Proper gynaecological nurse should be aware of the common gynaecological tumours. So they can answer patients questions and actively share in the management.

Endometrial Carcinoma

Of the malignancies affecting women, endometrial carcinoma ranks 4th in frequency, after breast, colorectal, and lung cancers.

This adenocarcinoma is an epithelial lesion of the endometrium and is usually postmenopausal, with peak incidence between ages 50 and 60.

Etiology and Pathology

Endometrial carcinoma is more frequent in women with

¨1estrogen-producing ovarian tumors;

¨2with prolonged, and especially atypical,

¨3adenomatous endometrial hyperplasia;

¨4with delayed menopause; or

¨5with an abnormal menstrual history and infertility.

¨6Obesity,

¨7hypertension,

¨8diabetes mellitus,

¨9breast cancer, conditions that predispose to unopposed estrogen (ie, absence of ovulation and therefore no periodic progesterone), and a family history of breast or ovarian cancer are possible predisposing factors.

Endometrial carcinoma spreads

(1) down the surface of the uterine cavity into the cervical canal;

(2) through the myometrium to the serosa and into the peritoneal cavity;

(3) by transplantation via the lumen of the fallopian tube to the ovary, broad ligament, and peritoneal surfaces;

(4) via the bloodstream, leading to distant metastases; or

(5) via the lymphatics. Downward spread may lead to cervical stenosis and pyometra. Vaginal metastases may cause a mucosanguineous discharge that, upon examination, leads to diagnosis of the metastases in advanced stages.

Symptoms, Signs, and Diagnosis

The cardinal symptom is inappropriate uterine bleeding, such as

¨1any postmenopausal bleeding or

¨2recurrent metrorrhagia in the premenopausal patient; as many as 1/3 of all cases of postmenopausal bleeding are due to endometrial carcinoma.

¨3The presence of myomas should not lead to complacency regarding abnormal bleeding, especially in susceptible women (see Etiology above).

¨4A mucoid or watery discharge may precede bleeding by several weeks or months.

In diagnosis, the Papanicolaou test (Pap test–see below under Cervical Carcinoma) is helpful but undependable, since 30 to 40% of smears yield false-negative results.

Obtaining cellular material by aspiration of the endocervix may increase the rate of detection by Pap test to 70%.

Vaginal douching should be avoided for at least 24 h before the examination.

Endometrial biopsy has a 92% rate for detecting carcinoma.

However, if cancer is not diagnosed by biopsy and surgical staging is not performed, the diagnostic procedure of choice is fractional curettage (endocervical curettement, sounding of the uterus, dilation of the cervical canal, and curettement of the endometrium).

This procedure permits histologic confirmation and grading of the tumor, including determination of extension into the cervix, which may be important in planning therapy.

Care should be taken in biopsy performance, sounding of the uterus, or curettement, since perforation may occur with these procedures.

IVU, cystoscopy, procto-sigmoidoscopy, barium enema, and chest x-ray should be performed before initiating therapy.

Other studies (e.g., mammography, bone and liver scans, arteriography, lymph-angiography) may be considered and performed when appropriate but are not a routine part of staging.

Treatment and Prognosis

In the USA, the surgical approach includes extrafascial total abdominal hysterectomy with a wide vaginal cuff, combined with bilateral salpingo-oophorectomy and retroperitoneal lymph node sampling in the pelvic and para-aortic areas.

Radical hysterectomy with retroperitoneal lymph node dissection is not warranted unless the cervix is clearly involved.

Progesterone therapy in patients with advanced or recurrent disease has led to regression in 35 to 40% of cases. Continuous, large doses of nonestrogenic progesterone derivatives (hydroxyprogesterone caproate 1 gm/wk IM

Treatment continues indefinitely if a favorable response is noted.

Progesterone therapy also has produced regression of pulmonary, vaginal, and mediastinal metastases; difficulties with sodium and water retention are rarely encountered. Remissions last 2 to 3 yr or occasionally longer.

Recently, cytotoxic chemotherapy has been used with progestins for metastatic cancer.

Monthly chemotherapy combining cyclophosphamide 500 mg/m2, doxorubicin 50 mg/m2, and cisplatin 50 mg/m2, given IV, plus megestrol acetate 120 mg/day orally has improved the overall response in 60% of patients.

Frequent monitoring and complete knowledge of potential toxicity are essential with this regimen.

