Gynecologic Oncology

Health Centers > Cancer Health Center > Gynecologic Oncology

Gynecologic Cancers

Oct 12.2012
- Angeles A. Alvarez and Daniel L. Clarke-Pearson

Introduction

Genital tract cancer afflicts a significant portion of postmenopausal women. These malignancies account for 13% of all cancers in women. Approximately 75,400 new cases were diagnosed and 24,700 deaths resulted from gynecologic malignancies in 1999. Risk of developing a gynecologic cancer increases with age. Figures 37.1 and 37.2 show the age-related incidence and mortality, respectively, of these malignancies. As with other cancers, early detection provides the best opportunity for successful management. Therapeutic strategies include surgery, chemotherapy, and radiation treatment. Integration of these diverse modalities is best coordinated by a gynecologic oncologist who has the skills necessary to accomplish surgical and medical treatment of these women, as well as the knowledge of appropriate circumstances for the use of radiotherapy.

GYNECOLOGIC NEOPLASMS

ENDOMETRIAL CANCER

Etiology and Pathology
Symptoms, Signs, and Diagnosis
Staging, Prognosis, and Treatment

OVARIAN CANCER

Etiology and Pathology
Symptoms, Signs, and Diagnosis
Treatment

CERVICAL CANCER

Pathology
Symptoms and Signs
Diagnosis
Prognosis and Treatment

VULVAR CANCER

Pathology
Symptoms, Signs, and Diagnosis
Prognosis
Treatment

VAGINAL CANCER

Symptoms and Signs
Prognosis and Treatment

FALLOPIAN TUBE CANCER

Symptoms, Signs, and Diagnosis

GESTATIONAL TROPHOBLASTIC DISEASE

Symptoms, Signs, and Diagnosis
Treatment

Additional Issues for the Geriatric Patient

Since 1990, Medicare coverage for Pap smears has been available. Presently, Medicare pays only the cost of laboratory analysis; the physician visit is covered only if Medicare-eligible services are rendered. Screening interval has been set at every 3 years under the current guidelines. The law permits provisions for more frequent Pap smears in high-risk women. However, no such benefits have been enacted to date.

Given that elderly women are at particularly high risk of developing malignancies, they should be entitled to receive adequate screening for these cancers. Older women are often uninformed about the importance of screening, and physicians are often reluctant to put elderly patients through the discomfort of a pelvic exami-nation if they are asymptomatic. Geriatric patients usually can safely undergo radical surgery, dose-intense chemotherapy, and radiotherapy after thorough medical evaluation. Decisions to withhold optimum therapy should be made in conjunction with the patient and should be based on intercurrent medical conditions rather than on age alone.

Treatment for gynecologic cancer commonly influences a woman's image of herself and her sexuality. It is imperative that physicians caring for these patients be sensitive to their concerns. Frank discussions about how treatment for cancer will affect appearance and sexuality must be conducted with the patient and her partner before initiation of therapy. Remediable causes of dysfunction should be corrected and referral for counseling considered if problems persist. It is important that sexual apprehensions be taken seriously and that practitioners recognize the importance of sexual issues to older individuals.

Ovarian Cancer

Ovarian cancer is one of the most treatable solid tumors, as the majority will respond temporarily to surgery and cytotoxic agents.

Introduction

Endometrial Cancer

Ovarian Cancer

Cervical Cancer

Vulvar Cancer

Additional Issues for the Geriatric Patient

Summary

References

Breast cancer overview

Breast cancer is a malignant proliferation of epithelial cells ...

Endometrial Cancer

Endometrial cancer is the most common invasive gynecologic cancer, representing 5.4% of all malignancies of womens...

Cervical Cancer

Cervical cancer accounts for about 20% of all gynecologic cancer..

Vaginal Cancer

Primary cancers of the vagina are rare, representing approximately 3% of gynecologic cancers..

Bladder Cancer

The bladder is a hollow organ in your lower abdomen that stores ..

