Pattern of Gynaecological Malignancies in a Tertiary Care Hospital

Background: Gynaecological malignancies are the second most common cancer of females after cancer breast. Gynaecological malignancies contribute significantly to cancer burden and have a higher rate of mortality and morbidity. Carcinoma cervix is the commonest gynaecological malignancy in developing countries while in developed countries, ovarian cancer is the commonest. Comprehensive statistics on gynecologic malignancies reported from Bangladesh are deficient. This study was performed to ascertain the profile of gynecologic cancers reported at our center regarding demography, the frequency of involvement at various sites, clinical presentation, incidence, histologic subtypes and stage at presentation. Methods: This is a retrospective study where the records of the Departments of Gynecology and Pathology at Enam Medical College & Hospital, Dhaka, Bangladesh were retrospectively reviewed to identify all cases of Gynecologic malignancies and to determine the pattern of gynaecological malignancies identified between January 2015 and December, 2018. Results: Cervical cancer (53%) was the most common gynaecological malignancy, followed by ovarian cancer (29%), uterine cancer (8%), vulvar cancer (5%) and gestational trophoblastic neoplasm (GTN 5%). In the case of cervical and ovarian cancer the most common age group was 41 50 years and gestational trophoblastic neoplasm (GTN). The majority of patients presented at the ages of 31 40 years while uterine cancer presented in the elderly (>60 years). Among the patients studied 88% were multiparous. Of the cervical cancer cases, 96.22% was squamous cell carcinoma and commonest presenting complains were contact bleeding (33.96%) and excessive and irregular menstruation (26.41%). Among ovarian tumor cases 69% had epithelial while 31% had non-epithelial cancer and predominant complaint was abdominal distension (86.21%). Squamous cell carcinoma was 100% in vulva while endometrial adenocarcinoma (87.5%) was more frequent in uterus and commonest complain was postmenopausal bleeding (75%). For gestational trophoblastic neoplasm (GTN) 60% of patients had How to cite this paper: Afroz, S., Ara, G. and Sultana, F. (2019) Pattern of Gynaecological Malignancies in a Tertiary Care Hospital. Open Journal of Obstetrics and Gynecology, 9, 449-457. https://doi.org/10.4236/ojog.2019.94044 Received: March 8, 2019 Accepted: April 8, 2019 Published: April 11, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
Gynaecological malignancies are those involving the genital tract and include those of the ovary, cervix, uterus, vulva, vagina and gestational trophoblastic malignancies.These malignancies are leading cause of cancer-related deaths [1].
The pattern of gynaecological malignancies differs in various geographical areas owing to different environment, life style, genetic pattern and socioeconomic background [2].Cervical cancer is one of the most common types of cancer in women after breast cancer [3].Carcinoma cervix is the commonest gynaecological malignancy in developing countries while in developed countries, ovarian cancer is the commonest gynaecological malignancy [4].Approximately 80% of cervical cancer occurs in developing countries [5].In African and Indian studies, cervical cancer is the second most common type of cancer in women, following breast cancer [6] [7].The incidence & mortality of cervical cancer had declined in North America during the last 50 years by two thirds to its present rank as the eight leading cause of cancer mortality, as an outcome of effective cervical screening program & treatment of premalignant lesions of cervix [8].Ovarian cancer has the highest mortality rate in developing countries because as two-thirds of the cases present at the advanced stage [9].Endometrial (uterine) cancer is the 6 th most common cancer in women worldwide & leading genital malignancy in United States & other developed nations [7].
Age and parity are known to affect the incidence of gynecological cancers.
Endometrial and ovarian cancers occur later in reproductive life than carcinoma of the cervix which is seen commonly in premenopausal or perimenopausal women.Endometrial carcinoma arises mainly in postmenopausal women, the peak incidence is in 55 to 65 age group and ovarian cancers are more common between the ages of 45 and 65 years.The peak incidence of cervical carcinoma is 45 years.Women of high parity have relatively low risk of developing endometrial and ovarian cancers, while multiparity is associated with increased risk of cervical carcinoma [8].
In Bangladesh, genital cancer is increasing day by day.Among those cervical cancer is the most common and it ranks as the second most frequent cancer among women.According to hospital-based statistics it constitutes 22% to 29% Open Journal of Obstetrics and Gynecology of the female cancers in different areas of the country.Current estimates indicate that annual incidence of cervical cancer is 11,956; about 80% women come for treatment in advance stage and 6582 die from the disease [10] [11].
Cervical cancer occurrence is related to the human papillomavirus (HPV).
HPV infection is transmitted through sexual activity and the possibility of transmission is increased with early stage of initiation of sexual activity, multiple sexual partners and high-risk sexual partner [12].The highest prevalence of genital tract cancer in underdeveloped countries is due to lack of awareness, risky sexual behavior and absence of population-based screening procedure especially for cervical cancer [13].
Despite the high frequency of some female genital tumors in our country, there is paucity of literature on the subject.Therefore, this study was designed to provide information regarding the pattern of gynecological malignancies.These findings could have a significant implication to devise strategies for effective screening, early diagnosis and timely management to reduce the morbidity and mortality from these cancers.

Materials and Methods
This was a retrospective cross-sectional study of all the patients of gynaecological Cancers diagnosed only on aspiration or cervical scrape smears, not followed by histologic confirmation were excluded.Tumors of borderline malignancy and metastasis to genital organs from other primary sites were also excluded from the study.The patients who had poorly maintained records & incomplete results were excluded from the study.Results were presented as number and percentage.Ethical clearance was taken from ethical review committee of Enam Medical College.

