seminar

1. Prof. Dr. M. Fauzie Sahil, SpOG (K)

2. Kanker Serviks
penyebab
kematian ke- 2
kaum perempuan berusia
15-45 tahun
Insiden 25-45 per
100.000 penduduk
wanita pertahun
Terdeteksi Pada
stadium lanjut
Papanicolaou,WHO,
NIS & Bethesda
IVA 71%, 74%
PAP Smear 67,3%,76,9%
Thin-Prep / LBC 73.6%,76.2%
Hybrid Capture 90.3%,70.9%
Genotyping 82.4%, 71.1%
Analisis
Deteksi
Dini

3. Pencegahan
Primer
F. Resiko
F. Penyebab
Vaksin
Sekunder
Deteksi Dini
Penatalaksanaan
Lesi Prakanker
Bedah eksisi /
Terapi Ablasi

4.  Vaksin diberikan pada kelompok umur 10-55 tahun
 Pada pasien yang sudah melakukan aktivitas seksual,
vaksinasi dapat diberikan setelah hasil tes Pap (-).
 Vaksin dapat diberikan minimal oleh dokter
 Vaksin diberikan 3 suntikan, pada bulan 0, 1-2 bulan, dan 6
bulan setelah penyuntikan pertama.
 Booster belum diperlukan
 Tidak diberikan pada perempuan hamil
 Pada perempuan menyusui boleh diberikan vaksin
 Efek samping minimal dan yang paling sering adalah nyeri
ditempat suntikan
Himpunan onkologi Ginekologi Indonesia, Jakarta 2011

5. Papanicolou NIS (CIN ) WHO Bethesda
Kelas I Normal Normal Normal
Kelas II Normal Atipia Squamosa ASC (US,H)
AGCUS/AGUS/AGCNOS/AGC
Kelas III NIS I
NIS II
Displasia ringan
Displasia Sedang
LSIL
HSIL
Kelas IV NIS III Displasia berat
Karsinoma Insitu
HSIL
HSIL
Kelas V Karsinoma Invasif Karsinoma Invasif
Adenokarsinoma
Karsinoma sel skuamosa
Adenokarsinoma

6. Non-invasif
Mudah- murah
Pelayanan kesehatan sederhana
Hasil langsung didapat
Sensifitas dan spesifitas cukup baik
Cocok dinegara berkembang
INSPEKSI VISUALISASI DENGAN APLIKASI ASAM ASETAT
(IVA)

7. IVA
IVA (+)
KRIOTERAPI
LEEP/LLETZ
KOLPOSKOPI
IVA (-) FOLLOW UP
SKRINING DENGAN IVA

8. Colposcopy
•
• Merupakan mikroskop dengan derajat pembesaran lemah ( 16-20x)
• Diindikasikan untuk pada kasus-kasus dengan Abnormal Pap Test /
IVA (+)
• Untuk melihat apakah ditemukan kelainan pada cerviks dan
menuntun tindakan biopsi agar tepat sasaran

9. Conization

11. Protokol Kanker Ginekologi, FK USU/ RSHAM 2015

12. CIN 2 & CIN 3
Terapi Ablasi /
Bedah Eksisi
Repeat co-testing
in 3 years
Co-testing
6-12 bulan
2x Negatif
result
Colposcopy
Any test
abnormal
RCOG Guideline, Ovarian Cyst in Postmenopausal Women, Reviewed 2010.
Routine
Screening

13. STAGE Ia1 & Ia2
Based on Conization

17.  RMI : Risk Of Malignancy Index
 ROMA : Risk of Ovarian Malignancy Algorithm
 OMPS : Ovarian Malignancy Probability Score
 Indeks Morfologi Ultrasonography ( Sassone )
 Ova 1
Prediksi Keganasan Pada Tumor Ovarium

19. “Adnexal” massExclude
Nongynecologic
Problem
Premenopausal
Observation ±
Suppression for 2
months
>8 cm
Cystic Solid
≤8 cm
Progression Surgery
Berek, Jonathan S, Neville F. Preinvasive Dissease. Berek and Hecker’s Gynecologic Oncology.
Liipincott Williams & wilkins, 5th edition,2010.

20. “Adnexal” massExclude
Nongynecologic
Problem
Postmenopausal
Observation ±
Suppression for 2
months
Cystic Solid
≤5 cm
Progression Surgery
RCOG Guideline, Ovarian Cyst in Postmenopausal Women, Reviewed 2010.
> 5 cm
Or With elevated CA 125
and/or
Complex mass
On ultrasound

21. Management
NB : Ca Ovarium stadium IA ( pasca full Surgical staging  no Adjuvant treatment ( follow up)
•Pelvic Ultrasound
•CA 125
•Calculate RMI
Exclude non-
Gynecological
problems if necessary