Ovarian Cancer

Ovarian cancer is the fifth most common cancer among women..

Uterine Cancer

Carcinomas of the renal pelvis and ureter are rare, accounting for only 4% of all urothelial cancers..

Ovarian Cancer

Ovarian Germ Cell Tumors

Carcinoma of the Fallopian Tube

Uterine Cancer

Cervix Cancer

Gestational Trophoblastic Neoplasia

References

1. Ries LAG, Eisner MP, Kosary CL,Hankey BF, Miller BA, Clegg L, Edwards BK:SEER Cancer Statistics Review, 1973-1999, National Cancer Institute. Bethesda, MD. http://seer.cancer.gov/csr/1973_1999/, 2002.

2. Ries LAG, Hankey BF, Miller BA, et al. Cancer Statistics Review. NIH pub 91-2789. Bethesda, MD: National Cancer Institute, 1991.

3. Edwards BK, Howe HL, Ries LA, Thun MJ, et al. Annual report to the nation on the status of cancer, 1973-1999: featuring implications of age and aging on U.S. cancer burden. Cancer. 2002;94:2766-2792.

4. Parazzini F, La Veccia C, Bocciolone L, et al. The epidemiology of endometrial cancer. Gynecol Oncol. 1991;41:1-16.

5. Gambrell RDJ, Bagnell CA, Greenblatt RB. Role of estrogens and progesterone in the etiology and prevention of endometrial cancer. Am J Obstet Gynecol 1983;146:696- 707.

6. Smith DC, Prentice R, Thompson DJ, et al. Association of exogenous estrogen and endometrial carcinoma. N Engl J Med. 1975;293:1164-1167.

7. Seoud MA, Johnson J, Weed JCJ. Gynecologic tumors in tamoxifen-treated women with breast cancer. Obstet Gynecol. 1993;82:165-169.

8. Quinn MA, Cauchi M, Fortune D. Endometrial carcinoma: steroid receptors and response to medroxyprogesterone acetate. Gynecol Oncol. 1985;21:314-319.

9. Centers for Disease Control. Oral contraceptive use and the risk of endometrial cancer. The Centers for Disease Control Cancer and Steroid Hormone Study. JAMA. 1983;249:1600-1604.

10. Lawrence C, Tessaro I, Durgerian S, et al. Smoking, body weight, and early-stage endometrial cancer. Cancer. 1987;59:1665-1669.

11. Smith EM, Anderson B. Symptomatology, delay, and stage of disease in endometrial cancer. Cancer Detect Prev. 1987;10:247-254.

12. Walters D, Robinson D, Park RC, et al. Diagnostic outpatient aspiration curettage. Obstet Gynecol. 1975;46:160-164.

13. Tsuda H, Kawabata M, Yamamoto K, et al. Prospective study to compare endometrial cytology and transvaginal ultrasonography for identification of endometrial malignancies. Gynecol Oncol. 1997;65:383-386.

14. Cohen I, Beyth Y, Tepper R. The role of ultrasound in the detection of endometrial pathologies in asymptomatic postmenopausal breast cancer patients with tamoxifen treatment. Obstet Gynecol Surv. 1998;53:429-438.

15. Hall KL, Dewar MA, Perchalski J. Screening for gynecologic cancer. Vulvar, vaginal, endometrial, and ovarian neoplasms. Prim Care. 1992;19:607-620.

16. Creasman WT, Morrow PC, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer. 1987;60:2035-2041.

17. Sant CL, Weppelmann B, Shingleton H, et al. Management of early endometrial carcinoma. Gynecol Oncol. 1989;35:362-366.

18. Cowles TA, Magrina JF, Masterson BJ, et al. Comparison of clinical and surgical-staging in patients with endometrial carcinoma. Obstet Gynecol. 1985;66:413-416.

19. Sutton GP, Geisler HE, Stehman FB, et al. Features associated with survival and disease-free survival in early endometrial cancer. Am J Obstet Gynecol. 1989;160:1385- 1391.

