cervical vulva r cancer 2012

8/10/2019 Cervical Vulva r Cancer 2012

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The Management ofCervical , Vulvar and

Vaginal Cancers

Kerry J. Rodabaugh, M.D.

Division of Gynecologic OncologyUniversity of Nebraska Medical Center


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Incidence:

global public health issue

450,000500,000 women diagnosed each

year worldwide

In developing countries, it is the most

common cause of cancer death

340,000 deaths in 1985


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United States Incidence

15,000 women diagnosed annually

4,800 annual deaths


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Mortality Rates


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Lifetime risk of developing

cervical cancer

5% - South America

0.7% - USA


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Cervical CA Risk Factors

Early age of intercourse

Number of sexual partners

Smoking

Lower socioeconomic status

High-risk male partner

Other sexually transmitted diseases Up to 70% of the U.S. population is infected with

HPV


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Screening Guidelines for the Early

Detection of Cervical Cancer,

American Cancer Society 2003

Screening should begin approximately three years after a womenbegins having vaginal intercourse, but no later than 21 years ofage.

Screening should be done every year with regular Pap tests orevery two years using liquid-based tests.

At or after age 30, women who have had three normal test resultsin a row may get screened every 2-3 years. However, doctors maysuggest a woman get screened more if she has certain risk factors,such as HIV infection or a weakened immune system.

Women 70 and older who have had three or more consecutive Paptests in the last ten years may choose to stop cervical cancerscreening.

Screening after a total hysterectomy (with removal of the cervix) isnot necessary unless the surgery was done as a treatment forcervical cancer.

American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005


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Pap Smear

Single Pap false negative rate is 20%.

The latency period from dysplasia to

cancer of the cervix is variable.

50% of women with cervical cancer have

never had a Pap smear.

25% of cases and 41% of deaths occur in

women 65 years of age or older.


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Clinical Presentation

CIN/CIS/ACISasymptomatic

Irregular vaginal bleeding

Vaginal discharge

Pelvic pain

Leg edema Bowel/bladder symptoms


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Physical Findings

Exophytic, cauliflower like mass

Cervical ulcer, friable or necrotic

Firm barrel-shaped cervix

Hydronephrosis Anemia

Weight loss


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Histology

Squamous 85-90%

Adenocarcinoma 10-15%

Lymphoma

Neuroendocrine/small cell

Melanoma


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Route of Spread

Cervical cancer spreads by direct

invasion or by lymphatic spread

Vascular spread is rare


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Staging

Physical exam

Cervical biopsies

Chest x-ray

IVP (Ct scan)

Barium enema, cystoscopy, proctoscopy Surgical staging


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Staging

Stage Iconfined to the cervix

IA1


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Staging

Stage III

IIIAlower 1/3 of vagina

IIIBextension to pelvic sidewall or

hydronephrosis

Stage IV

IVAbladder or rectal mucosa

IVBdistant metastases


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5 year survival rates

Stage IA 90-100%

Stage IB 70-90%

Stage II 50-60%

Stage III 30-40%

Stage IV 5%


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Therapy

Cervical conization

Simple hysterectomy

Radical hysterectomy

Radiation therapy withchemosensitization


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5 year Survival

Stage I 70%

Stage II 51%

Stage III 33%

Stage IV 17%


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Pros and Cons

Surgery

Bladder dysfunctionVesico/uretero fistula

Bowel obstruction

Ovarian preservation

Vaginal preservation

Radiation

SigmoiditisRectovaginal fistula

Bowel obstruction

Vesico/uretero fistula

Ovarian failure


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Radiation Therapy

External BeamWhole pelvis or para-aortic window

4000-6000 cGyOver 4-5 weeks

Brachytherapy

Intracavitary or interstitial2000-3000 cGy

Over 2 implants


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Recurrent Cervical Cancer

10-20% of patients treated withradical hysterectomy

Recurrence has an 85% mortality

83% are diagnosed within the first twoyears of post-treatment surveillance


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Recurrent Cervical Cancer

Radiation

Pelvic exenteration

Palliative chemotherapy


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Vulvar Cancer

3870 new cases 2005

870 deaths

Approximately 5% of Gynecologic

Cancers

American Cancer Society. Cancer Facts & Figu res. 2004. Atlanta, GA; 2005


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Vulvar Cancer

85% Squamous Cell Carcinoma

5% Melanoma

2% Sarcoma

8% Others


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Vulvar Cancer

Biphasic Distribution

Average Age 70 years

20% in patients UNDER 40 and appears to

be increasing


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Vulvar Cancer Etiology

Chronic inflammatory conditions and

vulvar dystrophies are implicated in older

patients Syphilis and lymphogranuloma venereum

and granuloma inguinal

HPV in younger patients

Tobacco


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Vulvar Cancer

Pagets Disease of Vulva

10% will be invasive

4-8% association with underlyingAdenocarcinoma of the vulva


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Symptoms

Most patients are treated for other

conditions

12 month or greater time from symptoms todiagnosis


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Symptoms

Pruritus

Mass

Pain Bleeding

Ulceration

Dysuria Discharge

Groin Mass


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Symptoms

May look like:

