G. CHAKALOVA
Int. J. Gynecol. Cancer, vol. 23, Suppl 1, 2013, p.268.
Department of Gynecological Oncology, National Oncology Hospital, Sofia, Bulgaria.
Female sexual dysfunction is common complication after most pelvic surgeries. Sexual dysfunction is a major quality-of-life issue in these young women and a common problem among postmenopausal women. Hysterectomy (simple or radical) is the most common type of pelvic surgery in women and is one of the most important causes of female sexual dysfunction. From 2007 till 2011, a study of sexual dysfunction of 189 female cancer patients was performed. Primary tumor was in 151 cases, primary multiple malignant tumor – in 28 cases and familial cancer – in 10 cases. Patient self-report of the severity of sexual symptomology at follow-up visit was used. Patients received symptomatic treatment recommendations including hormone therapy alternatives, psychosexual counseling, minimally absorbed vaginal estrogen suppositories, and vaginal dilators. Median age at initial visit was 52 years and 111 patients (58%) were postmenopausal. Symptoms management was carried out. The most frequent presenting complaint encountered was dyspareunia (69%), atrophic vaginitis (66%), hypoactive desire (44%), and orgasmic dysfunction (21%). Female sexual dysfunction is an important issue after breast cancer (radical mastectomy) and colorectal cancer (simple and radical proctocolectomy) in combination with the PMMT gynecological cancer. At a median of 6 months 92 patients (49%) self-reported improvement in their symptoms. The establishment of a well-structured sexual health program in a cancer setting can result in a 49% subjective improvement in sexual health complaints. Modifications in the surgical technique (nerve sparing) are recommended in the field of gynecologic surgery. It is reasonable to prescribe hormonal replacement therapy to symptomatic, well informed patients.
THE ANALYSIS OF CERVICAL CANCER FOR A 25-YEAR PERIOD
G. CHAKALOVA
Int.J. Gynecol Cancer, vol. 19, 2009, Supl. 2, 128.
Clinic of Gynecology, National Oncological Hospital, Sofia, Bulgaria
Background: Cervical cancer is the most frequent oncogynecologic disease in Bulgaria. In the last decades an increased number of cases were detected.
Patients and methods: From 1982 till 2006 3581 patients with cervical cancer were treated in our clinic.
Results: 1419 cases were stage I, 1201 – stage II, 924 – stage III, and 37 – stage IV. In a 25-year period we found a decreasing number of cases in stage I – from 53% to 39%, and an increasing number of cases in stage II – from 25% to 34%, and stage III – from 21% to 26%. In 14,4% (516 patients) of the cases of cervical cancer patients were 44 years of age or younger. In the last years we also found an increasing number of cases in the early age group (from 36 in the first years to 112 in the last years). Treatment was in correlation with the stage of the disease and in 2115 cases a radical hysterectomy with lymph node dissection was performed. A postoperative radiation therapy was used in stage I, and in stage II - both. Operation in stage III was performed because of the persistence of the disease after radiotherapy. In 1466 cases only radiation therapy was performed.
Conclusion: Our results suggest that cervical cancer has increased the stages, and decreased age in the last 25 years because of the absence of a national screening program.
THE INCIDENCE OF GERIATRIC GYNECOLOGICAL ONCOLOGY PATIENTS FOR A 25 YEAR PERIODE
PROF. G. CHAKALOVA
Journal of BUON, 13, Supll. 1, 2008, 46, OP-150.
Head of the Clinic of Gynecology, National Oncological Hospital, Sofia, Bulgaria
Background: The incidence of geriatric oncology patients has not been studied very well. A prospective study of the incidence of geriatric oncogynecological patients was presented.
Patients and methods: From 1982 till 2006 in our clinic 8377 patients with gynecological malignancies and 1198 patients with carcinoma in situ were treated. 834 (10%) of them were 70 years of age or more.
