Cancer of the Vulva

Essentials of Diagnosis•Typically occurs in postmenopausal women. •Long history of vulvar irritation with

pruritus, local discomfort, and bloody discharge.

•Appearance of early lesions like that of chronic vulvar dermatitis.

•Appearance of late lesions like that of a large cauliflower, or a hard ulcerated area in the vulva.

•Biopsy necessary for diagnosis.

Types of Vulvar Cancer

•Squamous Cell Carcinoma- most common type of tumor (85-90%) and most frequently involves the anterior half of the vulva.

•Malignant Melanoma- second most common vulvar cancer (5%)

•Carcinoma of Bartholin's Gland- most common site for vulvar adenocarcinoma

•Basal Cell Carcinoma- arise almost exclusively in the skin of the labia majora

Squamous Cell carcinoma

•65% arises in labia majora and minora•25% percent in clitoris or perineum •Appearance varies from a large,

exophytic, cauliflowerlike lesion to a small ulcer crater superimposed on a dystrophic lesion of the vulvar skin

•primary determinant of nodal metastases is tumor size.

Malignant Melanoma

•Accounts for 5% of vulvar cancers•most commonly arises in the labia minora

and clitoris•superficial spread toward the urethra and

vagina•nonpigmented melanoma may closely

resembles squamous cell carcinoma•darkly pigmented, raised lesion is a

characteristic finding

•All small pigmented lesions of the vulva are suspect and should be removed by excision biopsy with a 0.5- to 1-cm margin of normal skin

•large tumors, the diagnosis should be confirmed by a biopsy

Carcinoma of Bartholin's Gland

•Rare (1%) but the most common site of vulvar adenocarcinoma

•Most common type is squamous cell

metastasis

•Primarily lymphatics to the superficial inguinal lymph nodes

•Direct extension to vagina, urethra and anus

Treatment

•TOC: wide local excision with inguinal lymph node metastasis

•Stage I: ipsilateral lymphadenectomy•Stage II and III: bilateral

lymphadenectomy•Late stage III and IV: radical vulvectomy,

lymphadenectomy and/or chemoradiation

Cancer of the Vagina

•Rare, approximately 3% of gynecologic cancers

•Squamuos cell(85%)>adenocarcinomas> sarcomas>melanomas.

•Can be ulcerative or exophytic

Essentials of Diagnosis

•Asymptomatic: abnormal vaginal cytology. •Early: painless bleeding from ulcerated

tumor. •Late: bleeding, pain, weight loss,

swelling.

Endometrial Cancer• 3rd most common gynecologic malignancy in the

Philippines• Affects mostly peri/postmenopausal womenRISK FACTORS: Estrogen replacement therapy 4-8x Menopause after 52 years 2.4x Obesity 3x-21 to 50lbs, 10x->50lbs Nulliparity 2-3x Diabetes 2.8x Feminizing ovarian tumors Polycystic ovarian syndrome Tamoxifen therapy for breast cancer >2 years

•Protective factors:•Ovulation•Progestin therapy•Combination oral contraceptives•Menopause prior to 49 years•Normal weight•Multiparity

•Etiology: unopposed estrogen exposure•Clinical presentation:Abnormal uterine bleeding (80)Physical exam ussually unremarkable

Staging FIGO Surgical Staging of Carcinoma of the Corpus Uteri •     Stage I•     Stage Ia G123 Tumor limited to endometrium•     Stage Ib G123 Invasion to less than one-half the myometrium•     Stage Ic G123 Invasion to more than one-half the myometrium•     Stage II•     Stage IIa G123 Endocervical glandular involvement only•     Stage IIb G123 Cervical stromal invasion•     Stage III•     Stage IIIa G123 Tumor invades serosa and/or adnexa, and/or positive

peritoneal cytology•     Stage IIIb G123 Vaginal metastases•     Stage IIIc G123 Metastases to pelvic and/or paraaortic lymph nodes•     Stage IV•     Stage IVa G123 Tumor invades bladder and/or bowel mucosa•     Stage IVb Distant metastases including intra-abdominal and/or inguinal

lymph nodes•

Treatment

•Primary: surgerybilateral salpingo-oophorectomy,

peritoneal washings for cytology, and removal of pelvic and periaortic lymph nodes

•Adjuvant Chemotherapy: for advanced stages

Doxorubicin and cisplatin

Cancer of the Ovary

•Epithelial -65%•Germ cell- 20-25%•Sex cord-6%

•Etiology =frequent ovulatio n•Risk factors=nullipairty, decreased

fertility, early and late menopause, ovulatory drugs

Clinical presentation

•Asymptomatic until late stage •Enlarging abdomen, abdominal mass•Urinary frequency, dysuria, GI complaints•Metastasis to the umbilicus is known as

Sister Mary Joseph Nodule

Epithelial Ovarian Cancer

•SEROUS - most common type•MUCINOUS•ENDOMETRIOID•CLEAR CELL•BRENNER

Management

•SURGERY- primary management•CHEMOTHERAPY-

▫Paclitaxel-Carboplatin 6 cycles every 3-4 weeks

•CA-125- elevated in 80% of px with ovarian Ca

-use to evaluate treatment

Germ cell Tumors

•20-25% of ovarian cancers•Arises from undifferentiated germ cells

Histologic Classification•Dysgerminoma- most common malignant

GCT•Teratoma- most common GCT•Endodermal sinus tumor•Embryonal carcinoma•Polyembryoma•Choriocarcinoma•Mixed forms

Serum Tumor Markers for Germ Cell Neoplasistumor hCG AFP LDH CA-125

dysgerminoma + +

Mixed germ cell tumor

+ + + +

Embryonal Carcinoma

+ + +

Endodermal sinus

+

Clinical manifestation

•Tumors grow rapidly•Distention of the ovarian capsule•Hemorrhage•Pelvic pain•Pressure on rectum or bladder

Treatment•Unilateral salpingo-oophorectomy•Sensitive to chemotherapy- bleomycin,

etoposide, cisplatin (BEC)•Dysgerminomas- radiation theraPY•SURVIVAL RATE(5 year): •Dysgerminomas-85%•Immature teratomas-70 to 80%•Endodermal sinus tumors- 60 to 70%

Sex Cord-Stromal Tumors

•Low-grade malignancies•Occur at any age•Usually unilateral and do not often recur•Functional tumors- produced hormones•Granulosa-theca cells: large amounts of

estrogens•Sertoli-Leydig cells: testosterone and

androgens

Granulosa-theca cell tumors

•Precocious puberty•Menstrual irregularities•Secondary ammenorrhea•Post-menopausal bleeding•Endometrial hyperplasia and/or

endometrial cancer

Sertoli-Leydig Cell tumors

•Virilization: breast atrophy, hirsutism, deepened voice, acne, clitoromegaly and receding hairline

•Oligomenorrhea or amenorrhea

treatment

•Unilateral salpingo-oophorectomy•Chemotherapy- not effective5 year survival rate: 70-90%

Fallopian Tube Cancer

•Extremely rare: 0.5% of genital tract cancers

•80-90% of FT malignancies are metastatic from other sites (ovary, uterus, GIT

•Unknown etiology•Hereditary association (BRCA1)

Clinical manifestation

•Hydrops tubae profluens: profuse watery discharge, pelvic pain and pelvic mass

- Classic triad of fallopian Ca, only 15% of cases, pathognomonic

Treatment

•TAHBSO, retriperitoneal lymph node sampling

•Carboplatin and paclitaxel- adjunct therapy