Gynecological Malignancies
Susana Campos, MD, MPH
A 35-year-old female presents with pelvic pain. She describes postcoital bleeding. A pelvic examination reveals a clinically visible lesion measuring 4 cm in size. There is no parametrial invasion by examination. There is involvement of the upper vagina. A biopsy reveals squamous cell carcinoma. Imaging studies which include a PET scan reveals no distant metastasis.
Per the 2009 FIGO staging system, what stage is the patient’s cervical cancer?
View Answer
Stage IIA1 cervical cancer.
Cervical cancer is staged clinically.
Stage II cervical cancer means that the cancer has grown beyond the cervix and uterus but has not reached the walls of the pelvis or the lower third of the vagina.
A stage IIA cervical cancer does not involve the parametrium.
Stage IIA1 is a visible tumor that measures 4.0 cm or less, while a stage IIA2 cervical measures greater that 4.0 cm in greatest dimension.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 35-year-old female presents with pelvic pain. She describes postcoital bleeding. A pelvic examination reveals a clinically visible lesion measuring 4 cm in size. There is no parametrial invasion by examination. PET scan reveals no para-aortic involvement of distant metastasis. A biopsy reveals squamous cell carcinoma. She is staged clinically as a stage IIA cervical cancer.
What pathogen is the most important factor in the development of this disease?
View Answer
Human papillomavirus infection (HPV-16 and HPV-18 are the strains most associated with cervical cancer).
Immunization against HPV can prevent the development of HPV-associated cancer and is recommended for both men (age 9-21 years) and women (age 9-26 years).
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 55-year-old woman with a history of stage IIA1 cervical cancer present with cervical adenopathy. Imaging studies reveal FDG-avid cervical, mediastinal, and axillary disease. No other sites of disease is reported. A biopsy of the axillary node reveals metastatic cervical cancer. The patient’s previous treatment included external beam radiation therapy with cisplatin as a radiosensitizer followed by brachytherapy.
What is the first-line therapy for metastatic cervical cancer?
View Answer
Cisplatin, paclitaxel, and bevacizumab.
First-line therapy for metastatic cervical cancer is based on GOG 240. This was a randomized trial of cisplatin and paclitaxel versus topotecan/paclitaxel +/− bevacizumab. GOG 240 reported a survival advantage with bevacizumab in first-line metastatic cervical cancer.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
Bevacizumab is a monoclonal antibody to the vascular endothelial growth factor.
What are the potential adverse effects of bevacizumab?
View Answer
Common side effects of bevacizumab include hypertension, proteinuria, bleeding, clotting, bowel perforation, reversible posterior leukoencephalopathy, and fistula formation.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 45-year-old woman with a history of metastatic squamous cell carcinoma of the cervix progresses after 6 cycles of therapy with cisplatin, paclitaxel, and bevacizumab. Imaging studies reveal multiple foci of disease in her liver and lungs. The patient denies any autoimmune diseases. She inquires about the potential for immunotherapy.
What is the appropriate strategy for this patient?
View Answer
Test her tumor for PD-L1.
A combined positive score of >1% is considered positive. The FDA approved pembrolizumab for advanced cervical cancer with disease progression during or after chemotherapy based on the KEYNOTE 158 study. Overall response rate was 14.3%.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
Which epidemiologic risk factors are associated with the development of cervical cancer?
View Answer
Epidemiological risk factors associated with the development of cervical cancer include:
Persistent HPV 16 and 18 infection (most important factor)
History of smoking
Parity
OCP use
Early age of onset of sexual activity
Larger number of lifetime sexual partners
History of STD
Autoimmune disease or chronic immunosuppression
In utero exposure to diethylstilbestrol (DES) associated with clear cell adenocarcinoma of the vagina and cervix
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 38-year-old woman presents with a 2-week history of abdominal distention. Imaging studies reveal bilateral enlarged ovarian cystic masses and ascites. Her CA125 is elevated at 100. She no longer desires fertility and undergoes a THO/BSO/omentectomy and lymph node sampling. Pathology reveals a serous borderline tumor (no invasive implants).
What is the appropriate recommendation?
View Answer
Active surveillance.
Borderline serous tumors of the ovary represent a separate entity of ovarian neoplasm. Surgery is the current management of these neoplasm without proven benefit from adjuvant therapy based on four trials failing to show survival advantage. Late recurrences are possible, but there is a low risk of developing invasive ovarian cancers.
Suggested Readings:
NCCN Clinical Practice Guidelines in Oncology. Ovarian Cancer. Version 1.2020. Accessed July 30, 2020. www.nccn.org/patients
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
Match the following epidemiologic factor with the appropriate change (increased or decreased) in risk for ovarian cancer.
Older age (>35 years) at first pregnancy and first birth: _________
Younger age at first pregnancy and first birth (≤25 years): _________
Late menopause: _________
Early menarche: _________
Use of oral contraceptives: _________
Postmenopausal hormone therapy: _________
Breastfeeding: _________
Higher parity: _________
Nulliparity: _________
Diet high in animal fat: _________
View Answer
Match the following epidemiologic factor with the appropriate change (increased or decreased) in risk for ovarian cancer.
Older age (>35 years) at first pregnancy and first birth: increased
Younger age at first pregnancy and first birth (≤25 years): decreased
Late menopause: increased
Early menarche: increased
Use of oral contraceptives: decreased
Postmenopausal hormone therapy: increased
Breastfeeding: decreased
Higher parity: decreased
Nulliparity: increased
Diet high in animal fat: increased
Suggested Readings:
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