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• Ovarian Cancer
• Staging of Ovarian Neoplasm
• Uterine Cancer
• Staging of Uterine Cancer
• Cervical Cancer
• Vulva Cancer
• Handouts

Ovarian Cancer

History

Presenting Complaint

"I just haven't been feeling very good lately.  My stomach seems bloated.  My skirts are tight.  I seem to have more gas than I used to and I've been using Mylanta for indigestion lately."

These are typical complaints.  Hardly red flags for ovarian cancer.  The latest symptom is the increasing abdominal girth.  The tumor has probably metastasized by then.

Physical

• General physical and pelvic exam.
• May find an enlarged ovary, but difficult to detect.  
• May detect acites. Shifting dullness.  Flank fullness.
• Assess lymph nodes
• Do Pap smear
• Stool for guaiac

Differential Diagnoses

• Pregnancy
• Functional ovarian cyst
• Alcoholism
• Ovarian tumor, benign
• Ovarian tumor, malignant
• Polycystic ovarian syndrome

Tests

• Sonogram to look for masses, particularly solid
• CA-125.  Would be done only if symptoms warrant or sonogram demonstrates suspicious mass.  Too expensive to use as a screen tool.
• Chest x-ray if signs of solid mass, etc.
• CBC, electrolytes, hCG, AFP, LDH

Plan

Perform above listed tests

Refer to OB-GYN specialist/oncologist

Staging of Ovarian Neoplasm

Stage I Growth limited to the ovaries.  75% 5 year survival

• 1a-  one ovary involved
• 1b -Both ovaries involved
• 1c-la or b and ovarian surface tumor, ruptured capsule, malignant ascites, peritoneal cytology positive for malignant cells

Stage II.  Extension of the neoplasm from the ovary to the pelvis  60% 5 year survival

• 11a-extension to the uterus or fallopian tube
• 11b-extension to other pelvic tissues
• 11c-11a or b and ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology positive for malignant cells.

Stage III. Disease extension to the abdominal cavity'  35% 5 year survival

• 111a-Abdominal peritoneal surfaces with microscopic metastases
• 111b-tumor metastases <2cm
• 111c-tumor metastases>2cm or metastatic disease in the pelvic, para-aortic or inguinal lymph nodes

Stage IV  Distant metastic disease  10% 5 year survival.

• Malignant pleural effusion
• Pulmonary parenchymal metastases
• Liver or splenic parenchymal metastases
• Metastases to the supraclavicular lymph nodes or skin

Statistics:

• Average of diagnosis is 60 years, incidence increases with age.
• Only 5-10% of cases are familial.  Women with BRAC 1 and BRAC 2 mutations are most at risk and the risk combines breast and uterus.
• The use of birth control pills lowers the risk of ovarian cancer.  The longer the use of pills, the lower the risk.  (Frequent ovulators are at the highest risk)
• Breast feeding and higher parity reduce risk.

Uterine Cancer

History

" I'm 58 years old.  I went through menopause 10 years ago and I've started having periods or at least spotting, again"

Postmenopausal bleeding in always assumed to be cancer until proven otherwise.  The differential diagnosis is more complicated when the postmenopausal woman is on hormone replacement therapy.

Women with periods of unopposed estrogen are at highest risk.  PCOD, anovulation, DUB, Estrogen replacement therapy in a woman with a uterus without progesterone, tamoxifen.obesity, late menopause, obese, chronic liver disease.

Major Signs and Symptoms

• Bleeding:  hypermenorrhea, intermenstrual or postmenopausal.(in 80% of women)
• Abnormal vaginal discharge especially after menopause. 
• Lower abdominal cramps and pain.
• AGUS

Physical

• General physical and pelvic exam.
• Evidence of bleeding in the vagina.
• Uterus may be enlarged and fixed.

