Gynecologic Cancers



Gynecologic Cancers


Miriam Shustik MD



Gynecologic malignancies represent 13% of all cancers affecting women. They are the fourth most common cancers in American women. Cervical, endometrial, and ovarian cancers make up the majority of these tumors and contribute significantly to the morbidity and mortality of the female population. Whereas cervical and endometrial cancers can be detected early in their development, many patients with ovarian cancer present with already advanced disease. If detected early, cancer is more easily treated and the possibility of long-term cure is greatest. All cancer survivors face the issue of uncertainty.

This chapter reviews gynecologic cancers, including cervical, vaginal, vulvar, endometrial, ovarian, and trophoblastic disease, and also addresses how the primary care provider can work effectively with patients having any of these conditions. Family and community resources will also be discussed.


CARCINOMA OF THE CERVIX


Anatomy, Physiology, and Pathology

The cervix is a fusiform cavity that communicates below with the vagina and above with the uterine body. The epithelium of the upper two thirds is cylindrical, whereas the lower third gradually changes to squamous close to the external os. The junction between the primarily columnar epithelium of the endocervix and the squamous epithelium of the ectocervix is a site of continuous metaplastic change. This change is most active in utero, at puberty, and during the first pregnancy, and then declines after menopause. The greatest risk of neoplastic transformation coincides with periods of vast metaplastic activity, and most carcinomas arise from this zone of metaplastic transformation in the squamocolumnar junction.


EARLY DISEASE

Preinvasive disease is usually detected during routine screening from cervical cytology. Patients with early invasive disease may also be asymptomatic.



LATE DISEASE

The triad of sciatic pain, leg edema, and hydronephrosis is almost always associated with extensive pelvic involvement by the tumor. Hydronephrosis may cause flank pain and may be associated with pyelonephritis.



Epidemiology

The American Cancer Society estimates that there are 15,800 new cases of invasive cervical cancer and 65,000 cases of carcinoma in situ diagnosed in the United States per year. Forty-eight hundred patients are expected to die of cervical cancer; this represents approximately 2% of all cancer deaths in women and 18% of all gynecologic cancers. Cervical cancer is the third most common gynecologic cancer in the United States.

Squamous cell carcinoma of the cervix follows a pattern of sexually transmitted disease. The risk of cervical cancer is increased in female prostitutes. The risk also is high for women whose first episode of sexual intercourse occurred at less than age 17, those with a history of multiple sex partners or sexually transmitted diseases, or those who bear children at less than age 17. Molecular studies have demonstrated a strong relation between human papillomavirus (HPV), cervical intraepithelial neoplasia, and invasive carcinomas of the cervix. HPV has been identified in more than 60% of cervical cancers (Duggan et al, 1995; Zur Hausen, 1997). Other important risks include having a male partner whose sexual behavior is promiscuous or who is uncircumcised and has poor hygiene. Several significant personal risk factors are also associated with an increased incidence of cervical cancer. These include cigarette smoking, immunodeficiency, vitamin A and C deficiency and, possibly, oral contraceptive use. In the United States, the incidence of cervical cancer is higher among women of Native American, African, and Hispanic heritage.

Cervical cancer continues to be the leading cause of cancer deaths for women in underdeveloped countries. Incidence and death rates are particularly high in South and Central America, Africa, India, and Eastern Europe (Kurman & Solomon, 1994). Twenty-five percent of all cancer-related deaths in Mexican women are caused by cervical cancer. Screening and prevention programs are not yet completely effective in developing countries.


Diagnostic Criteria

Several systems have been developed to classify cervical cytology. The Bethesda system is now used commonly in the United States for classifying cervical changes (Berek & Hacker, 1994).



History and Physical Exam

All patients with cervical cancer should be evaluated with a careful history and physical exam, with particular attention to inspection and palpation of pelvic organs with bimanual and rectovaginal exams. Attention to the psychosocial aspect of the patient is very important. The provider must consider the difficulties of this moment and should be comfortable and knowledgeable enough to encourage patients to express and discuss their concerns.


