Most common gynecologic malignancy

Arises from the epithelial lining of the uterus

Primarily affects postmenopausal women 55 to 70 years of age

Most present with early-stage disease

Overall 5-year survival rate about 85%

See Table 14-2 for staging of endometrial cancer.

Arises from the surface epithelium of the ovaries

Accounts for about one third of all cancers of the female reproductive tract and a little more than half of all deaths from gynecologic cancers

Overall 5-year survival rate is approximately 44%, with a greater than 90% 5-year survival rate for early-stage disease.

Epithelial tumors account for 80% to 90% of all malignant ovarian neoplasms.

See Table 14-3 for staging of ovarian cancer.

Progressive disease, beginning with neoplastic cells in the epithelial layer of the cervix, that spread into the stromal tissue causing invasive cervical cancer

Incidence has steadily decreased as a result of the Pap smear, which can detect the disease in a preinvasive state.

Comprises approximately one third of all gynecologic malignancies

Overall 5-year survival rate for all stages is close to 70%.

See Table 14-4 for staging of cervical cancer.

Accounts for only 3% to 4% of all gynecologic cancers and has a 70% to 75% 5-year survival rate

Lesions can develop anywhere on the vulva, 70% occurring on the labia. Tumors can also arise on the clitoris, Bartholin’s glands, and the perineum.

Usually remains a localized disease with definite margins

90% are squamous cell malignancies, and the remaining are Bartholin’s gland, sarcoma, basal cell, Paget’s, and verrucous cancer.

See Table 14-5 for staging of vulvar cancer.

Obesity

Hypertension

Diabetes

History of infertility, breast or ovarian cancer

Irregular menses or failure to ovulate

Prolonged estrogen replacement therapy

Endometrial hyperplasia

Nulliparity

First pregnancy after age 35

High-fat diet

Family history of ovarian cancer

Late menopause

Early menarche

Hormonal therapy

Exposure to environmental toxins, such as coal, tar, and talc

Infection with human papilloma virus (HPV) or herpes simplex virus 2 (HSV2)

Sexual intercourse before age 17

Multiple sexual partners

History of smoking

Spouse whose previous wife had cervical cancer

Maternal use of diethylstilbestrol (DES).

Immunosuppression

Multiparity

Lower socioeconomic status

African-American or Hispanic descent

A spouse with penile cancer

Age > 60 years

Chronic vulvar irritation

History of other lower genital tract malignancy

History of infection with HSV2, HPV, or other STDs

Exposure to coal tar derivatives

Postmenopausal vaginal bleeding is the classic presenting symptom.

Tumors arising in the epithelium and spreading to the myometrium may cause bleeding within the uterine cavity.

Irregular or heavy menstrual flow may be a symptom in the premenopausal patient.

Pain, particularly in the lumbosacral, hypogastric, or pelvic regions, and an enlarging nonpregnant uterus can be signs of advanced disease.

No typical symptoms have been correlated with early-stage ovarian cancer, and lack of specific symptoms usually leads to diagnosis at a later stage of disease.

GI complaints such as abdominal discomfort, bloating, indigestion, dyspepsia, increased flatulence, changes in bowel habits, loss of appetite, and pelvic pressure may be experienced as the tumor grows within the pelvis. GI workup is usually negative.

Genitourinary symptoms such as burning, urgency, and frequency may occur.

Palpable mass, ascites, and shortness of breath are signs of late disease but may be the first symptoms experienced.

Watery vaginal discharge may be experienced by women with cervical cancer in a preinvasive state, although most cervical cancers are asymptomatic.

Postcoital bleeding, bleeding between menstrual cycles, and heavy menstrual flow are later symptoms.

Malodorous, serosanguineous, or yellowish vaginal discharge from necrotic tissue is often a complaint in advanced stages.

Pain in the pelvis, hypogastrium, flank, or leg is a symptom of late disease secondary to involvement of the pelvic sidewall, lymph nodes, ureters, or nerves.

Urinary or rectal symptoms, such as urgency, frequency, or rectal pressure, may indicate invasion of the bladder or bowel by tumor.

Lower-extremity edema may develop in late-stage disease due to lymphatic or venous obstruction.

Mass or growth in the vulvar area is most common symptom.

Some vulvar cancers are asymptomatic with lesions detected only during annual examinations.

Vulvar bleeding may occur due to irritation by the tumor.

Vulvar pain may also be experienced.

Bimanual pelvic examination allows the evaluation of the shape size, and consistency of the uterus.

