22.1 Gynecological Malignancies

S: Doxorubicin 45 mg/m² IV on day 2 plus cisplatin 50 mg/m² IV on day 1 plus paclitaxel 160 mg/m2 IV over 3h on day 2 plus filgrastim 5 μg/kg SC on days 3–12; regimen repeated every 21 days

OR

S: Carboplatin AUC 5–6 IV plus paclitaxel 175 mg/m² IV over 3 hours on day 1 every 3 weeks

Note:

• All patients should be referred to a gynecologist for evaluation and surgical treatment
• All surgical specimens should be sent to lab for further histopathology diagnosis and staging.
• After surgery and histopathology report, all patients should be referred to cancer specialized center for further management and follow up.

 

 

22.1.3 Cancer of the Vulva

Vulva cancer is predominantly a disease of older women. Squamous cell carcinoma is the commonest histological type, usually arising from premalignant lesions–vulva intraepithelial neoplasia (VIN). Risk factors contributing to development of VIN and later vulva cancer include HPV infection, infection with HIV, and cigarette smoking.

Diagnostic Criteria

• A lump or vulva mass
• Presence of leukoplakia and other dystrophic changes on the vulva
• Itching is a common manifestation and may become ulcerative (“non-healing ulcers”)

Investigations

• FBC, LFTs, Urea, creatinine, HIV test
• CXR, Ultrasonography or CT scan of abdomen and pelvis
• Colposcopy to determine presence of other lesions in the vagina and cervix
• Biopsy from the vulvar lesion to confirm the diagnosis

Staging: FIGO and TNM.

Management:

Treatment is individualized, taking into considerations of histological type, disease stage and patient factors

Primary treatment is surgery. Adequate surgery involves wide local excision of primary tumor together with groin lymphnode dissection.

Radiotherapy is indicated in the following conditions:

• As primary therapy for patient with small primary tumors particularly young patients in whom surgical resection would have significant psychological consequences.
• For patients with locally advanced disease where resection is not possible.
• After surgery to treat the pelvic and groin nodes.
• After surgery in patients with positive surgical margins.

Pharmacological treatment: As for cervical cancer

22.1.4. Gestational trophoblastic disease

22.1.4.1. Hydatidiform mole

Two types; complete and partial hydatidiform mole. Treatment is suction curettage or hysterectomy. Careful risk assessment is needed to determine patients who require chemotherapy after surgery. Patient with high risk hydatidiform mole will have to reserve single agent chemotherapy; methotrexate or Actinomycin D

Note: Patient should be followed up with weekly serum β–hCG after surgery until it is undetectable.

22.1.4.2. Choriocarcinoma

Choriocarcinoma is extremely chemo sensitive; cure is possible even in metastatic disease. All patients with choriocarcinoma should undergo a careful pre-treatment evaluation for proper staging and risk stratification.

Investigations:

• Serum β-hCG level
• LFT, RFT, TSH, T3, T3
• CXR and or CT Scan
• Abdominal and Pelvic USS or CT Scan
• Brain MRI
• Tissue sample for histology
• CSF hCG level

Management:

Treatment is based on disease stage and risk score. Patient with stage l disease usually have a low risk score, and those with stage IV disease have a high risk score. Staging and scoring as shown below.

 

 

Stage I and low risk stage II&III patients are treated with single agent as shown in table below.

 

Note: if no response to single agent, give combination drugs. Stage IV and high risk stage II & III patients receive combination chemotherapy. The current standard regimen for combination therapy is EMA–CO with dose and schedule as shown below.

 

Note:

• Cycles are repeated after every 14 days until β–hCG is normal
• Surgery and/or radiotherapy may be considered in some cases of metastasis

Follow-up

• Weekly measurement of hcg level until they are normal for 3 consecutive weeks
• Monthly hcg levels until levels are normal for 12 consecutive months
• Effective contraception during the entire period of hormonal follow–up

22.1.5 Cancer of the Ovary

Epithelial tumours comprise 90% of all ovarian malignancies. Due to anatomical location, most patients present with advanced disease.

Diagnostic Criteria

• Minimal or no symptoms in early stage
• Abdominal distension with palpable mass, pain and ascites are all late signs

Investigations:

• Inspection and bimanual examination under anesthesia (EUA) recto–vagina are mandatory to exclude primary disease or extension from other sites such as cancer of the cervix
• FBC, RFT, LFT, CA 125 & CEA
• CXR
• CT scan of the Abdominal and pelvic
• Pelvic and abdominal ultrasound
• Histology of oophorectomy specimen or biopsy obtained at laparotomy

Staging: Is based on surgical diagnosis (laparotomy): FIGO: IA, IB, IC, IIA, IIB, IIC, III, and IV

Management: Surgery

Total hysterectomy with Bilateral Salpingo –Oophorectomy (TAH+BSO) and omentectomy should be performed in resectable tumor. If total tumor removal is not possible, then maximum debulking (Cyto –reductive) surgery is done. Unilateral salpingooophorectomy is only justified for stage IA tumour with favourable histology

Pharmacological Treatment 

Adjuvant chemotherapy

Indicated in all patients at high risk i.e. stage IC or II, high grade or clear cell cancers of any stage.

Standard regimens include combination of platinum and taxanes

S: Carboplatin AUC 6 IV Day 1 + IV Paclitaxel 175 mg/m² over 3 hrs day1, repeated every 3weeks for 6 cycles

For recurrent disease give same regimen if tumor is platinum sensitive (recurrence after 6 months since last chemotherapy cycle)

For platinum resistant disease give gemcitabine or bevacizumab as single agent or in combination with taxanes. When available, liposomal doxorubicin is active and indicated in recurrent disease.

S: Gemcitabine IV 1000 mg/m² Day 1, D8 and D15, Repeat every 4 weeks for 6 courses.

S: Bevacuzimab 15 mg/kg IV day1, every 3 weeks until disease progression

Endocrine therapy is indicated in selected cases with recurrent disease.

S: Tamoxifen 20mg PO bid, daily + s/c Goserelin 3.6mg once a month

Note: All patients must be referred to a gynecologist and cancer specialized center for evaluation and proper management