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OVERVIEW
There are five different sites from which
gynecologic cancers may arise. They are, the uterus, cervix, vagina, fallopian
tubes, and ovaries. Each of these types of cancers is unique in its behavior and
its response to treatment. For example, tumors of the uterus are generally
treated by doing a hysterectomy. Further treatment may be given based upon
the results of the surgical findings. Cancers of the fallopian tubes and ovaries
are very responsive to chemotherapy. Cervical and vaginal cancers may be treated
with surgery, radiation, and/or chemotherapy depending upon how advanced they are
and the age and health of the patient.
Below and to the left is an illustration of the pelvis,
looking in from the side. You can see the bladder in the front, and
the rectum behind. The closeness of these normal tissues complicates
the treatment of gynecologic tumors. In the illustration on the right, you
can see the various parts of the anatomy from the front.
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Cancers of the Uterus and Cervix:
The uterus is the structure in which the fetus
develops. It is also known as the womb.
The inner most lining, known as the
endometrium, is rich in blood vessels and glands
which nourish and support the growing child during pregnancy. It is also where
most uterine cancers start. These cancers are called carcinomas, the most common
of which is called adenocarcinoma.
That is, it arises from the glands of the endometrium. The wall of the uterus is
comprised of muscle and connective tissue. A small percentage of uterine cancers
start in the wall of the uterus and these muscular tumors are called
sarcomas. There are approximately 35,000 new
cases of uterine cancer each year, and between 6,000-7,000 deaths occur annually
from cancers of the uterus.
The cervix is the canal connecting the uterus
to the vagina. During pregnancy, it holds the uterus closed. Therefore it
is mostly made up of thickened bands of muscle and connective tissue with only a
very thin layer glandular tissue. The cervix can be seen at the top of the vagina
by a physician during a gynecological examination.
Pap smears are
performed by scraping the cervix with a plastic spatula and smearing a small number
of cells onto a microscopic slide. By examining these cells, cancers of the
cervix and uterus can often be detected. Thanks largely to Pap test screening,
the death rate from cervical cancer has decreased greatly over the last 40 years.
Still, every year more than 12,000 women in the United States find out that they
have invasive cervical cancer, and approximately 4,500 die of the disease.
However, pap smears sample only the outside
of the cervix and the lining of the cervical canal. They are not a perfect
medical test. Abnormal pap smears usually require confirmation with a
cervical biopsy.
This requires the doctor to take a small bite of tissue for microscopical examination.
Most cancers of the cervix arise from its covering surface, and, like the uterine
counterpart, are called carcinomas.
The most common variety is called squamous
(rhymes with famous) carcinoma, although adenocarcinomas similar to uterine adenocarcinomas
occur in the cervix as well. Rarely, sarcomas and other rare types of
cancer will start in the cervix. These are beyond the scope of this web site.
There are approximately 15,000 new cases of cancer of the cervix each year in the
United States.
The best way to treat cancers of the cervix
and uterus depends its extent (Stage I-IV). Physical examination, x-rays,
and various scans are used to determine the extent of disease. Also, if there
is a possibility that the rectum or bladder are involved, the physician may perform
a, sigmoidoscopy or
cystoscopy looking directly into the rectum or
bladder.
Cancers of the uterus and cervix tend to spread
in predictable ways. At their earliest stages they are limited and may be cured
by performing a hysterectomy (an operation remove the uterus and cervix, usually
with the ovaries as well). Later, however, as these cancers advance,
they grow through the wall of the womb and begin to invade surrounding organs. The
deeper the tumor cells invade, the greater the risk that cancer cells can escape
and become trapped in the pelvic lymph nodes. Lymph nodes are part of the
body's immune system and are located along the blood vessels to the legs, next to
the pelvic bones. Tumors can also grow directly into adjacent structures.
Cancers of the uterus can grow into the cervix, tubes, and ovaries and even into
the upper abdomen. Cancers of the cervix can grow into the uterus, vagina, bladder,
and rectum in advanced stages. Eventually if they are not treated, cancer cells
gain access to the bloodstream and spread throughout the body. They may lodge
and grow in other organs such as lung, liver, and bone.