Results: 528 patients (63,3%) were between 70 and 74 years of age, 215 patients (25,8%) were between 75 and 79 years of age and 91 patients (10,9%) were 80 years of age and older. The highest number of patients was the ones with endometrial cancer – 240 cases. Ovarian cancer was detected in 192 cases, and vulvar cancer – in 180 cases. Cervical cancer was diagnosed in 169 cases, uterine sarcoma – in 37 cases and vaginal cancer – in 16 cases. The highest percentage of geriatric patients were those with vulvar cancer – 23,4%, and uterine sarcoma – 22,22%. 17% were with vaginal cancer, 15,9% were with endometrial carcinoma, and 9,5% were with ovarian cancer. The percentage of geriatric patients with cervical cancer was only 4,7. The operation and radiation were used in cases of endometrial, cervical and vulvar cancer. The patients with vaginal cancer were treated with radiation therapy. In cases of ovarian cancer operation and chemotherapy were performed. Uterine sarcomas were treated with operation, radiation or chemotherapy.
The therapy management in geriatric gynecological oncology patients is the same like in the cases of young patients. In some cases the operation was contraindicated because cardio-vascular, pulmonary or cerebral diseases.
Conclusion: Our results suggest that very old patients with gynecological malignancies are 10 % of the all patients with those pathology. The key in choosing the treatment therapy is the localization and the stage, while the age is not relevant to the tactics. The cases of geriatric gynecological malignancies were treated following the same guidelines like younger patients.
THE INCIDENCE OF LYMPH NODE METASTASIS IN CASES OF ENDOMETRIAL CANCER
G. CHAKALOVA
Int. J. Gynecol. Cancer, vol. 20, Suppl 2, October 2010, р. 86.
Dep. Gynecological Oncology, National Oncologic Hospital, Sofia, Bulgaria
Background: Endometrial cancer is the most frequent of gynecologic neoplasm. The staging is being done surgically, and the prognosis is worst in cases with lymph node metastasis.
Aim: A prospective study of the incidence of the lymph node metastasis in cases of endometrial cancer.
Materials and methods: 567 patients with endometrial cancer (8 with carcinosarcoma) were treated surgically at our department (2004-2009). Before the operation the clinical stages detected were as: Stage I - 427 patients, Stage ІІ - 95 patients, Stage ІІІ - 44 patients and Stage ІV- 1 patient.
Results: In 430 cases (75%) a lymph node dissection was performed. In 144 cases (33,5%) a pelvic lymph node metastasis was detected. 59 patients (40,9%) were staged as Stage I, 75 patients (52,1%) - as Stage ІІ and 10 patients (7%) - as Stage ІІІ had metastases.
After surgical staging from 427 patients with Stage I (IA and IB) only 368 remained, 59 were staged as IIIC1 - with positive pelvic lymph nodes, from 95 patients with Stage II only 20 remained, and 75 were staged as IIIC1 - with positive pelvic lymph nodes.
After surgical staging the cases in Stage ІІІ increased from 44 to 178.
Conclusions: Because of the surgical staging 134 patients were restaged and were treated with the necessary radiation and chemotherapy. Our results suggest that pelvic lymph node metastasis can often be found.
TOPICAL ADMINISTRATION OF INTERFERON-alfa
IN CASES OF HPV INFECTION AFTER TREATMENT OF CIN FOR PREVENCION OF RECURENCES AND CERVICAL CANCER
GALINA CHAKALOVA, MD, PhD*, GANCO GANCEV, MD, PhD **
Int. J. Gynecol. Cancer. 23, 2013, (in press)
Department of Gynecological Oncology*, Department of Pathology **,
National Oncological Center, Sofia, Bulgaria
Summary
Objective: The aim of the present study was to investigate the optimal follow-up after treatment for CIN and the efficacy and the optimal dose of topical Interferon-alfa in cases of HPV infection after treatment of CIN for prevention of recurrences and cervical cancer.
Materials and Methods: Between 3 and 6 months after the treatment of 750 patients with CIN II-III, in 175 cases (23%) the cytological abnormalities were detected. HPV DNA was examined by the PCR. The most frequent types was HPV 16 (101 cases), HPV 31 in 50 cases, and HPV 18 in 24 cases were found. Interferon-alfa was injected locally tree-times per week- 3 Mio UI for a total of 10 administrations.
Results: After 5 applications cytological control was performed. In 99 cases (56,6%) cytology reversed to normal and in 76 cases (43.4%) Pap IIID were found. Of those 76 cases, 56 patients were with HPV 16, 5 patients were with HPV 18 and 15 patients were with HPV 31. After 10 applications cytologically Pap I-II were detected in all cases.
