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Методички онкология / 5 курс / САРС / 8 гинекология

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MINISTRY OF HEALTH OF UKRAINE

Kharkiv National Medical University

 

Approved

on the methodical meeting Department of Oncology

Head of Department

MD, professor Starikov VI

'28"August 2011

 

 

A methodical DEVELOPMENT

For independent work of students

 

Course 5

Faculty of Medicine (specialty "General Medicine", "Pediatrics", "Prophylactic medicine")

Study Subject: Oncology

Module number 1

Content module № 3

Subject: № 9. Uterine cancer, cervical, ovarian

number of training hours -5

 

Kharkiv November 2011

Topic.

In the last decade of the last and beginning of this century marked a steady incidence of uterine body cancer. In countries such as Sweden and the United States, endometrial cancer came in first place in the structure oncogynecology department of pathology. In Ukraine the increasing incidence of localization on average 6% a year. Increased morbidity associated not only with an increase in life expectancy, but with increasing frequency in women of various endocrine and metabolic disorders (diabetes, obesity, giperestrogeniya, anovulation, hypercholesterolemia, and others.). Uterine cancer (CUC) took 1st place in the structure oncogynecology department and 4th place in the structure of total cancer incidence. In Ukraine, the incidence is 23.8 cases per 100,000 women us. RTM common in older women - 55 years. The average age of patients with endometrial cancer 56.1 years. Women aged 50-59 years constitute 40-45% of all diseased. Proportion of women of reproductive age does not exceed 7%.

In frequency among malignant tumors of female genital cervical cancer ranks second. Over the past decade revealed a clear downward trend in the incidence of invasive cervical cancer, which explains the broad holding in former years, preventive examinations and cytological screening followed by treatment of dysplasia and preinvasive cancer. Dynamics of cervical cancer is age features. The peak incidence of cervical cancer is observed in 50-60 years. The greatest reduction in the incidence occurs in the reproductive age, a little less - premenopausal. There is no reduction in the incidence in women who are postmenopausal (probably it is associated with a rare visit to the obstetrician-gynecologist at this age). Mortality from cervical cancer has also distinct, downward trend, but still remains high, which necessitates storozhkosti cancer in physicians. No enough conclusive evidence to explain the cause of the background, precancerous and cancer of the cervix. The solution to this problem, the subject of numerous experimental and clinical studies. The role of age, early sexual activity, abortion, childbirth, birth injuries, diseases transmitted sexually by viral infection, heredity, hormonal disorders, diseases of sexual partners and others.

According to the incidence of ovarian cancer (OC) was 14 cases per 100 000 population. On average OC suffers one of seventy women (1.4%). The average age when there is ovarian cancer is 61 years old. Despite advances in the study of malignant tumors, the true causes of ovarian cancer are still poorly understood. Found that ovarian cancer is more common in women with a lack of parity, as well as those who have not applied for contraception oral contraceptives. In modern data demonstrated that oral contraceptives have a "protective" effect against cancer of the ovaries. Overall objective: to be able to diagnose and treat tumors of the body of the uterus, cervix, ovaries

Know:

Clinical picture of benign uterine, cervical, ovarian.

Pathological anatomy, risk factors for cancer of the uterine body, cervix, ovaries.

Classification, clinical manifestations, complications, diagnosis of cancer of the body of the uterus, cervix, ovaries.

Methods of treatment of cancer of the body of the uterus, cervix, ovaries.

Be able to:

1. On the basis of complaints, anamnesis, objective research, to identify the main syndromes tumors uterine, cervical, ovarian, put a preliminary diagnosis. 2. Appoint additional examination methods and evaluate their data 3. Conduct a differential diagnosis, to put the final diagnosis. 4. Appoint treatment

5. To carry out rehabilitation and preventive measures

Contents of training

Theoretical questions to topics that must learn studentyi: 1. Clinical symptoms of uterine cancer, cervical cancer, ovarian cancer.

2. Diagnosis of tumors of the body of the uterus, cervix, ovaries.

3. Classification of tumors of the body of the uterus, cervix, ovaries.

4. Question metastazuva tion.

5. Epidemiology of tumors of the uterine corpus, cervix, ovary, morbidity and mortality in cancer of the body of the uterus, cervix, ovaries, etiological factors and ant uhlynni disease pathogenesis.

6. The principles and tactics of treatment of tumors of the body of the uterus, cervix, ovaries, and long-term results of treatment of tumors of the body of the uterus, cervix, ovaries, diagnosis and l ikuvannya recurrence and metastases.