20. Palmer DC, Muir IM, Alexander AI, et al. The prognostic importance of steroid receptors in endometrial carcinoma. Obstet Gynecol. 1988;72:388-393.

21. Roberts JA, Brunetto VL, Keys HM, et al. A phase III randomized study of surgery versus surgery plus adjunctive radiation therapy in intermediate risk endometrial adenocarcinoma (GOG 99). Presented at Society of Gynecologic Oncologists, 28th Annual Meeting, Orlando, FL, 1998.

22. Soper JT, Creasman WT, Clarke-Pearson DL, et al. Intraperitoneal chromic phosphate P32 suspension therapy of malignant peritoneal cytology in endometrial carcinoma. Am J Obstet Gynecol. 1985;153:191-196.

23. Martinez A, Podratz K, Schray M, et al. Results of whole abdominopelvic irradiation with nodal boost for patients with endometrial cancer at high risk of failure in the peritoneal cavity. A prospective clinical trial at the Mayo Clinic. Hematol Oncol Clin North Am. 1988;2:431-446.

24. Potish RA, Twiggs LB, Adcock LL, et al. Paraaortic lymph node radiotherapy in cancer of the uterine corpus. Obstet Gynecol. 1985;65:251-256.

25. Martinez A, Schray M, Podratz K, et al. Postoperative whole abdomino-pelvic irradiation for patients with high risk endometrial cancer. Int J Radiat Oncol Biol Phys. 1989;17:371-377.

26. Ahmad K, Kim YH, Deppe G, et al. Results of treatment in locally advanced carcinoma of the endometrium. Acta Oncol. 1990;29:203-209.

27. Bonte J, Ide P, Billiet G, et al. Tamoxifen as a possible chemotherapeutic agent in endometrial adenocarcinoma. Gynecol Qncol. 1981;11:140-161.

28. Kauppila A. Oestrogen and progestin receptors as prognostic indicators in endometrial cancer. A review of the literature. Acta Oncol. 1989;28:561-566.

29. Thigpen T, Vance RB, Balducci L, et al. Chemotherapy in the management of advanced or recurrent cervical and endometrial carcinoma. Cancer. 1981;48:658-665.

30. Price FV, Edwards RP, Kelley JL, et al. A trial of out- patient paclitaxel and carboplatin for advanced, recurrent, and histologic high-risk endometrial carcinoma: preliminary report. Semin Oncol. 1997;24:S15-S15.

31. Kosary CI. FIGO stage, histology, histologic grade, age and race as prognostic factors in determining survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulva, and vagina. Semin Surg Oncol. 1994;10:31-46.

32. Olt G, Berchuck A, Bast RC Jr. The role of tumor markers in gynecologic oncology. Obstet Gynecol Surv. 1990;45:570-577.

33. Creasman WT. Recommendations regarding estrogen replacement therapy after treatment of endometrial cancer. Oncology. 1992;6:23-26.

34. Ozols RF, Rubin SC, Thomas GM, et al. Epithelial ovarian cancer. In: Hoskins WJ, Perez CA, Young RC, eds. Principles and Practice of Gynecologic Oncology, 2nd Ed. Philadelphia: Lippincott-Raven; 1996:919-986.

35. Yancik R. Ovarian cancer. Age contrasts in incidence, histology, disease stage at diagnosis, and mortality. Cancer. 1993;71:517-523.

36. Heintz APM, Hacker NF, Lagasse LD. Epidemiology and etiology of ovarian cancer: a review. Obstet Gynecol. 1985;66:127-135.

37. Rossing MA, Daling JR, Weiss NS, et al. Ovarian tumors in a cohort of infertile women. N Engl J Med. 1994;331:771-776.

38. Piver MS, Baker TR, Jishi MF, et al. Familial ovarian cancer. A report of 658 families from the Gilda Radner Familial Ovarian Cancer Registry 1981-1991. Cancer. 1993;71:582-588.