Conclusion: Short term monitoring post-treatment of women with combined HPV testing and cytology at 3, 6, 12 and 24 months seems to be sufficient to detect post-treatment cervical disease. Topical Interferon-alfa treatment is an effective therapeutic method for persistent HPV infection (types 16, 18 and 31) after the treatment of CIN II-III, and total dose of 30 MIU are the optimal dose. In cases of persistent HPV or reinfection an Interferon treatment will be a good prevention of CIN and cervical cancer.
Key Words: CIN; HPV; Interferon treatment
VAGINAL CANCER-INCIDENCE, STAGE AND TREATMENT
G. CHAKALOVA
Int.J. Gynecol Cancer, vol. 18, 2008, Supl., p.120.
Dep. Gynecological Oncology, National Oncologic Hospital, Sofia, Bulgaria
Purpose: Vaginal cancer is a very rare tumor. The aim of this study is to analyze the incidence of vaginal malignancies.
Materials: From 1982 until 2006 in our department 9575 patients with gynecological malignancies were treated. A prospective study of vaginal pathology was performed. For a 25-year period 100 patients (1%) were diagnosed with a vaginal disease.
Results: Carcinoma in situ was detected in 6 cases, Stage I was detected in 32 cases, Stage II – in 29 cases, and Stage IV – in 3 cases. Histological investigation detected squamous cell carcinoma in 96 cases, adenocarcinoma in 2 cases and malignant melanoma in 2 cases. Primary multiple malignancy was found in 10 cases. Four cases of the combination of carcinoma in situ of the vagina and cervical cancer and three cases of the combination of invasive vaginal cancer and cervical cancer were found. One case with endometrial, one case of ovarian and one case of breast cancer in combination with vaginal cancer were found. Operative treatment –hysterectomy with lymph node dissection and vaginal extirpation were used in 67 cases (and in 61 of them postoperative radiation therapy was used). In 33 cases only radiation therapy was used. Three and five-year survival is 73 and 59% respectively.
Conclusion: Vaginal cancer is a rare tumor with a large number of advanced stages and only a half of the patients survive for more than 5 years.
Chakalova, G.
Stage I endometrial cancer: 5,10 and 15-year survival.
Int.J. Gynecol Cancer, vol. 15, 2005, p.108.
Meeting website: www.kenes.com/esgo14prog/ program/SessionIndex.asp.
VULVAR CANCER: CHARACTERISTICS OF THE DISEASE, DETECTION, RECURRENCES AND MULTIPLE MALIGNANCIES
K. Angelov, G. Chakalova
Journal of BUON, 13, Supll. 1, 2008, 46, OP-151.
National Oncologic Hospital, Sofia, Bulgaria
Background: Vulvar cancers is one the most rare gynecologic cancer. The treatment is operation and radiation therapy. The recurrences are a common event.
Objective: The aim of this study is to evaluate the characteristics of the disease, the frequency of the recurrences and multiple malignancies.
Materials and methods: A prospective study for a 10-year period (1996-2005) in our clinic was held. 331 patients with vulvar malignancies were treated. Hystologically squamous cell cancer was detected in 313 cases, adenocarcinoma - in 12 cases, and malignant melanoma in 6 cases. Stage determination is: Stage I - 86 patients, Stage II - 115 patients, Stage III - 118 patients, and Stage IV - 12 patients. The radical vulvectomy with bilateral ingvinofemural lymphadenectomy was performed in 41 cases, and postoperative radiation therapy was used in 95% of the cases. Two patients were treated only with radiation therapy.
Results: In 66 cases (19,93%) recurrences of the disease was detected. The age characteristics of the patients with recurrences was: Till 45 years of age there were 2 patients, in the group 46-55 years of age there were 7 patients, in the group 56-65 years of age there were 15 and in the group with patients older than 66 years of age there were 42. Well differentiated cancer was detected in 35 cases, moderate differentiated was detected in 19 cases and low differentiated was detected in 7 cases. The initial stages were: Stage I – 1 patient, Stage II - 21 patients, Stage III - 26 patients, and Stage IV - 1 patient. In 30 cases lymph node metastasis were found. Till the first two years after the initial treatment recurrences were detected in 62% of the cases. Multiple primary malignant tumors were detected in 22 cases (6,68%). In 20 cases - a spinocellular and in 2 cases - malignant melanoma was found. In 1 case a triple malignancies was diagnosed. Vulvar cancer was the second one, and most cases were detected in Stage III. Vulvar cancer was detected in 10 cases with breast cancer, in 6 cases - with cervical cancer, in 2 cases - with colon cancer, in 2 cases - with skin cancer. One case with bladder cancer, rectal cancer and lymphoma was found.