7. Predisposing factors and precancerous conditions, prevention.

8. Examination of disability, prognosis, rehabilitation patients

Uterine cancer (CUC) is ranked 1st among other sites of cancer of female genitalia. In Ukraine, the incidence is 23.8 per 100,000 of us.

RTM refers to hormone neoplasms. Estrogens are important factor proliferative endometrium, and also plays the role of a genetic factor. In other cases, RTM is caused by a virus.

Risk factors include patients with obesity, diabetes, hypertension, uterine fibroids, women who gave birth to large fruit.

Predecessors RTM: endometrial polyp, endometrial hyperplasia, atypical endometrial hyperplasia. It is considered preinvasive cancer.

Malignant neoplasms: adenocarcinoma, svitloklitynnyy cancer, squamous cell carcinoma, mixed carcinoma, undifferentiated.

Classification of cancer RTM:

T1 - tumor confined body of the uterus; T1a - uterus is up to 8 cm in length; T1b - uterus has more than 8 cm in length; T2 - the tumor extends to the cervix, T3 - tumor extends beyond Ms. uterus, vagina, does not go beyond the pelvis; T4 - tumor spreads to the bladder mucosa or rectum and extends beyond the pelvis.

Complaints of patients with CUC: spotting, bleeding, fluid uplavy - appearance chylorrhea. Pain in advanced stages of the disease.

Increased uterine determined at 2.4 cancers. The presence of vaginal walls metastases indicates Stage 3 RTM.

Diagnosis. Diagnostic curettage of the uterine cavity and cervical canal. Hysterography can determine location, size and spread of tumors in the uterine wall.

Treatment. Surgical and combined treatment method and RTM - basic.

Elderly patients with obesity with comorbidities perform simple hysterectomy with appendages, the tumor in the bottom of the uterus and in mature histological structure or if the tumor captures the entire uterus and passes to the cervical canal and a low degree of maturity used extended hysterectomy with appendages, removing parametrial tissue with regional lymph nodes. In order to prevent a recurrence of ablation and used before surgery radiation cryodestruction tumor.

In the presence of contraindications to surgical treatment and patient refusal of surgery is the method of choice combined-beam method of treatment - the parameters of remote exposure and intrauterine irradiation main focus in the uterus. Can be used hormones (17-alpha-hidrooksyprohesteron kapronat, Depo-Provera) at vysokodyferentsiyo - Vano RTM.

Cervical cancer is more common in the age of 50. There is a high incidence rate of cervical cancer among women of easy virtue. Incidence in Ukraine 21.4 per 100,000 population. It is more common in women with frequently changing sexual partners, as well as the sexual activity of carcinogenic action of smegma. It is believed that the virus herpes simplex 2 serotype (VGP-2) getting in smehmu virus is sexually transmitted.

PatAnatomy cervical cancer.

Background processes: pseudo, leukoplakia, cervical polyp.

Precancerous processes: mild dysplasia, moderate dysplasia, severe dysplasia CMM degree.

Intraepithelial carcinoma.

Mikroinvazivny cancer.

Invasive cancer.

Patients with dysplasia CMM is 20 times more likely to get sick than healthy intraepithelial cancer and 10 times more likely to invasive cervical cancer.

There are:

a) cervical intraepithelial or peredinvazyvnyy (no invasion of the stroma);

b) CC mikroinvazivny. Germinating in the stroma to a depth at 0, 3 cm.

Histologically, cervical cancer is:

Squamous - 95%.

Glandular.

Undifferentiated.

Intraepithelial cervical cancer has no clinical signs. Initial stages of cervical cancer are shaped ulcers. There are exophytic and endophytic form of cervical cancer.

Pre invasive cancer and mikroinvazivny asymptomatic. These stages are called preclinical preclinical cancer. The characteristic triad of symptoms of cervical cancer: pain, bleeding and uplavy characteristic of late, often inkurabelnoho cancer.

Pseudo at an initial invasive cancer - the touch pad and mirrors appears bleeding - an important symptom. Two-handed in intraepithelial vaginal examination and initial invasive cancer is not informative. In patients with severe clinical process - T 2 and T 3 - cervix dense or hryaschevydna available crater and infiltration. When suspected cervical cancer is mandatory research through the rectum - rektovahinalne and rektocherevne. In patients with stage II and higher cervical cancer in the parameters palpable infiltrates or sprouting in the rectum.

The method of early diagnosis of cervical cancer is cytology smear cervical scrapings churches of locally cervical canal. Material for cytology taken before bimanual examination. Cytology smears in cervical cancer is accurate in 95%.

The methods of early diagnosis of cervical cancer should colposcopy. Histological examination of tissue from the cervix is the most accurate method of diagnosis.

