Chapter 093. Gynecologic Malignancies (Part 8)

Clinical Presentation and Staging Patients with cervix cancer generally are asymptomatic, and the disease is detected on routine pelvic examination. Others present with abnormal bleeding or postcoital spotting that may increase to intermenstrual or prominent menstrual bleeding. Yellowish vaginal discharge, lumbosacral back pain, lower-extremity edema, and urinary symptoms may be present.The staging of cervical carcinoma is clinical and generally completed with a pelvic examination under anesthesia with cystoscopy and proctoscopy. Chest xrays, intravenous pyelograms, and CT are generally required, and MRI may beused to assess extracervical extension. ...
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Chapter 093. Gynecologic Malignancies (Part 8) Chapter 093. Gynecologic Malignancies (Part 8) Clinical Presentation and Staging Patients with cervix cancer generally are asymptomatic, and the disease isdetected on routine pelvic examination. Others present with abnormal bleeding orpostcoital spotting that may increase to intermenstrual or prominent menstrualbleeding. Yellowish vaginal discharge, lumbosacral back pain, lower-extremityedema, and urinary symptoms may be present. The staging of cervical carcinoma is clinical and generally completed witha pelvic examination under anesthesia with cystoscopy and proctoscopy. Chest x-rays, intravenous pyelograms, and CT are generally required, and MRI may beused to assess extracervical extension. Stage 0 is carcinoma in situ, stage I isdisease confined to the cervix, stage II disease invades beyond the cervix but notto the pelvic wall or lower third of the vagina, stage III disease extends to thepelvic wall or lower third of the vagina or causes hydronephrosis, and stage IV ispresent when the tumor invades the mucosa of bladder or rectum or extendsbeyond the true pelvis (Fig. 93-1). Five-year survivals by stage are: stage I, 85%;stage II, 65%; stage III, 35%; and stage IV, 7% (Table 93-1). Figure 93-1 Anatomic display of the stages of cervix cancer defined by location,extent of tumor, frequency of presentation, and 5-year survival. Cervix Cancer: Treatment Carcinoma in situ (stage 0) can be managed successfully by cone biopsy orby abdominal hysterectomy. For stage I disease, results appear equivalent foreither radical hysterectomy or radiation therapy. Patients with disease stages II–IVare primarily managed with external beam irradiation and intracavitary treatmentor combined modality therapy. Retroperitoneal lymphadenectomy has no proventherapeutic role. Pelvic exenterations have become increasingly rare due toimproved radiation control. However, they are sometimes performed for centrallyrecurrent or persistent disease. In women with locally advanced disease (stages IIB–IVA), platinum-basedchemotherapy given concomitantly with radiation therapy improves survivalcompared to radiation therapy alone. Cisplatin, 75 mg/m2 over 4 h, followed by 5-fluorouracil (5-FU), 4 g given by 96-h infusion on days 1–5 of radiation therapy, isa common regimen. Two additional cycles of chemotherapy are given at 3-weekintervals. Three randomized trials of platinum-based chemotherapy reduced therisk of recurrence by 30–50% across a wide spectrum of stages and presentationsand were found to improve the survival rate in bulky stage I as well as locallyadvanced (stages IIB–IV) cervical cancer. Chemotherapy has some palliative benefit in patients with unresectableadvanced disease or recurrent disease. Active agents with ≥20% response ratesinclude cisplatin, paclitaxel, vinorelbine, ifosfamide, and topotecan. Thecombination of topotecan and cisplatin has a modest survival advantage overcisplatin alone. Gestational Trophoblastic Neoplasia Gestational trophoblastic diseases are a group of related diseases that forma spectrum from benign hydatidiform mole to trophoblastic malignancy (placental-site trophoblastic tumor and choriocarcinoma). Malignant forms account for 45 years is a risk factor forhydatidiform mole as is a prior history of molar pregnancy. Choriocarcinomaoccurs in ~1 in 25,000 pregnancies or 1 in 20,000 live births. Prior history ofhydatidiform mole is a risk factor for choriocarcinoma. A woman with a previousmolar pregnancy is 1000 times more likely to develop choriocarcinoma than awoman with a prior normal-term pregnancy. Pathology and Etiology The trophoblastic neoplasms have been divided by morphology intocomplete or partial hydatidiform mole, invasive mole, placental-sitetrophoblastomas, and choriocarcinomas. Hydatidiform moles contain clusters ofvilli with hydropic changes, hyperplasia of the trophoblast, and the absence offetal vessels. Invasive moles differ only by invasion into the uterine myometrium.Placental-site trophoblastic tumors are predominately made up of cytotrophoblastcells arising from the placental implantation site. Choriocarcinomas consist ofanaplastic trophoblastic tissue with both cytotrophoblastic andsyncytiotrophoblastic elements and no identifiable villi. Complete moles result from uniparental disomy in which loss of thematernal genes (23 autosomes plus X) occurs by unknown mechanisms and isfollowed by duplication of the paternal haploid genome (23 autosomes plus X).Uncommonly (5%), moles result from dispermic fertilization of an empty egg,resulting in either 46XY or 46XX genotype. ...