Prognosis is influenced by the histologic appearance and grading of the tumor, age of the patient (older women have a poorer prognosis), and spread of the tumor before therapy.

The overall 5-yr survival rates for endometrial carcinoma are encouraging. Almost 63% of patients are alive without evidence of disease 5 yr after treatment; 28% succumb within 5 yr of treatment; 9% are alive with disease still present.

In stage I disease, the reported 5-yr survival rate is between 70 and 89%.

Cervical Carcinoma

Carcinoma of the uterine cervix, the 2nd most common malignancy of the female reproductive tract, usually affects women aged 40 to 55 yr.

The incidence is higher among women from lower socioeconomic groups and those with a history of early, frequent coitus and multiple sexual partners.

Recently, venereal transmission of human papillomavirus (HPV)– has been implicated in the etiology of cervical neoplasia.

Diagnosis

Early, asymptomatic cervical neoplasia can be detected preclinically by cytologic examination of cervical smears obtained during routine annual pelvic examinations.

The Papanicolaou (Pap) test can detect 90% of early cervical neoplasias, and its use has reduced deaths from cervical cancer by > 50% through recognition and treatment of preinvasive neoplasia.

Cervical cancer could be eliminated as a cause of death if all women had an annual Pap test; unfortunately, < 40% of women do so.

Biopsy is mandatory if a suspicious lesion (a friable mass or an ulcer) is seen.

Dysplasia or carcinoma detected on Pap smear can be investigated with the colposcope. Colposcopy may reveal the biopsy site (and avoid the need for cone biopsy) in 85% of cases. If colposcopy is not available, biopsy sites may be identified by staining the cervix with an iodine solution, such as Lugol's (strong iodine)

Nonstaining areas may be malignant, dysplastic, atypical, or glandular areas on the cervix.

Outpatient cervical punch biopsy and endocervical curettage (to identify lesions higher in the cervical canal) diagnose invasion in 90% of cases with abnormal smears.

Cold knife (noncautery) cone biopsy or laser cone biopsy with fractional D & C performed under local or general anesthesia is used only when simple biopsy fails to establish the presence or absence of invasion or when colposcopic examination is inconclusive or unsatisfactory.

Clinical staging of cervical carcinoma by physical examination of the pelvis is the basis for estimating prognosis and planning therapy

In addition, a metastatic survey, including cystoscopy and sigmoidoscopy (with biopsies as needed in each), IVU, and chest x-rays, is always done.

Treatment

Carcinoma in situ: Localized preinvasive lesions may be totally excised by cold knife or laser conization with diligent follow-up or by total hysterectomy.

The choice depends upon the patient's desire to remain reproductive and her reliability in follow-up. If conization is chosen,

Pap tests should be repeated every 3 mo for the first year and every 6 mo thereafter to ensure that all of the lesion has been removed and that it does not recur.

Cryotherapy and occasionally laser therapy are being used as outpatient treatment in carefully selected patients when colposcopy and biopsy have clearly defined the lesion and invasive cancer has been ruled out.

Invasive squamous cell carcinoma remains well localized for a considerable time, with distant metastases occurring only late in its course.

Since the tumor spreads by contiguity and via the lymphatics, effective treatment must include affected nodes as well as the primary tumor but without excessively or irreversibly damaging surrounding normal body tissues.

Radiotherapy and surgery, used alone or together, are nearly equally effective.

Radiotherapy: A common, effective technique consists of 2 cesium applications to the cervix for about 35 h each, followed by external radiation Major complications of radiotherapy include radiation proctitis and cystitis and occasionally recto- and vesicovaginal fistula formation.

With primary radiotherapy for invasive squamous cell carcinoma, the overall 5-yr survival rate is about 55%. In stages I and II, 5-yr cure rates are 75 to 90%.

Surgery: Primary surgical treatment is limited to patients in whom ovarian function can be preserved, lesions show limited local spread, and para-aortic lymph node biopsy is negative.

Young women with stages IB and IIA lesions are preferred candidates.

Surgery involves radical hysterectomy, including all of the parametria, and bilateral retroperitoneal lymph node dissection ending just above the bifurcation of the aorta.

Five-year cure rates of 85 to 90% for women with stages IB and IIA lesions have been reported following radical hysterectomy.