Doinvazyvnyy and mikroinvazivny (Tis and T1a) treated surgically (electroconization or amputation of the uterus, or a simple eksterpatsiya uterus).

Stage Cancer T 1b-2a cervical cancer treated with combined (radiation + surgery) or poyednanopromenevym method for radical program.

Poyednanopromenevyy method - is the use of two methods: contact (applique, intracavitary) and remote. The total course dose should not exceed tolerant dose of adjacent organs and constitute about 60 Gy.

Treatment of stage 2 in T -3 CC conducted combined - radiomethod the extent of the radical program.

Weather. In the first stage cervical cancer - 5-year survival rate - at 47-85%. In the second stage - 55-65%. In stage III - 20-30%.

The risk of OC increased twofold in patients with malignant breast tumors. Huge influence carries hereditary factor. A number of studies found that ovarian cancer can be transmitted hereditarily. In such cases, it is a family ovarian cancer. The probability of exposure to the disease is transmitted in 50% of cases from mother to daughter. Unfortunately, ovarian cancer is asymptomatic for a long time. Often she sees emerging symptoms as a manifestation adnexitis that is not uncommon in many of the fairer sex. Therefore, the first symptom that leads to see a doctor, there is an increase in the amount eaten. Conditional distribution of this symptom ovarian tumor in the abdomen, defeat omentum (fatty tissue located within the abdominal cavity) and accumulation in this regard, fluid (ascites). Early symptoms include the appearance of pain in the lower abdomen. Pains are often unexpressed, pulling character. Related the pain to those that occur in chronic inflammation of the uterus. Diagnosis of ovarian cancer, as well as other cancers, consisting of inspection and detection of symptoms and of instrumental methods. Gynecologist examines whether onkohinekoloh stomach sick, performed pelvic examination. In case of suspicion of ovarian cancer can be performed puncture of the abdominal cavity, followed by cytology obtained liquid. Instrumental methods include ultrasound, which can be detected ovarian tumor, and estimated prevalence of the process (of liver injury, the presence of ascites). In order to clarify the prevalence of the process may be carried out: radiography lung computed and magnetic resonance imaging of the abdomen. There laboratory techniques that can provide additional information. Thus, detection of high blood marker SA125 with persistent positive results of the study suggests that the presence of tumor. The main treatment for ovarian cancer combined - surgery and chemotherapy. The volume of surgical treatment depends on tumor spread. In the early stages remove the affected ovary. In the case of propagation process in the uterus is performed to remove it. At tumor in the gland, performed his resection (removal). Chemotherapy is usually complements surgical treatment. Now for the medicinal treatment of ovarian cancer using combinations of these drugs as cisplatin (and next-generation drug in this group - carboplatin), cyclophosphamide, taxol, and others. Control treatment is carried out in terms of tumor markers (SA125), ultrasound and other methods used to exclude / confirm tumor spread. At the first stage of ovarian cancer 5-year survival is 80% at the initial stage (defeat one ovary that does not apply to other organs), this figure is 95%. In the case of the running of ovarian cancer - stage 3 and 4 - to 5-year survival rate is 25-30%. For other cancers, such as cancer of the stomach or pancreatic cancer, it is pretty high figure. The main cause of death in OC disease is cardiovascular failure, intestinal permeability disorders, exhaustion. Similarly, the cause of death may become distant metastases to the lungs, liver and brain.

Literature Summary:

1.                   Bilynsky BT Oncology. Lviv, 1998.

2.                   Bilynsky BT Oncology. Lviv, 1992.

3.                   Peterson BE CANCER. Moscow: Medicine, 1980.

4.                   Slynchak SM CANCER. Kiev, 1989.

5.                   Trapeznikov NN CANCER. Moscow: Medicine, 1981.

6.                   Lecture material.

Further Reading:

1.       Bohman Y. Guide to onkohynekolohyy. Moscow: Medicine, 1989.-110 p.

2.       Vinnitsa VK Onkolohycheskaya lead researches. K. Health, 1983. - 248 p.

3.       Peterson BE, Chyssov VI, AI PABSEC Atlas Oncological operations. Moscow: Medicine, 1987. - 534 p.

4.       Chyssov VI Kombynyrovannoe and INTEGRATED Treatment of patients co zlokachestvennыmy tumors. Moscow: Medicine, 1989. - 560 p.

