Proctoscopy

• Intravenous urography

• X-ray examination of the lungs and skeleton

• Cervical conization.

Rules of taking biopsy.

1. Target

2. From 3 areas

3. Use special brush for biopsy

TREATMENT

Treatment consists of :

1. Surgery (including local excision)

2. Chemotherapy

3. Radiotherapy

4. The HPV vaccine, for the two most common strains of HPV has recently been

licenced

Stage IA (microinvasive cancer) is usually treated by hysterectomy (removal

of the whole uterus including part of the vagina)

* An alternative for patients who desire to maintain fertility is a local surgical

procedure such as a LEEP or cone biopsy.

Stage IA2 can be treated by hysterectomy with removed the lymph nodes

S tages IB1 and IIA (less than 4 cm):

1. radical hysterectomy with removal of the lymph nodes

2. radiation therapy as external beam radiotherapy and

brachytherapy (internal radiation).

Stage IB2 and IIA (more than 4 cm):

3. radiation therapy and cisplatin-based chemotherapy

4. hysterectomy (which then usually requires adjuvant radiation

therapy),

5. cisplatin chemotherapy followed by hysterectomy.

Stage (IIB-IVA ) are treated with radiation therapy and cisplatin-based

chemotherapy.

Vaccine

1. Vaccine against four strains of HPV (6,11,16,18) is called Gardasil™ (Merck

& Co.).

2. Gardasil is targeted at girls of age 9 before they begin having sex and women

of age 26.

3. The vaccine works if given before infection occurs.

4. Vaccine is called Cervarix™ (Glaxosmithkline) has been effective in

preventing HPV strains 16 and 18

PROGNOSIS

5-year survival

Ia - 98%

Iб - 78-95%

III - 18-53%

IV - 6-20%

Uterine cancer

EPIDEMIOLOGY

Uterine cancer is the 1st most common cancer of the female reproductive

system.

It affects about 140 000 women each year and causes death in about 9 - 10 per

100,000 per year in world and 7 – 8 per 100,000 in Western Europe, in Ukraine -

24,2 per 100,000

RISK FACTORS

Women who experience menstruation begins before the age of 12 years old and

continues into a woman’s 50’s.

Women who have never experienced pregnancy

Women who do not experience regular cycles

Women with Type 2 diabetes or women who are obese

Women who participate in Estrogen-only Replacement Therapy (ERT)

Uterine cancer is more prevalent in older women (over the age of 40)

Women who have gone through menopause are especially encouraged to

consult a physician

HISTOLOGY

Types of malignant endometrial cancer, or cancer of the uterus, include the

following:

Endometrioid adenocarcinoma

Serous-papillary adenocarcinoma

Adenosquamous carcinoma

Light-cells adenocarcinoma

Mucinous adenocarcinoma

Squamous adenocarcinoma

Secretory carcinoma

Non-differentiated carcinoma

Сlinical presentation

Signs and symptoms of endometrial cancer include:

watery discharges from the vagina

abnormal vaginal bleeding

bleeding after menopause

spotting from the vagina

discharges from the vagina

pelvic pain

weight loss

DIAGNOSIS

Palpation

Rectal exam

Hysological exam include endometrial curettage is made by doing a biopsy of

the edometrium

Cytological exam

Hysterography

Hysteroscopy,

Ultrasonography

TREATMENT

The most common treatments for uterine cancer are:

surgery,

radiation therapy,

chemotherapy,

hormone therapy.

I. Surgery involves having a hysterectomy.

1. Simple hysterectomy (removal of the entire uterus)

2. Radical hysterectomy (removal of the uterus, surrounding tissues, and

cervix)

II. The option of radiation therapy involves using high-energy radiation.

III. Chemotherapy is most often used when the cancer has spread to other areas of

the body.

IV. Hormone therapy is mainly used to treat patients with endometrial stromal

sarcomas.

A progesterone-like hormone drug or a drug which stops the production of

estrogen can be used. Synthetic progestin - Depostat .

