Gynecologic Oncology: Services

Ovarian cancer

Ovarian cancer most commonly manifests itself as an abdominal or pelvic mass. The mass is usually surgically removed through an abdominal incision (laparotomy). The surgery includes removal of the ovarian mass, uterus, fallopian tubes, omentum and any visible area of cancer spread. This surgery sometimes requires resection of a portion of intestine or lymph nodes. In some cases after surgery, the abdominal cavity will fill with fluid (called ascites) caused by the cancer. Patients are treated with chemotherapy after surgery.

Questions and Answers

Is ovarian cancer hereditary?
Approximately 5-10 percent of ovarian cancers are considered hereditary. Hereditary cancer is more likely if there is at least one primary relative (mother, sister or daughter) under 50 years old who is diagnosed with ovarian cancer. Ovarian cancer is more common in women who carry the BRCA gene mutation for breast cancer.

Is there a screening test for ovarian cancer?
Since ovarian cancer is rare (1 in 80 women), screening programs have not been successful in detecting the disease. The best method for detecting ovarian cancer is a pelvic ultrasound for evaluation of the ovaries.

Can ovarian cancer be cured?
Overall, 25-30 percent of ovarian cancer is cured with surgery and chemotherapy. More than half of women diagnosed with ovarian cancer in 2007 will survive longer than five years.

Uterine cancer

Uterine cancers are usually diagnosed by endometrial biopsy or uterine D&C (dilation and curettage). These cancers are treated by surgical removal of the uterus, tubes and ovaries, along with pelvic and para-aortic lymph nodes. Most of the time, this surgery is performed via laparotomy under anesthesia in an operating room. Occasionally, hysterectomy can be performed vaginally or by laparoscopy. Sometimes patients require treatment with radiation therapy after recovery from surgery.

Questions and Answers

Is vaginal bleeding after menopause normal?
No. Most women stop having monthly periods after about the age of 50. Once a woman stops menstruating for six months, she is considered menopausal. Any vaginal bleeding that occurs after this time requires evaluation by a gynecologist. This evaluation usually consists of a pelvic exam, pelvic sonogram and an endometrial biopsy or uterine D&C.

Who is at risk of developing endometrial cancer?
Endometrial cancer usually occurs in postmenopausal women who are overweight and more often diabetic. Use of hormones, such as estrogen, or treatment with Tamoxifen for breast cancer prevention also increases the risk for developing endometrial or uterine corpus cancer.

Cervical cancer

Cervical cancer can be diagnosed by an abnormal Pap smear or pelvic exam. On exam, the cervix is enlarged and bleeds easily on contact. When the cervical cancer is small and confined to the cervix, it can be treated surgically by radical hysterectomy with pelvic lymph node dissection via laparotomy. In more advanced cases, cervical cancer is treated with a combination of radiation therapy and chemotherapy.

Questions and Answers

Is it true that cervical cancer is caused by a virus?
Yes. Most cervical cancers occur as the result of long-term exposure to the human papilloma virus, also known as HPV. Men and women are exposed to this virus through intimate sexual contact. Most individuals develop immunity to the virus, but about 10 percent of the population fails to develop immunity, allowing it to remain in the genital tract. As a result, precancerous and cancerous tissue changes can occur in the cervix and other genital tissues. These changes can be detected by Pap smears, pelvic exams and viral testing.

Can the virus be prevented?
In most cases, yes. A vaccine against the most common types of HPV has been developed. This vaccine prevents the development of many precancerous and cancerous cervical changes. The vaccine works best when a woman is vaccinated prior to sexual contact. The vaccine has been targeted for use in girls and women ages 11 to 25 years.

Can invasive cervical cancer be cured?
Yes. Most cervical cancer can be cured with surgery or radiation therapy, if detected early.

Vulvar cancer

The vulva is the genital tissue around the vaginal opening. This area can be affected by skin cancer of the same type found in other parts of the body's squamous cell or melanoma. Cancers may be associated with itching or bleeding, but are often asymptomatic. They are usually detected by routine examination and confirmed through a tissue sample or biopsy. Treatment of vulvar cancer generally involves surgery to remove the affected area; however, laser treatment is sometimes an option. Advanced vulvar cancers require treatment with radiation or chemotherapy in rare cases.

Questions and Answers

What is the most common presentation for vulvar cancer?
Most women with vulvar cancer experience genital itching or note a lump or growth that prompts them to see a physician.

Do genital warts cause cancer?
No. Warts usually occur in young women as a result of intimate sexual contact. They can be prevented by the HPV vaccine. Growths on the vulva of older women are often mistaken for warts. A biopsy should be considered in all women over the age 30 who have growths.

Cancer of the fallopian tube

Cancer of the fallopian tube is extremely rare, accounting for only 0.1 percent of cancers of the female reproductive tract. The fallopian tube is located in the female pelvis between the ovary and uterus. Often, cancers of the ovary or uterus spread to the fallopian tube. Primary cancers of the tube are adenocarcinomas and usually detected as a pelvic mass similar to ovarian cancer. Only by careful evaluation of the tube can the diagnosis be established.

Tubal cancers are treated similarly to ovarian cancer. Surgery consists of the removal of the uterus, tubes, ovaries and omentum. Biopsies of the lining of the abdominal cavity (called the peritoneum) are taken and lymph nodes are sampled. After surgery, most patients are treated with intravenous chemotherapy. When the cancer is confined to the fallopian tube, the cure rate is over 70 percent.