 

Quiz:

Uterine cancer

1. Clinical symptoms of uterine tumors. 2. Diagnosis of uterine tumors. 3. Classification of tumors of the uterine body. 4. Question metastasis 5. Epidemiology of uterine tumors, morbidity and mortality, etiological factors and Precancer disease pathogenesis. 6. Principles and treatment in uterine tumors, and long-term results of treatment of uterine body cancer, diagnosis and treatment of recurrences and metastases. 7. Predisposing factors and precancerous conditions, prevention. 8. Examination of disability, prognosis, rehabilitation patients

Cervical Cancer

1. The frequency of cervical cancer

2. Precancerous diseases and their treatment.

3. Morphological structure of tumors.

4. Classification of cervical cancer.

5. Clinic cervical cancer, diagnostics.

6. Method of and value colposcopy, cytological and histological examination of cervical cancer.

7. Select at ptymalnoho of treatment of cervical cancer depending on the stage of the process.

8. Weather.

Ovarian Cancer

1. Clinical symptoms of cancer of the uterus. 2. Diagnosis of tumors of the uterus. 3. Classification of tumors of the uterus. 4. Question metastasis 5. Epidemiology of cancer of the uterus, morbidity and mortality, etiological factors and Precancer disease pathogenesis. 6. The principles and tactics of treatment of tumors of the uterus, and long-term results of treatment of cancer of the uterus, diagnosis and treatment of recurrences and metastases. 7. Predisposing factors and precancerous conditions, prevention. 8. Examination of disability, prognosis, rehabilitation patients

 

test tasks (Correct answers indicated *)

Task 1. Woman '60 addressed the precinct gynecologist with complaints of spotting the external genital tract, which appeared two months ago. Obese III level, hypertension of II. Menopause 10 years. When rektovahinalnomu study uterus is not enlarged, epididymis involyutni. Infiltrates in the pelvis there. The cervix is not changed. What additional test method can offer the patient for further diagnosis? A. Diagnostic vyskoblennya uterus * V. pelvic ultrasound; S. hysterography; D. CT abdomen; E. Colposcopy.  

Task 2. Woman '38 suffers menstrual cycle during the last year. When rectal examination and pelvic ultrasound uterus and ovaries are not enlarged. Infiltrates in the pelvis there. Done diagnostic vyskoblennya uterus, endometrial polyp elements derived from ozloyakisnennyam. What is the best treatment option? A. Chemotherapy; B. Hormone; S. supravaginal amputation of uterus with appendages; D. Bilateral ovariectomy; E. hysterectomy with appendages. *

Task 3. Female 62 years old, who is in menopause for 12 years, complains of bloody vaginal discharge that appeared 5 months ago. When rektovahinalnomu study enlarged uterus to 7 weeks of pregnancy, tistuvata, mobile. Appendages not enlarged. Infiltrates in the pelvis there. When diagnostic vyskoblenni derived elements adenocarcinoma. What kind of treatment can offer this patient? A. Radiation therapy; V. supravaginal amputation of uterus with appendages; S. Duplex tubovariektomiya; D. Hysterectomy with appendages * E. Chemotherapy.

Task 4. Female 56 years old, indicating intense acyclic month for the last 3 years, pain in the abdomen. In the history of two sorts, one abortion. When rektovahinalnomu study enlarged uterus before 12 weeks of pregnancy, represented by individual nodes to 3.5 cm in diameter, mobile. With ultrasound pelvic nodes in the uterus are subserous. Appendages not enlarged. What diagnosis can put this patient? A. Fibroids Fibroids * B. Glandular endometrial hyperplasia; S. Polyp endometrial D. Cervical erosion; E. uterine cancer.

Task 5. After morphological verification of diagnosis "Endometrial cancer" patient '55 performed hysterectomy with appendages. Postoperative period equal. Histological examination of the removed product revealed highly differentiated adenocarcinoma, prorstayucha in myometrium. What additional therapies to offer this patient? A. Symptomatic therapy; B. Chemotherapy; S. Immunochemotherapy; D. Immunotherapy; E. Radiation therapy to a small bowl. *

Task 6 Patient, '48, who works as a teacher, 2 months ago, the treatment of tumors of the endometrium. How to evaluate the performance of the patient? A. Not broken * B. Temporarily lost C. Steadily lost D. It can not work with children E. Requires the reduction of working time

Target 7 Woman '55 appealed to the district gynecologist with complaints of spotting the external genital tract, which appeared two months ago. Obese III level, hypertension of II. Menopause 5 years. When rektovahinalnomu study uterus is not enlarged, epididymis involyutni. Infiltrates in the pelvis there. At cervix ulcer with protruding edges and yellow bottom. What additional test method can offer the patient for further diagnosis? A. Diagnostic vyskoblennya uterus; B. CT abdomen; C. Hysterography; D. Ultrasound of the pelvic E. Colposcopy with biopsy. *  

