Health Questions and Answers

GYNECOLOGIC CANCERS

Define the risk groups on which current recommendations for cervical carcinoma screening are based.
Recommendations concerning periodic screening of women in the U.S. using Pap smears (Papanicolaou-Traut smears) have been developed for the various risk groups. Low-risk groups are those women who have never had sexual activity, have had a hysterectomy for nonmalignant reasons, or have reached the age of 60 and have never had a positive Pap smear. High-risk patients are those who are sexually active early, have had many partners, or are in low socioeconomic groups.

What are the current recommendations for cervical carcinoma screening.
The American Cancer Society and the American College of Obstetricians and Gynecologists recommend that asymptomatic women over 18 years of age and those under age 18 who are sexually active have annual screening for at least 3 years initially. Some groups recommend that women then be screened every 2-3 years until age 65, while others suggest yearly screening as long as the patient is sexually active. High-risk patients should be screened yearly.

Sumarize the appropriate management of a patient with an abnormal Pap smear.
A persistently abnormal Pap smear should lead to colposcopy and/or biopsy.

What should be done if carcinoma in situ or dysplasia is found?
Cryotherapy, laser therapy, cone biopsy, or hysterectomy should be performed, depending on the size and extent of the lesion.

What should be done if invasive cancer is found on biopsy?
A metastatic work-up is indicated. Stage I disease is treated with radical hysterectomy or radiation therapy, whereas all other stages are further evaluated with a CT scan. If the para-aortic nodes are enlarged, a needle biopsy should be done. Patients with a positive biopsy are treated with pelvic radiation therapy and concurrent chemotherapy. If nodes are normal on the CT scan or if the needle biopsy is negative, laparotomy with para-aortic node biopsies should be considered to determine the actual state of the nodes. If the biopsy is positive, then treatment should proceed as for other positive-node biopsies. If it is negative, treatment is external beam radiotherapy followed by intracavitary radioactive implants.

Which studies are used in the staging of carcinoma of the cervix?

  1. Pelvic exam
  2. Biochemical profile
  3. Chest x-ray
  4. CT scan or MRI (MRI is preferred)
  5. Lymphangiograms may be useful in selected cases
  6. Cystoscopy and proctosigmoidoscopy for advanced disease

How is stage I carcinoma of the cervix treated?
IA:Total or radical hysterectomy, conization, or intracavitary radiation.
IB:External-beam pelvic irradiation combined with two or more intracavitary applications; radical hysterectomy with bilateral pelvic lymphadenectomy ± postoperative total pelvic irradiation plus chemotherapy; radiation therapy plus chemotherapy with cisplatin or cisplatin/5-FU for patients with bulky tumors.

FIVE-YEAR SURVIVAL RATES RELATIVE TO STAGE
Stage/       Description/                                  5-Year Survival Rate
I /Tumor strictly confined to the cervix /89-100%
II /Tumor extends beyond the uterus but not to the pelvic wall The tumor involves the vagina but not the lower third /67%
III / Tumor extends to the pelvic wall, and/or involves the lower third of the vagina, and/or causes hydronephrosis or nonfunctioning kidney / 53%
IV / Tumor extends beyond the true pelvis, or has involved the bladder or rectal mucosa, or has distant metastases / 5-24%

Summarize the treatment of stage II carcinoma of the cervix.
IIA: Same as stage IB.
IIB: Radiation therapy plus chemotherapy: intracavitary radiation and external-beam pelvic irradiation combined with cisplatin or cisplatin/fluorouracil.

How is stage III carcinoma of the cervix treated?
Same as stage IIB.

Summarize the treatment of stage IV carcinoma of the cervix.
IVA: Same as stage IIB and stage III.
IVB: Chemotherapy with agents such as cisplatin, paclitaxel, ifosfamide-cisplatin, or irinotecan. Radiotherapy may be used for palliation.

Name the risk factors for carcinoma of the endometrium.