PROGNOSIS

5-year survival

Ia - 98%

Iб - 78-95%

III - 18-53%

IV - 6-20%

Ovarian cancer

EPIDEMIOLOGY

Ovarian cancer is the 2nd most commonly diagnosed gynecologic malignancy

and the 5th leading cause of cancer death in women.

The disease is more common in industrialized nations, with the exception of

Japan. In the United States, females have a 1.4% to 2.5% (1 out of 40-60

women) lifetime chance of developing ovarian cancer. In the Ukraine – 15,5

causes of 100 000 women

ETIOLOGY

Ovarian cancer is idiopathic, meaning that the exact cause is usually unknown.

The risk for developing ovarian cancer appears to be affected by several factors

RISK FACTORS

Age between 55 and 74 years old

Women who haven't been pregnant and never have a baby

Older ages of first pregnancy

Mutations of the BRCA1 or the BRCA2 gene

Personal history of breast cancer or a family history of breast

Syndrome hereditary nonpolyposis colorectal cancer (HNPCC, also known as

Lynch II syndrome)

CLASSIFICATION

Ovarian cancer is classified according to the histology of the tumor. Lesions differ

significantly in clinical features, management, and prognosis (ICD-O codes

provided where available).

I. Histology

Surface epithelial-stromal tumours are the most common and prototypic

ovarian cancers. They are include:

serous cystadenocarcinoma

mucinous cystadenocarcinoma.

Sex cord-stromal tumors include lesions that are hormonally active:

estrogen-producing granulosa cell tumor

virilizing Sertoli-Leydig cell tumor or arrhenoblastoma.

Germ cell tumors originate from dysplastic germ material and tend to occur in

young women and girls. Lesions include:

the dysgerminoma, a form of the choriocarcinoma

malignant forms of the teratoma.

II.History

Primary is the tumor which growth in ovary originally.

Secondary, the result of metastasis from primary cancers elsewhere in the

body. For example, from breast cancer, or from gastrointestinal cancer (in

which case the ovarian cancer is a Krukenberg cancer)

Staging

Ovarian cancer staging is by the FIGO staging system and uses information obtained

after surgery.

The AJCC stage is the same as the FIGO stage.

Stage I - limited to one or both ovaries

• IA - involves one ovary; capsule intact; no tumor on ovarian surface; no

malignant cells in ascites or peritoneal washings

• IB - involves both ovaries; capsule intact; no tumor on ovarian surface;

negative washings

• IC - tumor limited to ovaries with any of the following: capsule

ruptured, tumor on ovarian surface, positive washings

Stage II - pelvic extension or implants

• IIA - extension or implants onto uterus or fallopian tube; negative

washings

• IIB - extension or implants onto other pelvic structures; negative

washings

• IIC - pelvic extension or implants with positive peritoneal washings

Stage III - microscopic peritoneal implants outside of the pelvis; or limited to

the pelvis with extension to the small bowel or omentum

• IIIA - microscopic peritoneal metastases beyond pelvis

• IIIB - macroscopic peritoneal metastases beyond pelvis less than 2 cm in

size

• IIIC - peritoneal metastases beyond pelvis > 2 cm or lymph node

metastases*

Stage IV - distant metastases--in the liver, or outside the peritoneal cavity

* Para-aortic lymph node metastases are considered regional lymph nodes (Stage

IIIC).

DIAGNOSIS

Ovarian cancer at its early stages (I/II) is difficult to diagnose until it spreads and

advances to later stages (III/IV). This is due to the fact that most of the common

symptoms are non-specific.

Diagnosis includes:

Symptoms

Physical examination

Pelvic examination

Instrumental examination

Laboratory examination

sense of pelvic heaviness

vaginal bleeding

weight gain or weight loss

abnormal menstrual cycles

unexplained back pain that worsens over time

increased abdominal girth

non specific gastrointestinal symptoms:

vague lower abdominal discomfort

increased gas

indigestion

lack of appetite

nausea and vomiting

Bloody stool

inability to ingest usual volumes of food

bloating

Additional symptoms that may be associated with this disease:

increased urinary frequency/urgency

excessive hair growth

Fluid buildup in the lining around the lungs (Pleural effusions)

Positive pregnancy readings (in the absence of pregnancy. This is for germ cell

tumors only)

Note: There may be no symptoms until late in the disease.

