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Genital Tract Cancers
George Stransky MD, WWAMI Professor of Ob-Gyn, UW School of Medicine
Organs by Frequency
What Can You Do?
Cervix
Most common genital tract cancer worldwide
Squamous Cell Cervical Cancer
Cervical Adenocarcinoma
Cervix Summary
Look
Pap smears
Biopsy
Operate in office if non-invasive
Invasive treatment in the hospital
Radiation
Radical Hysterectomy.
Questions: True or False
1. Cervical cancer is caused by a Sexually Transmitted Infection (STI)
2. You can vaccinate against squamous cervical cancer
3. You cannot diagnose dysplasia from a Pap smear
4. Endo-cervical adenocarcinoma is cause by high-risk HPV DNA virus
5. You can vaccinate against endo-cervical adenocarcinoma
6. Vaccination is preferred in a 10 year old because antibody formation response is
better and she is not sexually active
7. Vaccination is preferred in an 18 year old because we have no protection data past 8
years and you can inform her (not her mother)
8. Yearly Pap smears pick up twice as many abnormalities as a Pap every 3 years
(10/1000 versus 5/1000)
9. Treatment for invasive cervical cancer is primarily radiation (not surgery)
Endometrium
Most common female genital tract cancer in the USA
Endometrial Cancer Risk Factors
Increased
HNPCC* 5% of endometrial cancers
Obesity
Anovulation
Drugs
Estrogen - unopposed
Tamoxifen
Decreased
Progesterone
Weight loss / exercise
Mirena IUS
Oral contraceptives
Diagnosis

Bleeding: Metrorrhage or postmenopausal

Endometrial +/- endocervical biopsy

D&C
▪
If office biopsy not adequate
▪
If mass/polyp/fluid in the endometrial cavity
▪
Sonogram
▪
Does NOT rule out cancer, but endometrial thickness matters
▪
Does detect myometrial invasion
Endometrial Adenocarcinoma
Endometrial Cancer: Treatment
Stage
Hysterectomy +/- node dissection
Pathology exams specimen at operation
Treatment
Hysterectomy: works for most
Irradiation
Chemotherapy
Hormones
Endometrial Cancer Summary
Biopsy the endometrium for
Bleeding between menses, esp. after 40 years old
Postmenopausal bleeding, esp. if no hormones
Unusual, persistent uterine bleeding
Fluid/masses in the endometrial cavity
Questions: True or False
Biopsy is needed to rule out endometrial adenocarcinoma (EA)
Hysterectomy is needed to stage every endometrial adenocarcinoma
Endometrial masses increase false-negative office endometrial biopsies from 2% to 10% = you miss
the cancer 5 times more frequently.
Sonograms and MRI studies show myometrial invasion by EA
Bleeding 5 years menopausal without hormones = 30% chance of EA
Bleeding 10 years menopausal without hormones = 80% chance of EA
Histologic grade (1, 2, or 3) is important for prognosis, more so than in other genital tract cancers
Ovary
Most deadly genital tract cancer
Cancer of the Ovary
Serouscystadenocarcinoma, Stage Ia
Ovarian Cancer Symptoms
Stage I and II disease
Nothing
Stage III and IV disease
Abdominal discomfort
Upper abdominal fullness
Early satiety
Progressive bowel obstruction
Starvation
Ovarian cancer
Stage I and II
No symptoms
No reliable testing: CA-125, CEA, β-HCG, Alpha-fetal protein, MRI, CAT scan, Sonogram, X-ray, PET
scan, pelvic examination, and history may all be negative.
70% bilateral
75% epithelial variety
80% stage III or IV
Ovarian Cancer
Epithelial
Serous - tube
Mucinous - endocervix
Endometrioid – lining of uterus
Mesonephric – transitional GU epithelium
Origin and Risk
Proportional to activity on surface of ovary
Pregnancy, breastfeeding, and oral contraceptives help prevent it (40-80%)
Hereditary Ovarian Cancer Syndrome
1 in 2000 females
1 in 30 if 2+ 1st degree relatives have ovarian cancer
Removing ovaries reduces 40% risk to 4%
Mutated BRAC-1 and BRAC-2 genes
May originate from tube or pelvic peritoneum
Ovarian Tumor Markers
Epithelial cell ovarian cancer
Ca-125
Germ cell ovarian cancer,5% of ovarian cancers, age 10-30 years old, and can make
Alpha-fetoprotein
β-HCG
Colon involvement
Carcinoembryonic antigen (CEA)
Mucinous Cystadenocarcinoma
Case 5: Enlarged Pelvic Mass
34 yo gravida zero has a 6 cm right adnexal mass present for 3 months. Complex by sonogram. CA-125
25 (n = 0-34).
Could this be cancer?
Is surgery indicated?
Would needle aspirate, open, or use laparoscope?
Do you suspect endometriosis?
If you do, would you treat it medically or surgically?
Ovarian Cancers
Ovarian Cancer Tissue Types
Sex cord – Stromal tumors
Granulosa cell
Resemble fetal ovaries
Produce estrogen, so consider endometrial biopsy
Produce inhibin A/B
Sertoli-Leydig tumors
Resemble fetal testes and make testosterone
Virilization may occur
Call-Exner bodies
Metastatic from
UGI
Colon
Breast
Metastatic Ovarian Cancer
Treatment for Ovarian Cancer
Operation
Chemotherapy
Irradiation
Follow-up care: use protocol for 5 years
Tumor markers
Periodic sonogram, CT, CXR
Ovarian Cancer Summary
Evaluate every adnexal mass
Counsel on ovarian suppression
Genetic testing rarely indicated
Use sonograms liberally
Questions: True or False
History of colon or breast cancer increases the risk of ovarian cancer
Ovarian suppression lowers ovarian cancer risk
Tumor markers for ovarian cancer are crude and can be falsely negative
Primary ovarian cancers are cystic
Cancers that metastasize to the ovary (ovaries) are solid
Aspiration of complex ovarian cysts is contraindicated
Vulva, Vagina, Tube
Malignant melanomas prefer vulvar skin
Vulvar Cancer

