Gynecologic Oncology is a combined surgical and medical specialty that works with cancers of the female reproductive system, with Gynecology being the study of the female reproductive system and Oncology pertaining to cancer or tumors.
Dr. Randall Gibb is a physician who specializes in the field; with over 100 publications and case studies, multiple presentations, book chapters, and lectures, he is a well-versed Gynecologic Oncologist. Etymologically, both words are derived from Greek,
gyne-meaning woman, onco coming from the Greek word óngko-meaning burden, volume, or mass, and –logia, or logos, both meaning the study of. Dr. Gibb explains that this field of medicine works to help diagnose, manage, and treat cancers of the uterus, ovaries, cervix, vagina, and the vulva, as well as other gynecologic conditions that have the potential to progress to cancer.
Uterine
Endometrial Cancers
In the United States, Type I endometrioid adenocarcinomas are the most common female reproductive cancers. Type I derives from atypical endometrial hyperplasia, an abnormal growth of cells originating in the endometrial lining of the uterus, explains Dr. Randall Gibb. They compose almost ¾ of all endometrial cancers, while Type II account for the other ¼.
Type II derive from serous, or clear cells of the lining and these tend to be more aggressive with a poorer prognosis. Endometrial cancers most commonly cause abnormal uterine bleeding (AUB) or bleeding that is unrelated to menses and also pain.
Patients that are obese are at higher risk, due to higher levels of unopposed estrogen circulation in the body, which causes proliferation of the endometrial lining. Diagnosis is generally through biopsy and treatment includes primarily surgery for early stage disease, and radiation or combination therapy with chemotherapy for advanced cases.
Sarcomas
Endometrial sarcomas are ones that arise from the smooth muscle of the uterus and signs and symptoms are similar to that of endometrial cancers. AUB, pelvic pain/pressure, discharge, and a rapidly growing non-pregnant uterus are signs for concern of a sarcoma.
Leiomyosarcoma, endometrial stromal sarcoma, and carcinosarcomas are the most common, with a group of “others” as well. Diagnosis can be difficult but can be accomplished through imaging such as MRI, CT, and most importantly biopsy, with histological findings being the key factor.
Uterine Leiomyoma
Also referred to as fibroids, these are benign smooth muscle growths that present as round, firm masses. They are fairly common with Caucasian prevalence being 25% and 50% in African-American women, says Randall Gibb. They are hormone sensitive and patients may feel an increase in symptoms of pressure or pain during pregnancy, with a decrease in these during menopause.
It is rare for this benign malignancy to turn malignant and can be treated with oral contraceptives, non-steroidal anti-inflammatory drugs, or ultimately surgical removal if warranted.
Ovarian
Ovarian cancers are ones that occur in or on either of the ovaries of the reproductive system. The ovaries are responsible for releasing an egg monthly, which corresponds with the menstrual cycle and women who have a higher count of ovulations in their lifetime are at an increased risk for these cancers; including nulliparous women (never had children), those starting menstruation at an earlier age, and those who start menopause later in life.
Modifiable risk factors include hormone therapy exposure, fertility treatments, and obesity. Genetics play a large role in many ovarian cancers, with certain genes, such as BRCA1, BRCA2, NF1, and p53 having been shown to increase the likelihood of having disease, says Dr. Randall Gibb. Those patients with a BRCA1 mutation should be screened annually through tumor marker CA-125 as well as through ultrasound.
Preventative removal of the ovaries is sometimes recommended for women who carry genetic mutations that make them more susceptible to developing ovarian cancer. There are various ovarian tumors, each arising from a particular cell line within the ovary and can sometimes easily be identified due to specific cellular markers, for example a granulosa cell tumor would exhibit the tumor marker inhibin, while choriocarcinoma would have high levels of hCG.
Cervical
The cervix is divided into two parts:
- the upper third, the endocervix, and
- the lower two-thirds, the ectocervix.
The endocervix is made up of columnar cells that are similar to that of the lower uterine segment, while the ectocervix is made up of squamous cells, similar to that of the vagina. When columnar cells of the endocervix are exposed to the low-pH of the vagina, they undergo metaplasia, slowly changing to squamous cells and this transformation zone of squamoculumnar cells when exposed to carcinogens can result in cervical intraepithelial neoplasia (CIN). This precancerous stage causes abnormal proliferation of the basal cell layer, and can eventually lead to full cervical cancer.
There is a strong relation with HPV, with 99.7% of all cervical carcinoma cases showing the presence of HPV, with strain 16 being the most prevalent in squamous cell carcinoma and strain 18 being the most common in adenocarcinoma.
Patients may complain of bleeding and pain; treatment includes cryotherapy, ablation, or excision. Cervical cancer screening is recommended through pap smear beginning from age 21 up to 65, during which time a swab of the cervix is taken to check for the histology of the cells.
Vaginal
While not common, vaginal cancers make up 1-2% of all gynecologic malignancies that he sees, says Dr. Randall Gibb, with the most common being squamous cell carcinoma. This cancer comes from the squamous — or epithelial — cells that line the vagina and is most commonly diagnosed in postmenopausal women.
Other types of cancers include adenocarcinoma arising from the glandular cells of the vagina and clear cell carcinoma, which is most famous for being caused by diethylstilbestrol (DES) use in mothers of those that have this cancer. DES was used for much of the mid-1900s in pregnant women to help prevent miscarriages and preterm labor.
If the woman were carrying a female fetus, they were at significant risk for having clear cell carcinoma, usually before the age of 30, with increased risk for other vaginal cancers later in life. Radiation therapy for invasive disease or local excision has proven to be the most effective treatment methods.
Dr. Randall Gibb on Vulvar Cancers
These cancers are ones that occur on the outer parts of the female genitalia and are commonly caused by HPV, diabetes, immunosuppression, and vulvar intraepithelial neoplasia (VIN). The most common vulvar cancer is squamous cell carcinoma, while others include adenocarcinoma, melanoma, and basal cell carcinoma. VIN is a precancerous stage, during which time the cells of the vulva have undergone changes that could potentially lead to cancer or disappear without treatment.
In almost 90% of VIN cases, HPV strains 16, 18, or 31 have been found, and therefore vaccination is highly recommended says Randall Gibb. These cancers can cause itching, bleeding, lumps, ulcers, and pain, and treatment is usually surgical in nature.
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