39. Lynch HT, Watson P, Lynch JF, et al. Hereditary ovarian cancer. Heterogeneity in age at onset. Cancer. 1993;71:573-581.

40. Kurman RJ. Blaustein's Pathology of the Female Genital Tract, 4th Ed. New York; Springer-Verlag; 1994.

41. Goff BA, Mandel LS, Muntz HG, et al. Ovarian cancer diagnosis: results of a national cancer survey. Presented at Society of Gynecologic Oncologists, 31st Annual Meeting, San Diego, CA 2000.

42. Podczaski E, Whitney C, Manetta A, et al. Use of CA 125 to monitor patients with ovarian epithelial carcinomas. Gynecol Oncol. 1989;33:193-197.

43. McGowan L. Patterns of care in carcinoma of the ovary. Cancer. 1993;71:628-633.

44. Clarke-Pearson DL, DeLong ER, Chin N, et al. Intestinal obstruction in patients with ovarian cancer: variables associated with surgical complications and survival. Arch Surg. 1988;123:42-45.

45. Bristow RE, Montz FJ, Lagasse LD, et al. Survival impact of surgical cytoreduction in stage IV epithelial ovarian cancer. Gynecol Oncol. 1999;72:278-287.

46. McGuire WP, Hoskins WJ, Brady MF, et al. Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N Engl J Med. 1996;334:1-6.

47. Ozols RF, Bundy BN, Fowler JM, et al. Randomized phase III study of cisplatin (CIS)/paclitaxel (PAC) versus carboplatin (CARBO)/PAC in optimal stage III epithelial ovarian cancer: a Gynecologic Oncology Group trial. Presented at Society of Gynecologic Oncologists, 31st Annual Meeting, San Diego, CA 2000.

48. Ozols RF, Young RC. Ovarian cancer. Curr Probl Cancer. 1987;11:57-122.

49. Thyss A, Saudes L, Otto J, et al. Renal tolerance of cisplatin in patients more than 80 years old. J Clin Oncol. 1994;12:2121-2125.

50. Alberts DS, Dahlberg S, Green SJ, et al. Analysis of patient age as an independent prognostic factor for survival in a phase III study of cisplatin-cyclophosphamide versus carboplatin-cyclophosphamide in stages III (suboptimal) and IV ovarian cancer. A Southwest Oncology Group study. Cancer. 1993;71:618-627.

51. Bicher A, Sarosy G, Kohn E, et al. Age does not influence taxol dose intensity in recurrent carcinoma of the ovary. Cancer. 1993;71:594-600.

52. Bolis G, Colombo N, Pecorelli S, et al. Adjuvant treatment for early epithelial ovarian cancer: results of two randomised clinical trials comparing cisplatin to no further treatment or chromic phosphate (32P). G.I.C.O.G.: Gruppo Interregionale Collaborativo in Ginecologia Oncologica. Ann Oncol. 1995;6:887-893.

53. Dembo AJ. Abdominopelvic radiotherapy in ovarian cancer. A 10-year experience. Cancer. 1985;55:2285-2290.

54. Trimble EL, Kosary CL, Cornelison TL, et al. Temporal trends in ovarian cancer survival. Presented at Society of Gynecologic Oncologists, 30th Annual Meeting, San Francisco, CA 1999.

55. Ries LA. Ovarian cancer. Survival and treatment differences by age. Cancer. 1993;71:524-529.

56. Gershenson DM, Mitchell MF, Atkinson N, et al. Age contrasts in patients with advanced epithelial ovarian cancer. The M.D. Anderson Cancer Center experience. Cancer. 1993;71:638-643.

57. Steiner M, Rubinov R, Borovik R, et al. Multimodal approach (surgery, chemotherapy, and radiotherapy) in the treatment of advanced ovarian carcinoma. Cancer. 1985;55:2748-2752.