Target 8 Patient K., 52 years old, turned on the appearance within their last 3 months of contact bleeding from the genital tract. Examination revealed Ca in situ of the cervix. What is the best treatment option? A. Chemotherapy; B. Hormone; S. Diatermoelektroekstsyziya cervical D. Bilateral ovariectomy; E. hysterectomy with appendages. *

Target 9 Patient B., 28 years embarked on account of pregnancy at 24 weeks of life. In the study revealed cervical cancer and stage. What is the treatment in this patient? A. Abortion, surgery and radiotherapy Wertheim B. Cesarean section, surgery and radiotherapy Wertheim C. Prolongation of pregnancy up to 36 weeks, cesarean section, Wertheim operation and radiotherapy * D. Cesarean section, radiotherapy E. Treatment after the independent labor

Target 10 Female 50 years indicates intense acyclic month for the last 3 years, pain in the abdomen. In the history of two sorts, one abortion. When rektovahinalnomu study enlarged uterus and 6 weeks pregnant, represented by individual nodes to 0.5 cm in diameter, mobile. With ultrasound pelvic nodes in the uterus are subserous. Appendages not enlarged. When viewed in the mirrors on the cervix area congestion of the internal os 1.5 cm in diameter. What preliminary diagnosis can put this patient? A. Fibroids uterine cervical erosion * B. Glandular endometrial hyperplasia; S. Polyp endometrial D. Uterine cancer, cervical erosion; E. uterine cancer.

Target 11 Patient '66 morphologically verified diagnosis "Cervical cancer stage II." What is the treatment strategy? A. Symptomatic therapy; B. Chemotherapy; S. Immunochemotherapy; D. Combined radiotherapy; E. Surgical treatment and radiation therapy *

Target 12 Patient, '48, who works as a teacher, 2 months ago about the treatment of ovarian tumors. How to evaluate the performance of the patient? A. Not broken * B. Temporarily lost C. Steadily lost D. It can not work with children E. Requires the reduction of working time

Target 13 Patient B., 62 years with severe ascites, after celiocentesis (deleted to 8 liters of fluid) was determined by the limited mobile, painless swelling in the right iliac area. When ultrasound determined tumor right ovary 15h13 cm, homogeneous structure, with clear contours. Cytology in ascitic fluid - puhlynovydni cells were not found. What research should be done to clarify the diagnosis? A. Fibergastroduodenoscopy; B. Diagnostic laparotomy; C. Laparoscopy * D. Fibrokolonoskopiyu; E. Urine for Bence-Jones protein.

Target 14 Patient A., 57 years, menopause 4 years, complains of weakness, lack of appetite, discomfort in the lower abdomen. During bimanual examination: the uterus of normal size in anteflexio, to the right of it in the zone right appendages palpable tumor formation to 15 cm in diameter, painless, movable. What research should be done to diagnose? A. Puncture rear construction; B. Plain radiographs of the abdomen; C. Sample Roberha; D. Fibrokolonoskopiyu; E. Ultrasonography of the pelvis. *

Target 15 Patient G., 58 years appealed to the doctor about the rapid increase in the volume of the abdomen, pain in his lower divisions, dyspnea on exertion, pastoznost leg weakness. Located on the records about coronary heart disease. As most correct to interpret the symptoms described? A. Chronic intestinal obstruction; B. Ascites obscure origin * C. Decompensated heart failure; D. Fibroids of the uterus; E. Ascitic form of ovarian cancer.

  Target 16 Patient B., 59 years old approached in hospitals by place of residence with complaints of increased abdominal in volume. He considers himself a patient for the past two months, when the weakness, poor appetite, stomach began to grow rapidly. The examination revealed that the supine form of belly does not change, although clearly marked ballot. How to interpret given the symptoms? A. Chronic intestinal obstruction; B. Giant cystoma * C. Ascites obscure origins; D. Tubal pregnancy; E. Fibroids of the uterus.

Target 17 Patient L., 69 years with severe obesity complains of a feeling of heaviness in the abdomen, constipation. During bimanual examination clearly defined tumor of the uterus is impossible. These ultrasound - localization of the ovaries and determining their size is difficult because of pronounced obesity and flatulence. What diagnostic study to be done to clarify the diagnosis? A. Laparotomy; B. Laparoscopy; C. Plain radiographs of the abdomen; D. Enema * E. Built with a rear puncture cytology obtained material.

 

Methodological development was by Doctor. M.Sc., Prof. Mihanovskyy AA

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