  1. Infertility
  2. Obesity
  3. Failure of ovulation
  4. Dysfunctional bleeding
  5. Prolonged estrogen use
  6. Diabetes mellitus
  7. Hypertension
  8. Polycystic ovaries
  9. Familial cancer syndrome (Lynch)
  10. Tamoxifen use

List the risk factors for ovarian cancer.

  • Nulliparity or low parity
  • Presence of basal cell nevus syndrome
  • Family history of ovarian cancer or ovarian cancer syndromes
  • Gonadal dysgenesis (46XY type)
  • History of breast, endometrial, or colon cancer
  • Asbestos exposure
  • Presence of Peutz-Jeghers syndrome
  • Use of fertility drugs (?)

Discuss the appropriate use of the CA-125 antigen.
CA-125 serum tumor marker, an antigenic determinant detected by radioimmunoassay, is elevated in 80% of epithelial ovarian cancers. Because it is high in only half of patients with stage I cancers and is increased in a significant proportion of healthy women and women with benign disease, it is not a sensitive or specific test and should not be used for screening in women with average risk for ovarian cancer. In high-risk patients or in patients suspected of having an ovarian cancer, it can be used in conjunction with bimanual rectovaginal pelvic examination and transvaginal ultrasonography. When the CA-125 value is elevated before treatment in a patient with an established diagnosis of ovarian cancer, it is useful as a marker of disease recurrence after surgical resection.

List the neurologic paraneoplastic syndromes associated with ovarian cancer.

  1. Peripheral neuropathy
  2. Organic brain syndrome
  3. Acute myelogenous leukemia-like syndrome
  4. Cerebellar ataxia (anti-Yo paraneoplastic cerebellar degeneration)
  5. Cancer-associated retinopathy
  6. Opsoclonus-myoclonus

What other paraneoplastic syndromes may be associated with ovarian cancer?

  1. Cross-matching of blood antigens
  2. Cushing’s syndrome
  3. Hypercalcemia
  4. Thrombophlebitis
  5. Dermatomyositis
  6. Palmar fasciitis and polyarthritis

Describe the treatment for advanced-stage ovarian cancer.
Patients with stage III epithelial ovarian cancers are first treated with surgery, consisting of total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as possible. This is followed by intravenous chemotherapy with cisplatin or carboplatin combined with taxol or cyclophosphamide. Patients with stage IV disease are given combination chemotherapy. The survival benefit of surgical debulking in patients with stage IV extra-abdominal disease is not yet known.

References
WEB SITES
National Cancer Database: http://www.facs.org/cancer/ncdb/index.html
National Guideline Clearinghouse: http://www.guideline.gov/
PDQ Cancer Information Summaries: http://www.cancer.gov/
SEER Cancer Statistics Review, 1975-2000: http://seer.cancer.gov/csr/1975_2000/
Cervical Cancer, PDQ Treatment Statements for Health Professionals, National Cancer Institute. Available at http://cancer.gov/cancerinfo/pdq/treatment/cervical/healthprofessional/.

BIBLIOGRAPHY

  1. American Joint Committee on Cancer: Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2002.
  2. Calabresi P, Schein PS (eds): Basic Principles and Clinical Management of Cancer, 2nd ed. New York, Macmillan, 1993.
  3. Casciato DA, Lowitz BB (eds): Manual of Clinical Oncology, 5th ed. Boston, Little, Brown, 2000.
  4. DeVita T Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of Oncology, 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2001.
  5. Haskell CM: Cancer Treatment, 4th ed. Philadelphia, W.B. Saunders, 1995.
  6. Holland JF, Frei E, et al (eds): Cancer Medicine, 6th ed. New York, BC Decker, 2003.
  7. Tannock IF, Hill RP (eds): The Basic Science of Oncology, 3rd ed. New York, McGraw-Hill, 1998.
  8. NIH Consensus Development Panel on Ovarian Cancer: Ovarian cancer: Screening, treatment, and follow-up. JAMA 273:491-497, 1995.

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