The major complication of radical surgery, uretero- and vesicovaginal fistula formation, occurs in about 1 to 2% of operations.

If para-aortic node biopsy is positive or if the disease extends outside the pelvis, surgery is generally contraindicated.

If tumors are restricted to the pelvis but involve the rectum or bladder, exenteration (excision of all pelvic organs) may be performed in physically and psychologically appropriate patients.

Exenteration usually is the treatment of choice for recurrent or persistent cancer confined to the central pelvis following conventional radiotherapy; occasionally it is used as primary therapy for advanced disease. It is successful in 25 to 45% of cases.

Chemotherapy: Systemic treatment usually provides only temporary pain relief.

When radiation therapy has failed, distant metastases appear to respond better to chemotherapy than the primary tumor.

Many cytotoxic agents are being investigated, but they have achieved objective regression in only 25 to 30% of tumors.

Cervical carcinoma in pregnancy: About 1% of all cervical carcinomas are complicated by pregnancy or occur in recently pregnant women.

With carcinoma in situ, treatment is delayed until after delivery, which may occur vaginally.

Invasive disease is treated as in nonpregnant women: in the first trimester, radical hysterectomy or therapeutic irradiation will terminate the pregnancy; in the 2nd trimester, the uterus is emptied by hysterotomy, followed by radiation therapy or surgical excision for early lesions; in the 3rd trimester, a short delay is encouraged to achieve fetal viability.

Vaginal delivery is contra-indicated in invasive cervical disease because it lowers the cure rate, regardless of treatment.

Vulvar Carcinoma

Malignancy of the vulva accounts for about 3 to 4% of all gynecologic neoplasms and usually occurs after menopause.

Though patients can readily visualize and palpate these malignancies, they may not seek treatment for up to 3 yr because of embarrassment or fear.

Also, the physician may delay treatment by striving to provide symptomatic relief of the accompanying pruritus rather than obtaining an immediate biopsy.

Pathology

About 90% of cases are squamous cell carcinomas and about 4% are basal cell carcinomas; the remainder include intraepithelial carcinomas, such as Paget's disease, adenocarcinoma of Bartholin's gland, fibrosarcoma, and melanoma.

Often, the intraepithelial lesions have multifocal origins. Growth is initially superficial, but later the tumors extend into the vagina, the urethra, or the anus.

The superficial inguinal and femoral nodes are involved in up to 50% of cases. Squamous cell carcinoma may be well differentiated or anaplastic.

Symptoms and Signs

Epithelial alterations, such as typical and atypical hyperplastic dystrophy, coexist in 40% of patients, and foci of lichen sclerosus may be associated with the cancer but are not necessarily considered precancerous.

Kraurosis vulvae, a gross clinical diagnosis characterized by shrinkage and constriction of the vaginal outlet, is histopathologically identical to lichen sclerosus.

Until the lesion reaches 1 to 2 cm or more in diameter, it is often asymptomatic, although carcinoma in situ tends to be pruritic.

When the tumor becomes necrotic and infected, symptoms resemble those of an ulcer with bleeding and/or watery discharge.

Diagnosis

Diagnosis usually is made by simple biopsy. Sites can be delineated by staining the vulva with toluidine blue (1%), allowing the dye to be absorbed for 3 to 5 min, and then decolorizing with dilute (2 to 3%) acetic acid ( a nursing job). Abnormal areas retain the blue dye.

Differential diagnosis must include the various venereal diseases (granuloma inguinale, chancroid, lymphogranuloma venereum, syphilis); basal cell carcinoma (rodent ulcer); intraepithelial (in situ) cancers characterized by small red, white, or pigmented friable papules;

Melanomas frequently appear as bluish-black, pigmented, or papillary lesions; they metastasize via the lymphatics, the bloodstream, or both.

Prognosis depends on the depth of involvement into the underlying epidermis.

Treatment

Since squamous cell carcinoma of the vulva spreads by local extension as well as by lymphatic embolization, all existing and potential tumor sites in this region should be removed.

The tumors drain to the inguinal lymph nodes; however, those extending deep into the vagina drain into the retroperitoneal nodes.

A correlation between tumor size and lymph node involvement has been noted. inguinal and femoral node dissection.

Preoperative external radio-therapy can be used to sterilize or decrease the size of large tumors. Radium needle implants may be used for inoperable tumors and metastases. The treatment of basal cell carcinoma is local excision.