Diagnostic Studies


PAP SMEAR

The false-negative rate of the Pap smear is about 10% to 15% in women with invasive cancer. The sensitivity of the test may be improved by proper sampling of the squamocolumnar junction and the endocervical canal. Smears without endocervical cells or metaplastic cells are inadequate and must be repeated. Because adenocarcinoma in situ originates near or above the transformation zone, it may not be sampled by a conventional smear. Detection of high endocervical lesions might be improved with the use of a cytobrush. Also, because hemorrhage, tissue necrosis, and inflammation may obscure the cytology report, the Pap is not a good test to diagnose gross lesions; they should always be biopsied (Miller et al, 1993).


COLPOSCOPIC EXAM

Patients with abnormal cytology and no gross lesion must be evaluated by colposcopy and directed biopsy. The skilled colposcopist can often differentiate between LSIL and HSIL, but microinvasive disease and intraepithelial lesions cannot be consistently distinguished (Burger & Hollema, 1993).


ENDOCERVICAL CURETTAGE

If the entire squamocolumnar junction cannot be visualized on colposcopy in a patient with an atypical Pap smear, endocervical curettage is indicated.


CONE BIOPSY

Cervical cone biopsy is used to diagnose occult endocervical lesions and is an important step in the diagnosis of microinvasive carcinoma of the cervix. It is indicated in the following cases.



  • When the squamocolumnar junction is poorly visualized on colposcopy and a high-grade lesion is suspected


  • When a high-grade dysplastic epithelium extends into the endocervical canal


  • When cytology results suggest carcinoma in situ


  • When endocervical curettage shows HSIL


  • When there is suspicion of adenocarcinoma in situ (Morris et al, 1993).


LABORATORY STUDIES

Standard laboratory studies should include a complete blood count and renal and liver function tests in all patients with invasive cervical cancer.


RADIOLOGIC STUDIES

All patients with invasive cervical cancer should have a chest radiograph to rule out metastatic disease to the lungs, and an intravenous pyelogram to determine the kidney’s location and to rule out ureteral obstruction by the tumor. The value of computed tomography (CT) or magnetic resonance imaging (MRI) is uncertain because the accuracy of these studies is compromised by their failure to detect small metastases and because patients with bulky tumors often have enlarged, reactive lymph nodes (Lien et al, 1993).


Treatment Options, Expected Outcomes, and Comprehensive Management

Several factors may influence treatment options, including tumor size, stage, and histology; evidence of lymph node involvement; risk factors for surgery or radiation; and patient preference. The International Federation of Gynecology and Obstetrics (FIGO) has defined the most widely accepted staging system for carcinomas of the cervix; it was last updated in 1994 (FIGO, 1995). As a rule, intraepithelial lesions are treated with superficial ablative techniques such as cryosurgery, laser therapy, or loop excision. These are all outpatient procedures that maintain fertility and carry a low recurrence rate; progression to invasion is rare. Lifelong surveillance of these patients is necessary, however, to detect early signs of recurrence.

Microinvasive cancers invading less than 3 mm (stage IA1) are managed with conservative surgery, such as excisional conization or extrafascial hysterectomy. Total or vaginal hysterectomy is the standard treatment for this stage of disease. For those who wish to maintain fertility, conization is the choice. Conization is performed with a cold knife or carbon dioxide laser under general or spinal anesthesia. Complications occur in 2% to 12% of patients and include sepsis, hemorrhage, infertility, stenosis, and cervical incompetence.

Early invasive cancers (stages IA2 and IB1 and some small stage IIA tumors) are managed with either radical surgery or irradiation. Locally advanced cancers (stages IB2 through IVA) are managed with radiation therapy (Landoni et al, 1995; Matthews et al, 1993). The prognosis is influenced by tumor characteristics such as bulk and diameter, lymph node metastasis, histology, and hemoglobin level (Eifel et al, 1994; FIGO, 1994; Matthews et al, 1993).