Raised

Erythematous

Ulcerated

Condylomatous

Nodular


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Vulvar Cancer

IF IT LOOKS ABNORMAL ON THE

VULVA

BIOPSY!

BIOPSY!

BIOPSY!


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Tumor Spread

Very Specific nodal spread pattern

Direct Spread

Hematogenous


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Staging

Based on TNM Surgical Staging

Tumor size

Node Status

Metastatic Disease


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Staging

Stage I T1 N0 M0

Tumor 2cm

IA 1 mm depth of Invasion

IB 1 mm or more depth of invasion


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Staging

Stage II T2 N0 M0

Tumor >2 cm

Confined to Vulva or Perineum


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Staging

Stage III

T3 N0 M0

T3 N1 M0

T1 N1 M0

T2 N1 M0

Tumor any size involving lower urethra, vagina,anus OR unilateral positive nodes


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Staging

Stage IVA

T1 N2 M0

T2 N2 M0

T3 N2 M0

T4 N any M0

Tumor invading upper urethra, bladder, rectum,pelvic bone or bilateral nodes


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Staging

Stage IVB

Any T Any N M1

Any distal mets including pelvic nodes


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Treatment

Primarily Surgical

Wide Local Excision

Radical Excision

Radical Vulvectomy with Inguinal Node

Dissection

Unilateral Bilateral

Possible Node Mapping, still investigational


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Treatment

Local advanced may be treated with

Radiation plus Chemosensitizer

Positive Nodal Status1 or 2 microscopic nodes < 5mm can be

observed

3 or more or >5mm post op radiation


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Treatment

Special Tumor

Verrucous Carcinoma

Indolent tumor with local disease, rare metsUNLESS given radiation, becomes Highly

malignant and aggressive

Excision or Vulvectomy ONLY


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Vulva 5 year survival

Stage I 90

Stage II 77

Stage III 51

Stage IV 18

Hacker and Berek, Practical Gynecologic Oncology

4th

Edition, 2005


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Recurrence

Local Recurrence in Vulva

Reexcision or radiation and good prognosis if

not in original site of tumorPoor prognosis if in original site


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Recurrence

Distal or Metastatic

Very poor prognosis, active agents include

Cisplatin, mitomycin C, bleomycin,methotrexate and cyclophosphamide


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Melanoma

5% of Vulvar Cancers

Not UV related

Commonly periclitoral or labia minora


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Melanoma

Microstaged by one of 3 criteria

Clarks Level

Chungs LevelBreslow


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Melanoma Treatment

Wide local or Wide Radical excision with

bilateral groin dissection

Interferon Alpha 2-b


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Vaginal Carcinoma

2140 new cases projected 2005

810 deaths projected 2005

Represents 2-3% of Pelvic Cancers

American Cancer Society. Cancer Facts & Figu res. 2004. Atlanta, GA; 2005


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Vaginal Cancer

84% of cancers in vaginal area are

secondary

CervicalUterine

Colorectal

OvaryVagina

Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva,nd


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Vaginal Carcinoma

Squamous Cell 80-85%

Clear Cell 10%

Sarcoma 3-4%

Melanoma 2-3%


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Clear Cell Carcinoma

Associated with DES Exposure In Utero

DES used as anti abortifcant from 1949-1971

500+ cases confirmed by DES RegistryUsually occurred late teens


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Vaginal Cancer Etiology

Mimics Cervical Carcinoma

HPV 16 and 18


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Staging

Stage I Confined to Vaginal Wall

Stage II Subvaginal tissue but not

to pelvic sidewall

Stage III Extended to pelvic

sidewall

Stage IVA Bowel or Bladder

Stage IVB Distant mets


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Treatment

Surgery with Radical Hysterectomy and

pelvic lymph dissection in selected stage I

tumors high in Vagina All others treated with radiation with

chemosensitization

cervical vulva r cancer 2012

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