Results
A total of 100 new cases of gynecologic malignancies were reported and treated at our center between January 2015 and December 2018.
Table 1 shows that the most common female genital tract malignancy was carcinoma cervix (53%).Table 3 shows that majority (88%) patients are multiparous and only 3% patient are nulliparous, and all of the nulliparous cases are ovarian cancer.
Table 4 shows presenting complains of different gynaecological malignancies.In case of carcinoma cervix majority patients complain of contact bleeding & menstrual irregularities.In ovarian cancer most patients presented with abdominal distension.Uterine cancer patients presented mostly with postmenopausal bleeding.Most vulval cancer patient presented with vulval growth.All GTN patients presented with menstrual irregularities.
Table 5 shows that among carcinoma cervix the main histological type was squamous cell carcinoma observed in 51 (96.22%) patients.Of the ovarian malignancies, epithelial tumors were observed predominantly in 20 (69%) patients, followed by germ cell tumors in 6 (20.6%) patients.Serous adenocarcinoma was the most common histological type of epithelial ovarian cancer with 10 patients (50%), followed by mucinous adenocarcinoma in 4 patients (20%); Dysgerminoma was the most common histological type of germ cell tumor with 3 patients (50%), followed by ovarian choriocarcinoma 2 patients (33.33%).Granulosa cell tumor was the most common histological type of sex cord tumor with 2 (100%) patients.Adenocarcinoma was the most common histological type of uterine cancer with 7 patients (87.5%).Of the vulval malignancies, squamous cell carcinoma was in all 5 (100%) patients.In gestational trophoblastic neoplasm, choriocarcinoma was observed in 3 (60%) patients, invasive mole in 2 (40%) patients.Open Journal of Obstetrics and Gynecology

Discussion
Gynaecological malignancies are an important cause of morbidity and mortality in females these days.In present study cancer cervix is the commonest gynaecological malignancy (53%) followed by ovarian (29%), uterine (8%), vulval (5%), GTN (5%).Almost similar result was found in study of Sarkar et al.  [20].Results from a study in Nigeria showed that the majority of ovarian cancer occurs in the 50 -59 year age group [21].Uterine cancer is the third most common site of gynecological tract malignancies (8%) with the majority of patients presenting in the older age groups (>60 years), which is comparable to study in Pakistan [22].In western countries uterine malignancies are significantly higher in proportion as to those reported at our center and median age is about a decade higher than our studies Open Journal of Obstetrics and Gynecology [9] [10].Above 75 years of age cervical, uterine and ovarian malignancies were significantly lesser in our study presumably due to a lower life expectancy in our country.No appreciable differences were seen in the distribution of vaginal and vulval cancers [18] [19] [20].This suggests disparity in the effectiveness of screening programs.
In our study percentage of multiparous females were more (88%) similar to Chaudhary S and these females are high risk for cervical malignancy due to early marriage, low socio-economic condition and lack of awareness for screening [15].

Conclusion
Most common gynaecological malignancy in our study is carcinoma cervix which is largely a preventable disease.There is a need to increase public awareness on the risk factors and the Government should try to enroll all eligible women in cervical cancer screening programs and ensure HPV vaccination malignancies in department of Gynae & Obstetrics at Enam Medical College & Hospital between January, 2015 and December 2018.The clinical records of the patients from Department of Gynae & Obstetrics, Department of pathology & department of Oncology were reviewed with factors including age, parity, site of cancer, staging and histological type.Staging was done according to FIGO and histologic classification was done according to World Health Organization Histological Classification system.All cases included for the study had a definite histologic diagnosis made either on biopsy or resection specimens which were collected from Department of pathology, Enam Medical College & Hospital.

Table 2
shows that both cervical and ovarian cancer were more common within the age range of 41 -50 years (30.19% and 31.03%respectively).Uterine

Table 1 .
Relative frequency of gynaecological malignancies.

Table 2 .
Distribution of gynaecological malignancies according to age of patient.
cancer was most common in older age group 61 -70 years (37.5%).Below the age of 20 years no other malignancies found except ovarian cancer (6.9%).

Table 3 .
Distribution of patients according to parity.

Table 4 .
Distribution of gynaecologic malignancies according to presenting complaints.

Table 5 .
Distribution of gynaecological malignancies according to histology.

Table 6
shows that majority patients of carcinoma cervix and ovarian cancer are presented at advanced stage.In carcinoma cervix patients only 16 patients

Table 6 .
Distribution of gynaecological malignancies according to FIGO staging.
[16]he ovarian malignancies, epithelial tumors were predominant (69%), followed by germ cell tumors at 20.6% and sex cord-stromal tumor (6.9%).Serous adenocarcinoma was the most common histological type of epithelial tumor while dysgerminoma was a common malignant type of germ cell tumor and granulosa cell tumor a common malignant type of sex cord tumor.In a study by Hina histological types were almost similar except mucinous adenocarcinoma was the commonest epithelial cancer.Similar findings were observed in other studies regarding histological types[23][24][25].It was found that most of cervical carcinoma cases reported in stage II, stage III and stage IV (88.68%) and only 11.32% patients were in stage I similar to studies of Jhansivani Y, Sarkar et al., Chaudhary S and Agarwal.In all these studies, gynaecological malignancies were reported in advance stages[14][15][16] [15]Chaudhary S [14][15].