and Karl Reinhard Aigner3
(1)
Department of Surgery, The University of Sydney, Mosman, NSW, Australia
(2)
The Royal Prince Alfred and Sydney Hospitals, Mosman, NSW, Australia
(3)
Department of Surgical Oncology, Medias Clinic Surgical Oncology, Burghausen, Germany
In this chapter, you learn about:
Cancers of the uterus
Cancer of the ovary
Cancer of the vagina
Cancer of the vulva
15.1 Cancers of the Uterus
There are two distinct types of cancer of the uterus. Squamous cell carcinoma (SCC) of the cervix or opening of the uterus is the more common. The other type is an endometrial or glandular cancer (adenocarcinoma) of the lining of the cavity of the uterus (the body of the uterus).
15.2 Cancer of the Cervix
15.2.1 Presentation and Risk Factors
Cervical cancer can occur in any woman especially over the age of 40, but there are particular risk factors in some groups of women, for example, it is more common in smokers and erosions and inflammation of the cervix are predisposing factors. Infection with a sexually transmitted virus, the human papillomavirus (HPV), has become a very significant factor. The HPV, being sexually transmitted, is more common in women who have had multiple sexual partners, particularly if sexual activity started early in life. Prostitutes are at particular risk. Cervical cancer is significantly more common in women in lower socio-economic groups and in recent years has been seen to be one of the cancers that more commonly develops in women with HIV infection or AIDS.
An annual routine cervical smear test (the Pap test) will usually detect these cancers early and at a very curable stage.
The earliest changes associated with this cancer are most often present in women between the ages of 30 and 40. Usually at this age, there are no symptoms but there may be a little blood staining from the vagina between periods, especially after intercourse, or there may be a watery discharge.
Cancers of the cervix tend to develop slowly but can usually be detected by routine cervical screening examination (the Papanicolaou or cervical smear test described in Sect. 7.2.1) in which abnormal (dysplastic) or frankly malignant cells may be found. An annual routine cervical smear test (the Pap test) will usually detect these cancers early and at a very curable stage.
15.2.2 Investigations
Sometimes the cancers cannot be seen on visual examination of the cervix, but at other times a cancer may be seen as a reddish, eroded, ulcerated or possibly bleeding lesion. Modern colposcopes are now often used to better visualise the inner lining of the cervix and uterus. In any case a biopsy is taken for pathological examination to confirm the diagnosis.
15.2.3 Treatment
Very small early cancers may be treated by surgical removal of the lining of the cervix only, especially in women who wish to have more babies. Larger invasive cancers are best treated by removal of the uterus (total hysterectomy). Cancers that have begun to spread from the cervix onto the adjacent vagina present more of a problem. They often respond well when initially treated with a combination of chemotherapy/radiotherapy given together as concomitant treatment and sometimes followed by hysterectomy.
If cancer of the cervix has not been diagnosed until it is quite advanced, there is a risk of metastatic spread to lymph nodes, especially lymph nodes in the pelvis. This situation is more likely in women of more than 40 years of age who have not had regular Pap tests. These women often complain of some bleeding and discharge between menstrual periods or after intercourse. If an advanced, ulcerating or fungating cancer is present, it should be obvious on examination of the cervix. Surrounding tissues such as the ureters or the rectum may become involved as well as the local draining lymph nodes in the pelvis. CT scans will help detect the extent of the cancer. Such advanced cancers are usually treated by radical surgery or by radiotherapy or both or by radiotherapy and chemotherapy concomitantly followed by radical surgery.
Early use of chemotherapy alone was disappointing with this cancer. It has been given as induction treatment both systemically and by regional infusion as part of an integrated treatment programme, and although early results were disappointing, studies have been continued in some centres using different treatment schedules in different combinations with more encouraging results. However, programmes of chemotherapy (using the anti-cancer agent cisplatin) and radiotherapy, given together as concomitant treatment, have given best results in several studies. Chemotherapy is also sometimes given as palliative treatment for widespread cancer but substantial prolonged benefit is not common.