Physical examination may reveal increased abdominal girth and /or ascites (fluid

within the abdominal cavity).

Pelvic examination may reveal an ovarian or abdominal mass. The pelvic exam

can include a rectovaginal component for better palpation of the ovaries.

Instrumental examination

1. Abdominal ultrasound

2. Ultrasound of small pelvis

3. Trans-vaginal ultrasound

4. CT scan of the abdomen and pelvis

5. MRI

Laboratory examination

The blood test called CA-125 is useful in differential diagnosis and in follow

up of the disease, but it has not been shown to be an effective method to screen

for early-stage ovarian cancer and is currently not recommended for this use.

The blood test on levels of lysophospholipids (a type of fatty acid)

TREATMENT

The treatment consist of

1. Surgery

2. Chemotherapy

3. Radiation therapy

4. Hormonal therapy

I. Surgery is the preferred treatment and is frequently necessary for diagnosis. The

type of surgery depends upon how widespread the cancer is when diagnosed (the

cancer stage), as well as the type and grade of cancer.

The types of surgery are:

Unilateral oophorectomy or bilateral oophorectomy - make only in stage 1, low

grade or low-risk disease, especially in young females who wish to preserve their

fertility

Panhysterectomy + omentectomy (in stage 1’2’3)

In advanced disease as much tumor as possible is removed (debulking surgery)

II. Chemotherapy can be used before and after surgery and to treat women who have

a recurrence.

1). Cysplatinum (Р) - 100 mg/м2 number 1 in 3 weeks; or

2). Cysplatinum (Р) - 50 mg/м2 number 1in week during 6-8 weeks; or

3). Carboplatinum (СвР) AUC 5-7 number 1 in 3 weeks; or

4). Cysplatin - 75 mg/м2 + cyclophophanum 750 mg/м2 number 1 in 3 weeks; or

5). Carboplatinum (СвР) AUC 5 + cyclophophanum 750 mg/м2 number 1 in 3

weeks;

III. Radiation therapy is not effective for treatment ovarian cancer.

IV. Hormonal therapy can be used androgens or/and ant estrogens

COMPLICATIONS

spread of the cancer to other organs

progressive function loss of various organs

ascites (fluid in the abdomen)

blockage of the intestines

PROGNOSIS

Size of residual tumor Duration of life

< 0,5 cm 40 months.

0,5 – 2 cm 18 months

2 cm 6 months

Ovarian cancer has a poor prognosis. It is disproportionately deadly because

symptoms are vague and non-specific. More than 50% of women with ovarian

cancer are diagnosed in the advanced stages of the disease because no cost-

effective screening test for ovarian cancer exists.

The 5-year survival rate for all stages is only 35% to 38%. If, however,

diagnosis is made early in the disease, 5-year survival rates can reach 90% to

98%.

Frequency of recidivations:

♦ in early stages - 20-30%

♦ in advanced stages - 65-96%.

1. What is the main cause of development cervical cancer?

a. simple herpes virus

b. human papillomavirus

c. mechanical trauma

d. radiation

2. What are kinds of special treatment stage Ia cervical cancer you will choose?

a. radical hysterectomy

b. radiation therapy

c. cisplatin chemotherapy

d. LEEP

3. What are complications of ovarian cancer?

a. pathological fractures

b. ascites (fluid in the abdomen)

c. bleeding

d. pancreatitis

4. What is main laboratory test of ovarian cancer?

a. level of leukocytes

b. CA-125

c. level of glucose

d. level of blood protein

5. Radical hysterectomy is:

a. removal of the entire uterus

b. removal of the uterus, surrounding tissues, and cervix

c. removal of the uterus, surrounding tissues, cervix, omentumectomy

d. removal of the entire uterus without ovaries