Conclusion: Squamous cell recurrent vulvar cancer is most often seen in the 56-75 years of age group. Regular gynecological examinations will help early detection of recurrent vulvar cancer and the cases with multiple primary malignancies.
Епидемиология на злокачествените тумори на маточната шийка, маточното тяло и яйчника в България.
Димитрова, Н., Г. Чакалова.
Онкология, 40, 2012, 3, 7-8.
РЕЗЮМЕ
Злокачествените тумори на маточната шийка, маточното тяло и яйчника представляват съответно 6.5%, 7.7%, и 5.2% от всички злокачествени заболявания, регистрирани при жените през 2009 г. Те са съответно на 5-то, 3-то и 6-то място по честота с 1072 нови случаи злокачествени тумори на маточната шийка (27.4 на 100 000 жени), 1278 - на маточното тяло (32.6 на 100 000 жени), и 862 – на яйчника (22.0 на 100 000 жени). Най-засегнатите възрастови групи са: 45-49 годишните при рак на маточната шийка (53.9 на 100 000), 65-69 годишните при злокачествените тумори на маточното тяло (90.3 на 100 000) и 60-64 годишните – при тези на яйчника. За периода 1993 – 2009 г. заболяемостта и при трите локализации се увеличава. Най-бързо е увеличението при рака на маточната шийка – средно с 2% годишно. Средно-годишното увеличение на заболяемостта от рак на маточното тяло и на яйчника е 1.6% и 1.5%, съответно. През 2009 г. от злокачествени тумори на маточното тяло са починали 242 жени (6.2 на 100 000), от рак на маточната шийка – 356 (9.1 на 100 000) и 395 (10.1 на 100 000) са починалите от злокачествени тумори на яйчника. В структурата на смъртността от злокачествени тумори, тези на маточната шийка заемат 5.1%, на маточното тяло – 3.4% и на яйчника – 5.6%. В последните години се наблюдава лека, макар и неуверена, тенденция за понижаване на смъртността и при трите разглеждани локализации. Преживяемостта и при трите локализации е по-добра при пациентите, диагностицирани след 2001 г, в сравнение с по-ранен период. Медианната преживяемост, 5-годишната преживяемост, статистическата значимост на разликата между периодите 1993 – 2000 г. и 2001 – 2009 г.
АЛГОРИТЪМ ЗА ЛЕЧЕНИЕ НА РАКА НА ВУЛВАТА, ПЕРСИСТЕНЦИЯТА И РЕЦИДИВИТЕ И ПРОСЛЕДЯВАНЕ НА БОЛНИТЕ
Г. ЧАКАЛОВА (1), Е. ПЕТКОВА (2)
Онкология, 40, 2012, 3, 25-28.
Клиника по гинекология (1), Клиника по лъчетерапия (2), СБАЛО
ЕПИДЕМИОЛОГИЯ
На възраст до 44 години е 1 на 100 000 жени, възраст от 45 до 64 години са 3 на 100 000 жени, а на възраст над 65 години са 13 на 100 000 жени. В България през последното десетилетие годишно заболяват малко над 120 жени.
ХИСТОЛОГИЧНА ДИАГНОЗА
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Хистологично в 90% е спиноцелуларен карцином,
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Останалите 10% са аденокарциноми, верукозен карцином, базоцелуларен карцином и малигнен меланом.
СТАДИРАНЕ НА РАКА НА ВУЛВАТА
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Сред ревизираните FIGO стадиращи системи и TNM класификацията има промени има при рака на вулвата.
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Въпреки, че предишния стадий IA остава непроменен, тъй като това е единствената група пациенти с незначим риск за лимфни метастази, старите стадии I и II се комбинират, защото големината на лезията при негативни лимфни възли не се приема за прогностичен фактор.
