What Are Gynecological Malignancies?
Gynecological malignancies are among the common malignancies in females after breast cancer. As per the latest statistics, cervical cancer is the second most common cancer in women in India, with nearly 1 lakh new registrations happening in 2018. 1,46,420 new cases were registered last year with either of the common gynecological malignancies (cervix, ovary, or uterus). 5-year survival rates for localized cervical, ovarian, and uterine cancers are 91.8 percent, 92.4 percent, and 95 percent; whereas those in case of node-positive cases are 56.3 percent, 75.2 percent, and 69 percent respectively. In the case of distant metastasis, these rates drastically drop to 16.9 percent, 29.2 percent, and 16.8 percent respectively. These rates reflect the importance of timely detection and treatment. 80 percent, 36 percent, and 89 percent of cases are either localized or node-positive, respectively.
These numbers demonstrate the obvious fact, that cervical and uterine cancers most commonly present at a stage where good cure rates are still possible, unfortunately, more often ovarian cancers present in the advanced stage. We have many guidelines which help us plan treatment for these malignancies. The most commonly employed guideline is the NCCN (National Cancer Comprehensive Network), which gives accurate management decisions based on the latest evidence.
As per the latest NCCN guidelines for cervical cancer, surgery is recommended only for early stages (FIGO stage IA and IB), for all other loco-regional cases, radiation with weekly concurrent platinum-based chemotherapy is the treatment of choice. Concurrent chemotherapy amplifies the effect of radiation and also has survival benefits.
Radiation is also recommended after surgery if the histopathological report is suggestive of adverse features such as positive margins, lymphovascular invasion, parametrium invasion, positive nodes, deep stromal invasion, and size more than 4 cm (Sedlis criteria). Multiple studies have demonstrated the increased chances of recurrence if radiation is not given in the presence of such adverse features.
What Are the Types of Gynecological Cancer?
Cervical Cancer: Cervical cancer originates in the cervix, the lower and narrow portion of the uterus, also known as the womb.
Ovarian Cancer: Ovarian cancer starts in the ovaries, situated on each side of the uterus. Some ovarian cancers may also develop in the fallopian tubes or peritoneum.
Uterine Cancer: Uterine cancer begins in the uterus, the pear-shaped reproductive organ located in a woman's pelvis where a fetus grows during pregnancy.
Vaginal Cancer: Vaginal cancer initiates in the vagina, a hollow, tube-like passage between the base of the uterus and the external body.
Vulvar Cancer: Vulvar cancer begins in the vulva, which is the outer area of the female genital organs.
What Are the Causes of Gynecological Cancer?
Gynecological cancers can arise from various factors, including:
Diabetes.
Estrogen therapy.
Past menstrual and reproductive challenges such as difficulty conceiving, early onset of menstruation (before age 12), or late menopause (after age 55).
Previous pelvic radiation therapy.
Family history of cancer.
Use of fertility drugs or oral contraceptives.
Smoking.
High-fat diet.
Advanced age.
Obesity.
Weakened immune system.
HPV infection.
HIV infection.
What Are the Symptoms of Gynecological Cancer?
The symptoms associated with gynecological cancers can differ significantly. While some symptoms may overlap, they vary depending on the individual, the type of cancer, and its stage. It is important to note that some women may not exhibit any noticeable symptoms at all.
Cervical Cancer Symptoms:
Pain in the pelvic region.
Irregular vaginal bleeding.
Unusual vaginal discharge.
Endometrial Cancer Symptoms:
Discomfort during sexual intercourse.
Discomfort during urination.
Irregular vaginal bleeding.
The sensation of pressure, pain, or the presence of a lump in the lower abdomen.
Unexplained weight loss.
Ovarian Cancer Symptoms:
Tiredness or fatigue.
Breathlessness due to fluid accumulation.
Difficulty passing stool (constipation) or loose stools (diarrhea).
Increased urge to urinate frequently.
Reduced appetite.
Unexplained weight loss.
Feeling nauseous.
Lower back pain.
Heartburn or indigestion.
Vaginal bleeding.
Experiencing gas.
Vaginal Cancer Symptoms:
Difficulty passing stools (constipation).
Presence of a growth or lump.
Unusual discharge.
Abnormal vaginal bleeding.
Painful urination.
Discomfort during sexual intercourse.
Frequent pelvic pain.
The symptoms of other types of gynecological cancers are more similar to the above symptoms.
How Is Radiation Therapy Helpful in the Treatment of Such Malignancies?
Radiation therapy is delivered in two formats external beam radiotherapy (EBRT) and brachytherapy (BT).
EBRT is delivered over five weeks, usually 25 fractions or sittings, in which the patient lies down in a supine position, similar to the positioning for a CT scan procedure. The radiation is delivered from the machine head called the gantry, which can rotate 360 degrees and is capable of providing from different angles, while the patient lies still. The duration of EBRT during each sitting is usually not more than 10 minutes. With advances in technology, now EBRT can be delivered by minimizing the doses to the urinary bladder and rectum, thus reducing the probability of radiation-induced genitourinary and gastrointestinal side effects without compromising tumor control probability.
Brachytherapy is an inpatient procedure, where metallic tubes are placed inside the uterus, in which a radiation source is placed with remote technology, thereby ensuring the safety of the personnel involved. This source then delivers radiation to the tumor, the effect of which is up to 2 to 3 cm from the tube (source), thus ensuring minimum side effects. Usually, 2 to 3 such sittings are required, depending upon response to EBRT, probability of side effects, patient’s age, etc.
What Are the Surgical Treatment Options?
Surgery is an essential treatment in the management of loco-regional uterine cancers. Usually, the recommended surgery is a hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic node dissection, or para-aortic nodal dissection, which depends upon baseline disease. It is very important that appropriate imaging (CT scan, MRI, or PET-CT) is done before proceeding towards surgery. Based on adverse histopathological features, further radiation therapy and chemotherapy are recommended.
Adverse features include high-grade, deep myometrial invasion, and lymphovascular invasion. In advanced stages, combination chemotherapy is recommended, usually 3 weekly for 6 cycles. The general principle is, that to minimize the risk of local recurrence, radiation therapy is needed, whereas to mitigate systemic relapses, chemotherapy is required.
Ovarian malignancies are known for their advanced-stage presentation. Usually, they are managed by surgery and combined chemotherapy. The role of radiation therapy is limited and still investigational.
Thus, for management of these malignancies is multimodality requiring the expertise of doctors of various knowledge inclusive of surgical, medical, and radiation oncologists; also a good pathologist, radiologist, and nuclear medicine expert is needed to provide the crucial information about the disease, thus helping in taking treatment decisions
Conclusion
Gynecological cancers, including cervical, ovarian, uterine, vaginal, and vulvar cancers, can have diverse causes and symptoms. Early detection through regular screenings and awareness of potential risk factors is crucial for timely diagnosis and effective treatment, highlighting the importance of women's health care and preventive measures.