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Invasive cervical cancer

Key points 1. Conservative management of early-stage cervical cancer in young women should be considered if childbearing is important to that patient. 2. In many developing countries, cervical cancer is the leading cause of cancer death in young women. 3. Adenocarcinoma of the cervix is increasing in frequency. 4. Positron emission tomography is a very sensitive method for detecting the extent of cervical cancer. 5. Adjuvant…

Preinvasive disease and dystrophies of the vagina and vulva and related disorders

Key points 1. Vaccination for human papilloma virus (HPV) should decrease the incidence of high-grade squamous intraepithelial lesions (HSILs) of the vulva and vagina. 2. Lichen sclerosus is associated with vulvar cancer. 3. If there is any concern for malignancy, wide local excision is the treatment of choice for vulvar HSIL. 4. Topical treatments such as imiquimod and cidofovir offer non-surgical management options for HSIL. Embryology…

Preinvasive disease of the cervix

Key points 1. Persistent expression of human papillomavirus (HPV) is required for progression to cancer. 2. HPV vaccination has the potential to eradicate cervical cancer. 3. Screening guidelines have changed dramatically with the use of contesting and increased intervals between screenings. 4. The main screening objective is to allow for modified evaluation and treatment based on an individual woman’s risk. 5. Self-collection HPV testing may increase…

Gestational trophoblastic disease

Clinical case A 32-year-old G1P0 at 9 weeks and 3 days gestational age by last menstrual period presents with new onset vaginal bleeding. A transvaginal ultrasound shows no embryo, but notes a complex, echogenic intrauterine mass containing many small cystic spaces ( Fig. 21.1 ). A serum human chorionic gonadotropin (hCG) level is 190,000 IU On physical exam, her chest is clear to auscultation. Speculum exam…

Other rare vulvovaginal cancers: Verrucous carcinoma, aggressive angiomyxoma, vulvar yolk sac tumor

Clinical case A 38-year-old woman presents to her general gynecologist with a complaint of a vaginal “cyst” at the introitus. She notes some fullness at the opening to the vagina and feels that this interferes with penetrative intercourse. She denies pain or drainage. She is G1P1 with a history of one prior uncomplicated vaginal delivery. She has an otherwise unremarkable medical and surgical history. On exam,…

Vulvar extramammary Paget disease

Clinical case A 72-year-old patient presents with a 6-month history of vulvar pruritus and irritation. She has tried multiple antifungal medications with no improvement. On physical examination, she has an erythematous plaque-like rash involving the perineum and bilateral labia majora ( Fig. 19.1 ). You perform a biopsy, which reveals extramammary Paget disease. What additional testing is indicated? How would you treat this patient? Epidemiology Incidence…

Bartholin gland carcinomas

Clinical case A 62-year-old woman presents to her general gynecologist with a complaint of right-sided vulvar itching and discomfort over the past 2 months. She is an otherwise healthy person who receives age-appropriate, routine health maintenance, and screening. She notes the vulvar discomfort is pronounced with vaginal intercourse. The patient does have a history of a right-sided Bartholin gland infection in her 40s, which was treated…

Vulvovaginal melanoma

Clinical case A 44-year-old nulliparous female presents with vaginal discharge. A vaginal tumor is biopsied, revealing invasive melanoma. On physical exam, there is a 5 cm polypoid and mostly hypopigmented lesion with a broad base arising from the right lateral vaginal wall starting at 3 cm from the vaginal introitus and extending approximately 4 cm along the lateral vaginal wall. A positron emissions tomography (PET) scan…

Clear cell carcinoma of the vagina and cervix

Clinical case A 29-year-old G2P2 woman with a known bicornuate uterus presents to the office with irregular vaginal bleeding. A pelvic exam demonstrates a 2 cm friable lesion on the proximal vagina adjacent to the cervix ( Fig. 16.1 ). A biopsy is consistent with clear cell carcinoma of the vagina. An MRI shows no parametrial involvement or invasion into nearby structures, and a PET scan…

Other rare cervical cancers: cervical rhabdomyosarcoma, adenoid cystic carcinoma, verrucous carcinoma

Introduction The overwhelming majority of cervical cancer cases will be either squamous cell or adenocarcinoma. In a National Cancer Database (NCDB) study of cervical cancer in the United States, 79.5% of cervical cancer cases consisted of the squamous cell subtype, 19.0% were adenocarcinoma, and 1.5% were high-grade neuroendocrine carcinoma. These estimates round to 100% meaning that there are very few cervical cancer cases of the ultra-rare…