Questions and Answers

Are there any unusual symptoms associated with fallopian tube cancer?
The classic signs and symptoms of a fallopian tube cancer include clear, watery discharge, irregular vaginal bleeding and pelvic mass.

What are the best tests used to detect fallopian tube cancer?
A pelvic sonogram confirms the presence of a pelvic mass and an elevated CA-125 blood test indicates the possibility of cancer. However, fallopian tube cancer cannot be distinguished from ovarian cancer unless surgery is performed and the tubal tissue analyzed in a laboratory.

Vaginal cancer

Vaginal cancers are rare and usually occur in women who have had a hysterectomy. These are cancers of the lower birth canal located between the cervix and vulva. Cancers in this area are sometimes detected by Pap smear, but can be detected by routine pelvic examination. A tissue sample is required to confirm the diagnosis. Most vaginal cancers are treated with radiation.

Questions and Answers

What are the signs and symptoms of vaginal cancer?
Vaginal cancer usually presents with vaginal bleeding, especially after intercourse. The cancer can be detected by a Pap smear before it becomes advanced, but is most often noted as a mass in the vagina at the time of a pelvic exam.

Can vaginal cancer be cured?
Yes. Most cases of vaginal cancer are cured with radiation. Treatment requires the use of both external beam radiation and intravaginal radiation called brachytherapy.

Cancer of the placenta (trophoblastic neoplasia)

Trophoblastic cancer is a rare type of cancer in which cancer cells grow in the tissues that are formed following conception. Gestational trophoblastic tumors start inside the uterus. This type of cancer occurs in women during the years when they are able to have children. There are two types of gestational trophoblastic tumors: hydatidiform mole and choriocarcinoma.

With a hydatidiform mole (also called a molar pregnancy), the sperm and egg cells have joined without the development of a baby in the uterus. Instead, the tissue that is formed resembles grape-like cysts. Hydatidiform mole does not spread outside of the uterus to other parts of the body.

If a patient has a choriocarcinoma, the tumor may have started from a hydatidiform mole or from tissue that remains in the uterus following an abortion or delivery of a baby. Choriocarcinoma can spread from the uterus to other parts of the body.

A gestational trophoblastic tumor is not always easy to find. In its early stages, it may look like a normal pregnancy. A woman should see her doctor if she has unusual vaginal bleeding or if she is pregnant and the baby hasn 't moved at the expected time.

Questions and Answers

How is a trophoblastic cancer diagnosed?
A trophoblastic cancer is suspected when a woman has a positive pregnancy test without evidence of a pregnancy within her uterus. In some cases, a woman will have a lung or brain mass and positive pregnancy test, yet no evidence of pregnancy within the uterus.

Can a woman get pregnant after being treated for a trophoblastic cancer?
Yes. In most cases, the cancer can be treated with chemotherapy alone, allowing the uterus, tubes and ovaries to be left in place. It is recommended that women wait at least a year after completing chemotherapy before trying to get pregnant.

What to Expect After Treatment

Gynecologic Cancer Surgery

Gynecologic patients have surgery performed through the abdomen, vagina or both. Abdominal surgery is done under general anesthesia. Abdominal surgery can be performed through a vertical incision that extends from the pubic bone upward toward the breast bone or though a horizontal incision located above the pubic bone. If a telescope or laparascope is used, the incision can be limited to multiple small incisions in the abdominal wall.

Vaginal surgery is performed through the vagina under general or spinal surgery. This approach allows the vulva, vagina and cervix to be carefully examined. Patients are placed on their back with their feet in stirrups during surgery. Common vaginal procedures include uterine D&C, hysteroscopy, vaginal hysterectomy and some pelvic support procedures.

In general, it takes four to six weeks to recover from major abdominal surgery to the point that normal activities can be resumed. Recovery time from vaginal surgery is typically shorter than that of abdominal surgery.

Radiation Therapy

Radiation therapy consists of a high energy invisible field of electromagnetic waves that are created by a machine called a linear accelerator and directed at a certain part of the body in a treatment field called a port. Treatments are usually given in an outpatient setting five days a week for approximately six weeks.

During this time, patients may experience fatigue and an increase in stool and urinary frequency. Occasionally, skin irritation and redness may result from radiation.

Intracavitary or brachytherapy involves insertion of a device into the vagina and uterus and then placement of radiation sources into these devices. Patients are given general anesthesia in an operating room setting for insertion of the radiation applicator. The radiation sources are subsequently placed into the applicator later when the patient is returned to her private room. The radiation sources and applicator are removed in the patient 's room within 24 to 48 hours. Normally, two intracavitary radiation treatments are planned for cervical or vaginal cancers. Once an area of the body has been treated with radiation therapy, this area cannot be treated again without the risk of serious tissue damage.

After radiation is complete, the effects of treatment on tissues may continue for as long a six months. Long-term side effects of radiation may include vaginal narrowing, chronic diarrhea or constipation and an increase in urinary frequency. Some patients have no long-term side effects and some only a few.

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Chemotherapy involves the administration of chemical agents that poison cancer cells and, to a lesser degree, normal cells. There are many different chemotherapy agents. These can be administered intravenously, intramuscularly, intraperitoneally or orally. Most IV and intraperitoneal regimens are given at three- to four-week intervals. Most oral regimens consist of daily medication for two to four weeks each month.

Chemotherapy agents may cause nausea, vomiting, hair loss, skin reaction or low blood counts. These side effects can often be controlled with additional medication. The side effects stop when treatment has ended. Some of the drugs used for chemotherapy in gynecologic oncology include Taxol, Carboplatin, Cisplatin, Doxal, Topotecan, cytoxan and methotrexate.

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