15.2.4 Prevention
In recent years the association of the HPV with cancer of the cervix has been more intensely investigated with a view to introducing more effective preventive measures. Types 16 and 18 of this virus are considered to be the most pathogenic and attempts at developing a vaccine against the virus are more than encouraging. A successful preventive vaccination trial in a large study group has recently been reported. National vaccination programmes are now being established in several countries to 12–13-year-old girls.
Case Report
Cervical cancer
When she first presented, Dianne was 46 years of age and had previously been in good health. She was married with three children. She had not had regular Pap smears, the last possibly some 5 years previously. On presentation she had recently experienced some menstrual cycle irregularity and post-coital bleeding. Her general practitioner initially treated her with progesterone agents to control what was thought to be dysfunctional bleeding.
She returned some 3 weeks later with reduced but ongoing irregular bleeding. She was then referred to a gynaecologist who on vaginal pelvic examination confirmed an obvious malignant growth involving her cervix. A biopsy in the clinic confirmed an invasive SCC.
Dianne was then referred to a specialist gynaecological oncologist. An examination under anaesthesia (EUA) was arranged; meanwhile an abdominal and pelvic CT scan confirmed a large cervical lesion measuring 5 cm in diameter without obvious extension and no radiological evidence of involvement of lymph nodes. The EUA, which included a cystoscopy, sigmoidoscopy, vaginal speculum examination and bimanual recto-vaginal pelvic examination, confirmed a large “barrel-shaped” cervical tumour approximately 5 cm in diameter without parametrial or vaginal extension. She was then staged (officially according to the international system) as a stage 1b2 cervical cancer, meaning a large locally invasive cancer (but apparently limited to the cervix).
At the post-operative consultation, the gynaecological oncologist discussed with Dianne and her husband the options for management. The first option was for an abdominal radical hysterectomy and pelvic lymph node dissection. Advantages of such an approach are the removal of the tumour and a formal assessment of the pelvic lymph nodes rather than relying on radiological evidence of apparent disease spread. Disadvantages of such an approach are that the majority of patients with large barrel-shaped tumours have pelvic lymph node metastases and the majority of patients also then need to undergo additional treatment comprising concurrent chemo-irradiation treatment. The second and largely favoured option was to treat with definitive chemo-irradiation therapy and avoid surgery. Advantages of such an approach would be an identical survival rate but significantly reduced morbidity, as surgery has not been undertaken.
Dianne considered her options and opted for the latter approach. She underwent 6 weeks of external pelvic irradiation therapy with weekly chemotherapy (using low-dose cisplatin). Towards the end of her external beam treatment, she was given additional treatment by internal or brachytherapy.
Now 3 years post treatment, Dianne remains well without clinical evidence of disease. She has undergone menopause, probably related to the effects of therapy on her ovaries. Her only ongoing morbidity is narrowing of the vagina requiring regular vaginal dilator treatment.
Exercise
Consider the reasons why there has been an increased incidence of cancer of the cervix over the latter part of the twentieth century and why this pattern is now likely to be reversed.
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15.3 Cancer of the Body of the Uterus (Endometrial Cancer)
15.3.1 Presentation
These cancers are most commonly seen in older women. It is believed that change in female sex hormones, and especially an imbalance of hormones, may contribute to development of this cancer, which is becoming rather more common, because more women are living longer. It is now recognised that endometrial cancer is sometimes associated with long-term post-menopausal oestrogen therapy or long-term use of tamoxifen to treat or prevent of breast cancer.
The most common feature of endometrial cancer is bleeding and blood-stained discharge after the menopause, but sometimes a watery discharge is the only feature.
15.3.2 Investigations
The uterus is usually enlarged, and to establish a diagnosis, curettage is performed. The scrapings from the curette are sent for pathology examination.
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