The Management of Cervical , Vulvar and Vaginal Cancers

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The Management of Cervical , Vulvar and Vaginal
Cancers

• Kerry J. Rodabaugh, M.D.
• Division of Gynecologic Oncology
• University of Nebraska Medical Center

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Incidence global public health issue

• 450,000 500,000 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

• lt2/100,000 Finland, France, Greece, Israel,
  Japan, Korea, Spain, Thailand
• 2.7/100,000 USA
• 12-15.9/100,000 Chile, Costa Rica, Mexico

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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 women begins having vaginal intercourse,
  but no later than 21 years of age.
• Screening should be done every year with regular
  Pap tests or every two years using liquid-based
  tests.
• At or after age 30, women who have had three
  normal test results in a row may get screened
  every 2-3 years. However, doctors may suggest 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 Pap tests in the last ten years may
  choose to stop cervical cancer screening.
• Screening after a total hysterectomy (with
  removal of the cervix) is not necessary unless
  the surgery was done as a treatment for cervical
  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/ACIS asymptomatic
• 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 I confined to the cervix
• IA1 lt3mm depth of invasion
• IA2 stromal invasion 3-5mm in depth
• or lt7 mm in width
• IB1- tumor lt 4 cm
• IB2 - tumor gt 4 cm in diameter
• Stage II extension beyond cervix
• IIA upper 2/3 of vagina
• IIB Parametrial involvement

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Staging

• Stage III
• IIIA lower 1/3 of vagina
• IIIB extension to pelvic sidewall or
  hydronephrosis
• Stage IV
• IVA bladder or rectal mucosa
• IVB distant 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 with chemosensitization

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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 dysfunction
• Vesico/uretero fistula
• Bowel obstruction
• Ovarian preservation
• Vaginal preservation

• Radiation
• Sigmoiditis
• Rectovaginal fistula
• Bowel obstruction
• Vesico/uretero fistula
• Ovarian failure

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Radiation Therapy

• External Beam
• Whole pelvis or para-aortic window
• 4000-6000 cGy
• Over 4-5 weeks
• Brachytherapy
• Intracavitary or interstitial
• 2000-3000 cGy
• Over 2 implants

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Recurrent Cervical Cancer

• 10-20 of patients treated with radical
  hysterectomy
• Recurrence has an 85 mortality
• 83 are diagnosed within the first two years 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 Figures. 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 underlying Adenocarcinoma
  of the vulva

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Symptoms

• Most patients are treated for other conditions
• 12 month or greater time from symptoms to
  diagnosis

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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 gt2 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 Status
• 1 or 2 microscopic nodes lt 5mm can be observed
• 3 or more or gt5mm post op radiation

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Treatment

• Special Tumor
• Verrucous Carcinoma
• Indolent tumor with local disease, rare mets
  UNLESS 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 tumor
• Poor 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 Level
• Breslow

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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 Figures. 2004. Atlanta, GA 2005
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Vaginal Cancer

• 84 of cancers in vaginal area are secondary
• Cervical
• Uterine
• Colorectal
• Ovary
• Vagina

Fu YS, Pathology of the Uterine Cervix, Vagina
and Vulva, 2nd ed. 2002
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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 Registry
• Usually 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