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Освен това основно внимание се обръща на броя и морфологията (големина и екстракапсуларно разпространение) на позитивните лимфни възли, тъй като това е с голямо прогностично значение, докато двустранността на позитивните възли се отхвърля поради противоречието на предишни изследвания
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При наличието на метастази в лимфните възли, стадият е ІІІА, ІІІВ и ІІІС в зависивост от техният брой и размери, а при фиксирани или улцерирани лимфни възли, стадият е ІVА
КОМПЛЕКСНО ЛЕЧЕНИЕ НА РАКА НА ВУЛВАТА
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Лечението е оперативно в съчетание със следоперативна перкутанна лъчетерапия.
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Обемът на операцията зависи от размера и локализацията на тумора, степентта на диференциация и най-вече от състоявието на ингвинофемуралните ЛВ.
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Лъчетерапевтичната доза и полето също завидят от разпостранението на тумора.
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Химиотерапията не се прилага рутинно, а само при авансирал туморен процес или при рецидиви.
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Химиотерапията най-често се съчетава с лъчетерапия и се провежда с цисплатина, 5 FU и/или Митомицин С.
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СЪЧЕТАНО ЛЕЧЕНИЕ НА РАКА НА ВУЛВАТА
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Първичната лъче- и химиотерапия се прилага при определени болни, с цел запазване на нормалната анатомия за улесняване на последващото оперативно лечение.
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Обикновенно това се прави при иноперабилни болни, при болни при които би се наложило частична или тотална екзентерация, при болни, при които не може за се гарантира отстра-няване на тумора в здраво (по-малко от 1 см от резекционната линия), или
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при болни в тежко общо състояние, което не позволява извършването на оперативно лечение.
КОМПЛЕКСНО ЛЕЧЕНИЕ НА РАКА НА ВУЛВАТА ПО СТАДИИ
СТАДИИ
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ОПЕРАЦИЯ
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ЛЪЧЕТЕРАПИЯ
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IA тумор до 1 см
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Широка ексцизия/ хемивулвектомия
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не
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IA тумор над 1 см
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Радикална вулвектомия
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50 Gy за вулвата само при:
+ ръбове, ръбове < 8 mm, лимфноваскуларна инвазия или дълбочина >5 mm
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IB-II латерални лезии
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Радикална вулвектомия
с хомолатерална повърхностна лимфна дисекция
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50 Gy за вулвата само при:
+ ръбове, ръбове < 8 mm, лимфноваскуларна инвазия или дълбочина >5 mm
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IB-II тумор над 4 см
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Радикална вулвектомия с хомолатерална повърхностна лимфна дисекция и биопсия на сентинелни лимфни възли контралатерално
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50 Gy за вулвата само при:
+ ръбове, ръбове < 8 mm, лимфноваскуларна инвазия или дълбочина >5 mm
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IB-II централни лезии или слабодиферен-циран тумор G3
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Радикална вулвектомия с двустранна повърхностна лимфна дисекция
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50 Gy за вулвата само при: + ръбове, ръбове < 8 mm, лимфноваскуларна инвазия или дълбочина >5 mm
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IIIА
IIIВ
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Радикална вулвектомия с двустранна
дълбока лимфна дисекция
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50 Gy за вулвата само при: + ръбове, ръбове < 8 mm, лимфноваскуларна инвазия или дълбочина >5 mm и лъчетерапия за ингвиналните и тазовите лимфни възли при
1+ лимфен възел
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IIIА и IIIВ за лезии близо до уретрата, клитора или ректума
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След лъчехимиотерапията- Радикална вулвектомия с двустранна дълбока лимфна дисекция
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Проблеми за радикалността при оперативно-то лечение алтернативно – предоперативна лъчехимиотерапия 50 Gy за сN или 54 Gy за cN+
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IIIС- IVA
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След лъчехимиотерапията -Радикална вулвектомия с двустранна дълбока лимфна дисекция и резекция на уретра, влагалище и др.
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При cN+предоперативна лъчехимиотерапия.
При метастатични лимфни възли – сюрдозаж до 60 Gy, при големи тумори – до 65-70 Gy !
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IVA
за лезии на уретрата, клитора или ректума при cNо
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Радикална вулвектомия с двустранна дълбока лимфна дисекция и резекция на уретра, влагалище и др.
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50 Gy за вулвата при позитивни ръбове, ръб < 8 mm, лимфноваскуларна инвазия или лезии > 5 mm. химиолъчетерапия за вулвата и ингвиналните тазови лимфни възли при повече от 1 + лимфен възел
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