58. Marchetti DL, Lele SB, Priore RL, et al. Treatment of advanced ovarian carcinoma in the elderly. Gynecol Oncol. 1993;49:86-91.

59. Newcomb PA, Carbone PP. Cancer treatment and age: patient perspectives. J Natl Cancer Inst. 1993;85:1580-1584.

60. Podczaski ES, Stevens CWJ, Manetta A, et al. Use of second-look laparotomy in the management of patients with ovarian epithelial malignancies. Gynecol Oncol. 1987;28:205-214.

61. Potter ME. Secondary cytoreduction in ovarian cancer: pro or con? Gynecol Oncol. 1993;51:131-135.

62. Friedman JB, Weiss NS. Second thoughts about second-look laparotomy in advanced ovarian cancer. N Engl J Med. 1990;322:1079-1082.

63. Hightower RD, Nguyen HN, Averette HE, et al. National survey of ovarian carcinoma. IV: Patterns of care and related survival for older patients. Cancer. 1994;73:377- 383.

64. Sutton GP, Stehman FB, Einhorn LH, et al. Ten-year follow-up of patients receiving cisplatin, doxorubicin, and cyclophosphamide chemotherapy for advanced epithelial ovarian carcinoma. J Clin Oncol. 1989;7:223-229.

65. Brinton LA, Herrero R, Reeves WC, et al. Risk factors for cervical cancer by histology. Gynecol Oncol. 1993;51:301- 306.

66. Vermund SH, Kelley KF, Klein RS, et al. High risk of human papillomavirus infection and cervical squamous intraepithelial lesions among women with symptomatic human immunodeficiency virus infection. Am J Obstet Gynecol. 1991;165:392-400.

67. Brinton LA, Hamman RF, Huggins GR, et al. Sexual and reproductive risk factors for invasive squamous cell cervical cancer. J Natl Cancer Inst. 1987;79:23-30.

68. La Vecchia C, Decarli A, Fasoli M, et al. Dietary vitamin A and the risk of intraepithelial and invasive cervical neoplasia. Gynecol Oncol. 1988;30:187-195.

69. Beral V, Hannaford P, Kay C. Oral contraceptive use and malignancies of the genital tract. Results from the Royal College of General Practitioners' Oral Contraception Study. Lancet. 1988;2:1331-1335.

70. Reeves WC, Rawls WE, Brinton LA. Epidemiology of genital papillomaviruses and cervical cancer. Rev Infect Dis. 1989;11:426-439.

71. Schneider V, Kay S, Lee HM. Immunosuppression as a high-risk factor in the development of condyloma acuminatum and squamous neoplasia of the cervix. Acta Cytol. 1983;27:220-224.

72. Benedet JL, Anderson GH, Matisic JP. A comprehensive program for cervical cancer detection and management. Am J Obstet Gynecol. 1992;166:1254-1259.

73. Runowicz CD, Goldberg GL, Smith HO. Cancer screening for women older than 40 years of age. Obstet Gynecol Clin North Am. 1993;20:391-408.

74. Gostout BS, Podratz KC, McGovern RM, et al. Cervical cancer in older women: a molecular analysis of human papillomavirus types, HLA types, and p53 mutations. Am J Obstet Gynecol. 1998;179:56-61.

75. Taylor RR, Teneriello MG, Nash JD, et al. The molecular genetics of gyn malignancies. Oncology. 1994;8:63-70.

76. DiSaia PJ, Creasman WT. Clinical Gynecologic Oncology, 5th Ed. St. Louis; Mosby; 1997.

77. DiSaia PJ. Surgical aspects of cervical carcinoma. Cancer. 1981;48:548-559.

78. Stehman FB, Bundy BN, DiSaia PJ, et al. Carcinoma of the cervix treated with radiation therapy. I. A multi-variate analysis of prognostic variables in the Gynecologic Oncology Group. Cancer. 1991;67:2776-2785.