Endometrial biopsy is 90% effective in detecting cancer, indicated with suspicious abnormal bleeding. It may also be used to screen women who are at increased risk of the disease (eg, women on estrogen replacement therapy).

Dilatation and curettage may obtain additional tissue for diagnosis if an endometrial biopsy is negative or contains suspicious cells that are not diagnostic

Cystoscopy or intravenous. pyelogram (IVP) may be performed if urologic involvement is suspected.

MRI, CT, hysterography, hysteroscopy, ultrasonography, and lymphangiography may be used to evaluate the size of the tumor and to determine nodal involvement.

Pelvic examination usually reveals a large pelvic mass in late-stage disease and is effective in detection of early-stage disease in only a small number of asymptomatic women.

Ultrasound (US), CT, or MRI evaluates the size and location of a pelvic mass and may help diagnose lymph node involvement.

CA-125 serum testing may determine if the antigen specific for epithelial ovarian cancer is detectable in the patient’s bloodstream.

Exploratory laparotomy with complete surgical staging is performed for definitive diagnosis and to determine the extent of the disease.

IVP can determine the location of the pelvic mass in relation to the ureters.

Tests to rule out other malignancies or detect metastatic disease:
—Proctoscopy, sigmoidoscopy, or barium enema
—Chest x-ray

Pap smear is the most accurate, convenient, and cost-effective technique used to detect cervical cancer. American Cancer Society recommends that women who are sexually active or who are 18 years of age or older have a Pap smear and pelvic examination annually. Pap smears can identify numerous infections, reactive changes, and cellular abnormalities. If a Pap smear is abnormal, other tests are necessary to diagnose the problem.

Colposcopy is a diagnostic test used to evaluate the cervix after an abnormal Pap smear. A 3% acetic acid solution is applied to the cervix which allows the examiner to visualize and biopsy abnormal areas.

A cervical biopsy may be performed for definitive diagnosis of abnormal areas seen during colposcopy.

Cystoscopy or IVP may be performed to rule out bladder or renal involvement.

Chest x-ray is done to rule out metastases in the pleural cavity.

Proctoscopy, sigmoidoscopy, or barium enema may be performed if bowel involvement is suspected. MRI or CT scan may be used to evaluate the size of the tumor and extent of the disease, including lymph node, bowel, or bladder involvement.

A supraclavicular lymph node biopsy is done if any of these nodes are palpable.

Physical examination of the external genitalia may reveal a mass or other lesion. Vulvar biopsy of a palpable mass or observable lesion is the most definitive method of diagnosing vulvar cancer. Colposcopy is sometimes used to pinpoint the areas to be biopsied.

Pap smear of the cervix is also performed because a small number of women diagnosed with vulvar cancer will also have preinvasive or invasive cervical cancer.

Chest x-ray is performed to rule out metastatic disease in the pleural cavity.

Colonoscopy, proctosigmoidoscopy, or barium enema may be performed to rule out bowel involvement.

Cystoscopy or IVP may be performed to rule out bladder or renal involvement.

CT scan or MRI may be useful in diagnosing lymph node involvement and disease spread.

Total abdominal hysterectomy and bilateral salpingo-oophor-ectomy (TAH-BSO) with pelvic and paraaortic lymph node dissection is the initial treatment for all stages of endometrial cancer (see Table 14-2).

Intracavitary or external beam radiation therapy may be initiated after surgery for stages III and IV to prevent local recurrence of the disease or in earlier stages if the patient is not a surgical candidate (see Table 14-2).

Initial treatment—total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) with pelvic and paraaortic lymph node dissection, along with cytoreductive surgery and adequate surgical staging.

Optimal cytoreductive surgery with less than 1 cm residual tumor volume is a favorable prognostic indicator for both response to chemotherapy and survival.

Systemic chemotherapy after initial surgery is required for stages Ic through IV using a combination regimen of cisplatin or carboplatin with paclitaxel for at least six courses.

Hormone therapy may be used to stabilize disease in patients who have failed chemotherapy regimens, but it usually does not promote tumor regression.

Depending on the degree of cervical invasion and the staging, treatment may include total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), or radical abdominal hysterectomy (RAH).

These may be performed as initial treatment or after the tumor volume is reduced by intracavitary or external beam radiation therapy (see Table 14-4).

Initial treatment is surgical removal of the tumor. Depending on the stage of disease, surgery may include a simple vulvectomy, radical vulvectomy, or total pelvic exenteration.

Radiotherapy may be used preoperatively as neoadjuvant therapy, or to treat groin or pelvic lymph node disease.