Uterine and cervical sarcomas behave very
differently rarely spreading into other organs or involving lymph nodes. Rather,
they tend to enter the blood stream and spread to the lungs.
Knowing how these tumors behave is essential
to devising an effective plan of treatment.
TREATMENTS FOR UTERINE AND CERVICAL CANCER:
For uterine cancers a
Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy
(TAHBSO) is the first step, if it can be done. This involves
the surgical removal of the cervix, uterus, both tubes and ovaries. It is
a major operation typically done through an abdominal incision. Often lymph
nodes and other tissues in the abdomen are examined and biopsied as well.
Depending upon the findings from this procedure, the need for further treatment
can be decided. In most cases of uterine cancer, surgery alone is sufficient.
In some cases, radiation treatments may also be needed. Chemotherapy for uterine
cancer is currently under investigation and is not necessary for most patients at
the present time.
Early Cervical Cancers are
usually treated with aRadical Hysterectomy (RH).
This is a much more aggressive and encompassing
surgery than a TAHBSO . Far more soft tissue surrounding the uterus is removed.
Usually, lymph nodes are also removed for microscopic evaluation. It is often
possible to perform a radical hysterectomy without removing the ovaries and
that is desirable in younger women. However, it may be a very difficult operation
for older women who often have other medical problems. In this case, or when
the tumor has obviously spread beyond the cervix, radical hysterectomy is deferred
in favor of a combination of radiation and chemotherapy.
External Radiation
External Beam Radiation
Therapy uses very powerful x-rays which can penetrate the body and kill the cancer
cells. Treatments are typically given daily, Monday through Friday over a
series of four to six weeks. Because the radiation also exposes normal pelvic
organs such as the bladder and rectum, it causes side effects such as diarrhea
and urinary burning and frequency. In addition there are limits to how much
dose can be given to normal tissues. The amount of external radiation and
the side effects expected depends upon each patient's individual situation.
Before receiving pelvic radiation, patients should have a frank discussion with
their physicians about the rationale for the treatment and the expected side effects.
Be sure to ask about long term effects on the body such as vaginal dryness, and
scarring of the bowel or bladder as these effects are occasionally severe and usually
permanent. To minimize these risks when high doses are needed,
brachytherapy is often
recommended.
Brachytherapy
Brachytherapy is the medical
term for a radioactive implant. Using special applicators, radioactive material
is “loaded” directly into the cancer. (This is usually done through the vagina with
the patient under anesthesia.) Using this technique, a high, localized dose
of radiation can be delivered to the identifiable cancer mass "from the inside out."
Surrounding normal structures are exposed to lower doses of radiation, decreasing
the risks of long-term side effects. There are several different techniques
for brachytherapy which address different situations. The doctor should explain
the logistics and side effects of the technique recommended to you--as with any
other minor surgical procedure.
CHEMOTHERAPY
Chemotherapy is a collective
term for medications that kill cancer. There are many chemotherapy agents
available but for cancers of the uterus and cervix, one of the most
useful is called platinum. Yes,
it contains a molecular form of the metal platinum. There are several types
of platinum compounds which are useful for the treatment of gynecologic cancers
of various types. For cervical cancer, it is usually combined with another
drug called 5 Fluorouracil, or 5 FU. Numerous studies have shown that the
combination of chemotherapy and radiation are better than chemotherapy or radiation
alone for most cancers of the cervix. As with all cancer treatment,
surgery and radiation included, chemotherapy has side effects that will vary with
the drugs being used.
It must be emphasized that
each individual will have unique clinical features that will impact upon the decision
making process which could alter the appropriate treatment options as suggested
above. At the St. Joseph's Cancer Center, your doctor and team will thoroughly
discuss your situation with you so that you will understand your situation and the
treatment plan recommended.
Coming soon--ovarian cancer, vaginal cancer and cancer
of the fallopian tube. Email us if you
have questions about these diseases.
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