79. Brookland RK, Rubin S, Danoff BF. Extended field irradiation in the treatment of patients with cervical carcinoma involving biopsy proven para-aortic nodes. Int J Radiat Oncol Biol Phys. 1984;10:1875-1879.

80. Keys HM, Bundy BN, Stehman FB, et al. Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med. 1999;340:1154-1161.

81. Rose PG, Bundy BN, Watkins EB, et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med. 1999;340:1144- 1153.

82. Whitney CW, Sause W, Bundy BN, et al. Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study. J Clin Oncol. 1999;17:1339-1348.

83. Magrina JF. Complications of irradiation and radical surgery for gynecologic malignancies. Obstet Gynecol Surv. 1993;48:571-575.

84. Fuchtner C, Manetta A, Walker JL, et al. Radical hysterectomy in the elderly patient: analysis of morbidity. Am J Obstet Gynecol. 1992;166:593-597.

85. Geisler JP, Geisler HE. Radical hysterectomy in patients 65 years of age and older. Gynecol Oncol. 1994;53:208- 211.

86. Hopkins MP, Morley GW. Radical hysterectomy versus radiation therapy for stage IB squamous cell cancer of the cervix. Cancer. 1991;68:272-277.

87. Carter J, Ramirez C, Waugh R, et al. Percutaneous urinary diversion in gynecologic oncology. Gynecol Oncol. 1991;40:248-252.

88. Sorbe B, Frankendal B. Bleomycin-adriamycin-cisplatin combination chemotherapy in the treatment of primary advanced and recurrent cervical carcinoma. Obstet Gynecol. 1984;63:167-170.

89. Giannone L, Brenner DE, Jones HW, et al. Combination chemotherapy for patients with advanced carcinoma of the cervix: trial of mitomycin-C, vincristine, bleomycin, and cisplatin. Gynecol Oncol. 1987;26:178-182.

90. Morley GW, Hopkins MP. Pelvic exenteration. In: Thompson JD, Rock JA, eds. Te Linde's Operative Gynecology, 7th Ed. Philadelphia: Lippincott; 1992:1329-1345.

91. Kodama S, Kanazawa K, Honma S, et al. Age as a prognostic factor in patients with squamous cell carcinoma of the uterine cervix. Cancer. 1991;68:2481-2485.

92. Chapman GW. Patterns of cervical carcinoma in women of advanced age. J Natl Med Assoc. 1997;89:801-804.

93. Jolles CJ, Freedman RS, Hamberger AD, et al. Complications of extended-field therapy for cervical carcinoma without prior surgery. Int J Radiat Oncol Biol Phys. 1986;12:179-183.

94. Brinton LA, Nasca PC, Mallin K, et al. Case-control study of cancer of the vulva. Obstet Gynecol. 1990;75:859- 866.

95. Rusk D, Sutton GP, Look KY, et al. Analysis of invasive squamous cell carcinoma of the vulva and vulvar intra-epithelial neoplasia for the presence of human papillomavirus DNA. Obstet Gynecol. 1991;77:918-922.

96. Stehman FB, Bundy BN, Dvoretsky PM, et al. Early stage I carcinoma of the vulva treated with ipsilateral superficial inguinal lymphadenectomy and modified radical hemivulvectomy: a prospective study of the Gynecologic Oncology Group. Obstet Gynecol. 1992;79:490-497.

97. Berek JS, Heaps JM, Fu YS, et al. Concurrent cisplatin and 5-fluorouracil chemotherapy and radiation therapy for advanced-stage squamous carcinoma of the vulva. Gynecol Oncol. 1991;42:197-201.

98. Hopkins MP, Morley GW. Pelvic exenteration for the treatment of vulvar cancer. Cancer. 1992;70:2835-2838.

99. Farias-Eisner R, Berek JS. Current management of invasive squamous carcinoma of the vulva. Clin Geriatr Med. 1993;9:131-143.

100. Lawton FG, Hacker NF. Surgery for invasive gynecologic cancer in the elderly female population. Obstet Gynecol. 1990;76:287-289.