Human papilloma virus, High-Risk

Colposcopy

Wide local incision of VIN & CIS

Invasive squamous lesions usually appear as ulcers

10% of melanomas occur on vulva, which is only 1% of skin’s surface on the body
Vulvar Cancers
Melanoma
Basal cell
Paget disease
VIN III – Vulvar Intraepithelial Neoplasia, Grade 3
Invasive Cancer of the Vulva
Vulvar Cancer Summary

Biopsy vulvar growths

Follow-up “infectious” lesions

Keep rechecking after vulvar cancer

Multifocal

Recurrences are common eventually
Vaginal Cancer

Primary squamous

Metastatic adenocarcinoma from cervix, rectum, or vulva

Biopsy persistent, solid, bleeding lesions
Vaginal Cancer
Fallopian Tube Cancer
Presents as an adnexal mass
Triad of mass, pain, and clear discharge
Rare but very malignant once out of tube
Treat with TAH BSO
Fallopian Tube
Cancer
Cancer and Pregnancy
The fetus and placenta are NOT maternal tissue.
Cancer and Pregnancy
Placenta: Hydatidiform Mole
Histology NOT proportional to malignancy
Cancer of the fetus – paternally derived
Suspect in anyone with a positive pregnancy
test or continued bleeding more than 3 months
after the end of a pregnancy
Curable if diagnosed early
50% fatal if diagnosis delayed a year
Epidemiology of Gestational Trophoblastic Neoplasia

1 in 1500 pregnancies in USA

1 in 150 in Asia

Choriocarcinoma
1 in 25, 000 pregnancies or
1 in 20,000 live births

If she had a molar pregnancy, choriocarcinoma is 1000 times more likely to occur compared to
normal pregnancy history.
Treatment
D&C of uterus
Follow HCG until negative
Avoid getting pregnant again for 1 year
Invasive mole is treated with hysterectomy
Chemotherapy with Methyltrexate is used
Summary for Female Cancers
Biopsy Growths
Vulva
Vaginal
Cervical
Endometrial
Fetal Cancers
β-HCG Negative
Evaluate Adnexal Masses
Ovarian
Tubal
Cancer with Pregnancy
Treat cancer primarily