SCREENING

The long preinvasive stage of cervical cancer, the relatively high prevalence of the disease in unscreened populations, and the sensitivity of cytologic screening all have made cervical carcinoma an ideal target for cancer screening. In the United States, screening with cervical cytology, as well as performing frequent pelvic exams, has led to a decrease in the mortality rate from cervical cancer of more than 70% since 1940 (Boring et al, 1996; Koss, 1993). Only countries that have invested in screening programs have experienced this kind of result.

Authorities disagree about the optimal frequency of screening for cervical cancer. Since the time of a 1988 consensus statement, the American Cancer Society has recommended annual Pap smears beginning at age 18 years or with the onset of sexual activity. After three consecutive normal exams, the evaluation could be performed less frequently at the discretion
of the provider. The U.S. Preventive Task Force (1994) has recommended that screening be discontinued at age 65 if results have been consistently normal. Because of a lack of objective measurement of low- and high-risk patients, physicians continue to recommend that patients be screened more often than recommended by national guidelines.

Patients who were diagnosed and treated for cervical cancer should be followed by the provider over their lifetime to maintain health. Periodic exams will prevent or at least delay the recurrence of the disease and further complications.


Referral Points and Clinical Warnings

Patients with abnormal Pap smears should be followed closely by the primary care provider with periodic Pap smears, colposcopy, and biopsy in case of LSIL. When needed, referral should be made to a gynecologic oncology practice that performs cone biopsies and loop and laser procedures; surgical procedures such as hysterectomy in case of HSIL or invasive carcinoma come under the venue of such a practice.



CARCINOMA OF THE VAGINA


Anatomy, Physiology, and Pathology

The vagina extends from the vulva to the uterus. It is situated in the pelvic cavity behind the bladder and in front of the rectum. It is about 2″ along its anterior wall and 3″ inches along its posterior wall. The vaginal epithelium is of the squamous type.

Squamous cell carcinomas account for 80% to 90% of primary vaginal malignancies, adenocarcinomas for 5% to 10%, vaginal melanomas for 3%, and vaginal sarcomas for another 3% (Kurman & Solomon, 1994).


Epidemiology

Vaginal intraepithelial neoplasms often accompany cervical intraepithelial neoplasia and are thought to have similar etiology. Carcinomas of the vagina are rare and represent 2% to 3% of gynecologic malignancies. Approximately 50% of vaginal cancers arise in the upper third of the vagina (Kirkbride et al, 1995; Stock et al, 1995). The vagina is a common site of metastasis or direct extension from tumors originating in other genital sites, such as the cervix and endometrium, or extragenital sites, such as rectum and bladder. Primary invasive carcinoma of the vagina is predominantly a disease of elderly women, with 70% to 80% of cases presenting in women older than age 60 (except for clear cell carcinomas, which are associated with maternal exposure to diethylstilbestrol [DES]) (Kirkbride et al, 1995). Predisposing factors for carcinoma of the vagina are chronic vaginitis, HPV, herpes simplex virus, and prior pelvic irradiation.


Diagnostic Criteria

Most patients with vaginal intraepithelial neoplasms are asymptomatic at diagnosis. The carcinoma is usually diagnosed during an investigation of an abnormal Pap smear. The FIGO categories are used for staging vaginal cancers (FIGO, 1995).



History and Physical Exam

The workup should include a careful exam of the cervix and vagina, including a bimanual exam. A careful history and assessment of the woman’s psychosocial status and needs should be included.


Diagnostic Studies

All patients should have a chest radiograph, complete blood count, and biochemical profile. Cystoscopy and ureteroscopy are strongly recommended for patients with large tumors and tumors involving the anterior wall of the vagina. Proctoscopy is recommended for lesions involving the posterior wall of the vagina.

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Aug 23, 2016 | Posted by in CRITICAL CARE | Comments Off on Gynecologic Cancers
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