22.  Pembilasan peritoneum
 Inspeksi dan perabaan secara cermat seluruh permukaan peritoneum
 Biopsi setiap lesi yang dicurigai metastasis tumor
 Histerektomi total abdominal dan salpingo-ooforektomi bilateral
 Omentektomi infrakolika
 Biopsi atau reseksi perlekatan didekat tumor primer
 Biopsi pada peritoneum, buli-buli, cul de sac, cekungan parakolik kiri
dan kanan, hemidiagfragma kanan.
 Biopsi dinding panggul pada sisi tumor primer ( ovarian fossa )
 Sampling KGB sepanjang arteri dan vena iliaka eksterna dan iliaka
komunis
 Sampling KGB sepanjang aorta dan vena cava termasuk daerah
a.Mesenterika inferior dan vena renalis kiri
Himpunan onkologi Ginekologi Indonesia, Jakarta 2011

23.  Didahului oleh hiperplasia endometrium
 Deteksi dapat dilakukan dengan pemeriksaan Transvaginal
Ultrasonografi.
 Ketebalan endometrium Wanita premenopause > 15 mm
 Ketebalan endometrium Wanita pasca menopause > 5 mm.
 Sensitivitas 83.3% dan Spesifisitas 75.8%
 Pronosis cukup baik karena sering terdiagnosa pada stadium
awal dengan keluhan perdarahan pervaginam, 5 year
survival rate mencapai 84 %
Patai K, et al. Early Detection of Endometrial cancer by combined use of vaginal ultrasound and endometrial
vacuum sampling. Int J Gynecol Oncol 2002;12:261-4.

24.  Hiperplasia tipikal ( non atipik )
- Hiperplasia simple tanpa atipia
- Hiperplasia kompleks tanpa atipia
 Hiperplasia Atipik
- Hiperplasia simple atipik
- Hiperplasia komples atipik
WHO 2002
Silverberg SG. The WHO 2002 Classification of Uterine Corpus Neoplasia. The 13th Annual Review
Course on Gynecologyc Oncology and Pathology Seoul, October 2002.

25. FIGO Staged 2008

26. Non Atypical Endometrial Hyperplasia
Desire to retain
uterus
No desire to
retain uterus• Provera 10-20 mg/day for
10 to 14 days per month if
premenopausal, or Provera
10 mg/day if postmenopausal
• LNG-IUS
Hysterectomy
Repeat
endometrial biopsy
in 3 to 6 months
Persistent
hyperplasia
Normal or atrophic endometrium
Trail of high dose
progestins (e.,g.,
Provera 40-100 mg/day
for 3 months)
Hysterectomy
• Continue Provera 5
mg/day 10
days/month for 12
months
• Annualtransvaginal
ultrasound
• Ovulation induction
if childbearing
desired
Persistent
hyperplasia
Berek, Jonathan S, Neville F. Preinvasive Dissease. Berek and Hecker’s Gynecologic
Oncology. Liipincott Williams & wilkins, 5th edition,2010.

27. (Atypical Endometrial Hyperplasia)
Desire to retain
uterus
Hysterectomy
( Recommendation)
Repeat
endometrial biopsy
in 3 to 6 months
Regresi/Normal or atrophic
endometrium
Hysterectomy
• Continue Provera 5
mg/day 10
days/month for 12
months
• Annualtransvaginal
ultrasound
• Ovulation induction
if childbearing
desired
Persistent
Hyperplasia
Green-top Guideline . The British Socoety for Gynaecological Endoscopy, 2015.
• LNG-IUS
• Oral Progestogens

29.  Peningkatan kadar HCG dalam 2 kali pemeriksaan secara berurutan
pada hari ke 1,7,14 atau lebih pasca evakuasi.
 Kadar HCG menetap 3 minggu atau lebih.
 Kadar HCG diatas normal sampai 14 minggu pasca evakuasi.
 Dijumpai lesi metastasis dengan kadar HCG > normal.
Kriteria Diagnosis
Hextan et al. Trophoblactic disease. FIGO Cancer Report 2015.
International journal of Gynecology and Obstetric, 2012.

30. WHO PROGNOSTIC SCORING SYSTEM AS ADAPTED BY FIGO
A WHO score of 6 or less : Low risk GTN  single agent chemotherapy
A WHO score of 7 or more : High risk GTN  combination chemotherapy
Score 0 1 2 4
Age < 40 > 40 - -
Antecedent pregnancy Mole Abortion Term -
Interval months from index
pregnancy
<4 4-7 7-13 >13
Pretreatment serum hCG ( IU/L ) < 1000 < 10.000 < 100.000 > 100.000
Largest tumor size ( incl uterus ) - 3 to <5 cm > 5 cm -
Site of metastases Lung Spleen/kid
ney
GI Liver/brain
Number of metastases - 1-4 5-8 > 8
Previous failed chemotherapy - - Single drug Two or
more drugs

31. Management
Kemoterapi
** Hysterectomy does not improve the prognosis, in exceptional cases where the tumor is confined to
the uterus; hysterectomy can be considered (no fertility desired, compliance problem, life saving).

33. Cervical Cancer

34. Ovarian Cancer

35. Ovarian Cancer Con’t