Differential Diagnoses

• Vaginitis with discharge
• Condoloma
• Cervical ectopy
• Acute and chronic cervicitis
• Cervical tuberculosis
• Ulceration secondary to STD's
• Abortion of cervical pregnancy

Tests

• CBC may indicate anemia
• Pap smear
• Endometrial biopsy (extremely important)
• D & C
• Stool of guaiac
• Ca-125
• Pelvic ultrasound

Plan

Do above tests

Revere to OB-GYN/ oncologist

Classification of Endometrial Changes

A. Endometrial hyperplasia

1. Hyperplasia without atypia
2. Hyperplasia with atypia
3. Carcinoma in Situ (Not cancer.  Does not cross the basement membrane, but very abnormal.)

B.  Endometrial Carcinoma

Staging of Uterine Cancer

Stage 1 85% 5 year survival rate

• 1a-tumor limited to
• 1b-invasion to less than 1/2 the myometrium
• 1c-invasion to more than 1/2 the myometrium

Stage II  60% 5 year survival rate

• 11a-Endocervical glandular involvement only
• 11b-Cervical stromal invasion

Stage III  30% 5 year survival rate

• 111a-Tumor invades serosa and/or adenexa, and/or positive peritoneal cytology
• 111b-Vaginal metastases
• 111c-Matastases to pelvic and/or para-aortic lymph nodes

Stage IV  10% 5 year survival rate

• IVa-Tumor invades bladder and/or bowel mucosa
• IVb-Distant metastases including intra-abdominal and/or inguinal lymph nodes

Statistics

80% of cancers are detected are in early, localized stage.

Cervical Cancer

History

"I'm 46 and I've started spotting after I have intercourse and I have a strange discharge.  I haven't had a Pap smear for 15 years, since my last child was born."

Major Signs & Symptoms

• Abnormal uterine and vaginal bleeding, intermenstrual bleeding, postcoital bleeding.
• Cervical lesion visible as a tumor or ulceration, early lesion may look like cervicitis.
• Abnormal Pap Smear
• Vaginal discharge.

Physical Exam

• General physical examination.
• Pelvic and Pap smear
• Cervical lesion visible

Lab Studies

• Pap smear
• Biopsy any lesion
• Colposcopy with endocervical curettage.
• Expect cone biopsy

Statistics

• 90% of cervical cancer's are related to the human papillomavirus (HPV).  Serotypes 16 and 18   are most often associated with cancer.
• 90% of squamous cell carcinomas develop in the intraepithelial layers, almost always at the squamocolumnar junction on the ectocervix or in the endocervical canal.
• Cervical cancer is considered a STD.
• 90% of cervical cancers are curable, if detected and treated early.
• Incidence increases with other STD's, particularly HIV, onset of sexual activity before age 20, smoking
• Time between initial exposure to Ca in situ to invasive cancer is 7-10 years.
• Early cancer is locally invasive.

Vulva Cancer

Note:  Review section on vulvar lesions.

72 year old woman.  "I was having itching on my privates, then I got a sore.   I've had it for quite awhile.  It seems to be getting larger, so I thought I should have it looked at."

History

When was lesion first noticed?  How has it changed?   What have you treated it with? Discharge?  Vulvar pain.

Physical

• General physical exam with pelvic exam
• Vulvar exam

Differential Diagnoses

• Non malignant vulvar lesions
• VIN (Vulvar intraepithelial disease) Bowen's disease of carcinoma in situ
• Malignant vulvar lesions.
• Vaginitis with purities
• Diabetes with chronic purities.
• Ulcerating STD's
• Condyloma
• Herpes
• Paget's disease

Tests

• General physical examination
• Pelvic exam with thorough exam of vulva and vagina.
• Pap smear
• Punch biopsy of any lesions.
• May use toluidine blue or acetic acid to highlight areas for biopsy.
• Colposcopic exam of vulva
• CBC, UA, ?chest x-ray

Plan

• Exam and tests as above.
• Refer to OB-GYN /oncologist
• Expect patient to have surgery

Statistics

• Squamous cell cancers account for 90-95%
• More common in older women.
• Surgery, often radical as well as chemotherapy is the treatment.

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