High grade neuroendocrine carcinoma of the cervix

Clinical case A 32-year-old G0 female presents with a newly diagnosed small cell neuroendocrine carcinoma (NEC) of the cervix. On physical exam, she is noted to have a 1.5 cm lesion on the anterior lip of the cervix with no evidence of vaginal or parametrial involvement. MRI of the pelvis reveals an isolated 1 cm lesion on the anterior lip of the cervix and confirms no…

Other rare uterine cancers: neuroendocrine tumors, yolk sac tumors, choriocarcinoma

Neuroendocrine tumors Epidemiology Incidence and mortality Neuroendocrine carcinomas (NEC) of the endometrium, which includes both small-cell and large-cell variants, are rare, highly aggressive tumors that account for approximately 0.8% of endometrial carcinomas. They generally present with advanced stage disease. The literature consists of only case reports and small case series. In one case series, 32% of patients presented with early (stages I–II) disease, whereas 68% presented…

Uterine serous carcinoma

Clinical case A 64-year-old female presents to the Gynecologic Oncology clinic for a second opinion regarding a new diagnosis of uterine serous carcinoma. She originally presented to her gynecologist within the last 3 months complaining of postmenopausal vaginal spotting. Pelvic ultrasound demonstrated a 3 mm endometrial stripe and endometrial sampling was deferred. However, the spotting persisted, and hysteroscopy, dilation and curettage (D&C) was performed. Final pathology…

Uterine carcinosarcoma

Clinical case A 75-year-old African American woman presents to your clinic with complaints of new onset vaginal bleeding. She has a past medical history significant for obesity and history of breast cancer managed with tamoxifen maintenance. On pelvic exam, she is noted to have a 7 cm tumor prolapsing through the cervix into the vaginal canal ( Fig. 11.1 ). Pelvic ultrasound confirms a hyperechoic mass…

Other rare uterine sarcomas: Adenosarcoma, endometrial stromal sarcoma, STUMP

Clinical case A 51-year-old patient presents with abnormal uterine bleeding and a 6 cm intrauterine, polypoid mass on pelvic ultrasound imaging ( Fig. 10.1 ). Office endometrial biopsy (EMB) was suggestive of uterine adenosarcoma. She was taken to the operating room for a TLH, BSO, and pelvic sentinel lymph node assessment. Final pathology revealed a stage IA uterine adenosarcoma with sarcomatous overgrowth and presence of lymphovascular…

Uterine leiomyosarcoma

Clinical case A 59-year-old nulliparous woman with history of multiple uterine fibroids status post myomectomy for abnormal uterine bleeding 20 years prior and recent total abdominal hysterectomy and salpingo-oophorectomy for recurrent, intermittent postmenopausal bleeding presented for management of pathological diagnosis of leiomyosarcoma. Workup prior to hysterectomy had included endometrial biopsies (EMBs) which were benign and serial pelvic ultrasounds over 18 months demonstrating a stable 5.4 cm…

Other rare ovarian cancers: Transitional cell carcinoma, malignant Brenner tumor, endometrioid carcinoma, mesothelioma, squamous cell carcinoma, sarcoma

Introduction Ovarian cancer encompasses a wide variety of tumors, all with different clinical patterns, histologies, and molecular features. Ovarian cancer is typically classified as epithelial (serous, mucinous, endometrioid, clear cell, carcinosarcoma, and mixed) vs nonepithelial (germ cell and sex cord stromal cell). Epithelial ovarian cancers, which comprise 90% to 95% of all ovarian cancer cases, are more common than nonepithelial ovarian cancer. However, there are a…

Small cell carcinoma of the ovary, hypercalcemic type

Clinical case A 22-year-old G0 female presents with a newly diagnosed small cell carcinoma of the ovary, hypercalcemic type (SCCOHT). She reported pelvic pain and her physical exam was within normal limits. Pelvic sonography identified a 5 cm complex cystic mass in the left ovary with increased vascularity in multiple nodules ( Fig. 7.1 ). She was thought to have an endometrioma and was taken to…

Low-grade serous ovarian cancer

Clinical case A 36-year-old, G1P1, previously healthy woman presents with left sided pelvic pain. She presents to her PCP who performs a CBC and comprehensive panel that are unrevealing, abdominal exam shows bloating without point tenderness. She has a history of normal menses. She has no family history of cancer, and her both parents are alive and healthy. She is referred to her gynecologist who performs…