The Management of Cervical , Vulvar and Vaginal Cancers - PowerPoint PPT Presentation

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The Management of Cervical , Vulvar and Vaginal Cancers

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Title: The Management of Cervical , Vulvar and Vaginal Cancers


1
The Management of Cervical , Vulvar and Vaginal
Cancers
  • Kerry J. Rodabaugh, M.D.
  • Division of Gynecologic Oncology
  • University of Nebraska Medical Center

2
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

3
United States Incidence
  • 15,000 women diagnosed annually
  • 4,800 annual deaths

4
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

5
Lifetime risk of developing cervical cancer
  • 5 - South America
  • 0.7 - USA

6
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

7
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
8
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.

9
Clinical Presentation
  • CIN/CIS/ACIS asymptomatic
  • Irregular vaginal bleeding
  • Vaginal discharge
  • Pelvic pain
  • Leg edema
  • Bowel/bladder symptoms

10
Physical Findings
  • Exophytic, cauliflower like mass
  • Cervical ulcer, friable or necrotic
  • Firm barrel-shaped cervix
  • Hydronephrosis
  • Anemia
  • Weight loss

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12
Histology
  • Squamous 85-90
  • Adenocarcinoma 10-15
  • Lymphoma
  • Neuroendocrine/small cell
  • Melanoma

13
Route of Spread
  • Cervical cancer spreads by direct invasion or by
    lymphatic spread
  • Vascular spread is rare

14
Staging
  • Physical exam
  • Cervical biopsies
  • Chest x-ray
  • IVP (Ct scan)
  • Barium enema, cystoscopy, proctoscopy
  • Surgical staging

15
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

16
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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18
5 year survival rates
  • Stage IA 90-100
  • Stage IB 70-90
  • Stage II 50-60
  • Stage III 30-40
  • Stage IV 5

19
Therapy
  • Cervical conization
  • Simple hysterectomy
  • Radical hysterectomy
  • Radiation therapy with chemosensitization

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23
5 year Survival
  • Stage I 70
  • Stage II 51
  • Stage III 33
  • Stage IV 17

24
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

25
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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28
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

29
Recurrent Cervical Cancer
  • Radiation
  • Pelvic exenteration
  • Palliative chemotherapy

30
Vulvar Cancer
  • 3870 new cases 2005
  • 870 deaths
  • Approximately 5 of Gynecologic Cancers

American Cancer Society. Cancer
Facts Figures. 2004. Atlanta, GA 2005
31
Vulvar Cancer
  • 85 Squamous Cell Carcinoma
  • 5 Melanoma
  • 2 Sarcoma
  • 8 Others

32
Vulvar Cancer
  • Biphasic Distribution
  • Average Age 70 years
  • 20 in patients UNDER 40 and appears to be
    increasing

33
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

34
Vulvar Cancer
  • Pagets Disease of Vulva
  • 10 will be invasive
  • 4-8 association with underlying Adenocarcinoma
    of the vulva

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37
Symptoms
  • Most patients are treated for other conditions
  • 12 month or greater time from symptoms to
    diagnosis

38
Symptoms
  • Pruritus
  • Mass
  • Pain
  • Bleeding
  • Ulceration
  • Dysuria
  • Discharge
  • Groin Mass

39
Symptoms
  • May look like
  • Raised
  • Erythematous
  • Ulcerated
  • Condylomatous
  • Nodular

40
Vulvar Cancer
  • IF IT LOOKS ABNORMAL ON THE VULVA
  • BIOPSY!
  • BIOPSY!
  • BIOPSY!

41
Tumor Spread
  • Very Specific nodal spread pattern
  • Direct Spread
  • Hematogenous

42
Staging
  • Based on TNM Surgical Staging
  • Tumor size
  • Node Status
  • Metastatic Disease

43
Staging
  • Stage I T1 N0 M0
  • Tumor 2cm
  • IA 1 mm depth of Invasion
  • IB 1 mm or more depth of invasion

44
Staging
  • Stage II T2 N0 M0
  • Tumor gt2 cm
  • Confined to Vulva or Perineum

45
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

46
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

47
Staging
  • Stage IVB
  • Any T Any N M1
  • Any distal mets including pelvic nodes

48
Treatment
  • Primarily Surgical
  • Wide Local Excision
  • Radical Excision
  • Radical Vulvectomy with Inguinal Node Dissection
  • Unilateral
  • Bilateral
  • Possible Node Mapping, still investigational

49
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

50
Treatment
  • Special Tumor
  • Verrucous Carcinoma
  • Indolent tumor with local disease, rare mets
    UNLESS given radiation, becomes Highly malignant
    and aggressive
  • Excision or Vulvectomy ONLY

51
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
52
Recurrence
  • Local Recurrence in Vulva
  • Reexcision or radiation and good prognosis if not
    in original site of tumor
  • Poor prognosis if in original site

53
Recurrence
  • Distal or Metastatic
  • Very poor prognosis, active agents include
    Cisplatin, mitomycin C, bleomycin, methotrexate
    and cyclophosphamide

54
Melanoma
  • 5 of Vulvar Cancers
  • Not UV related
  • Commonly periclitoral or labia minora

55
Melanoma
  • Microstaged by one of 3 criteria
  • Clarks Level
  • Chungs Level
  • Breslow

56
Melanoma Treatment
  • Wide local or Wide Radical excision with
    bilateral groin dissection
  • Interferon Alpha 2-b

57
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
58
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
59
Vaginal Carcinoma
  • Squamous Cell 80-85
  • Clear Cell 10
  • Sarcoma 3-4
  • Melanoma 2-3

60
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

61
Vaginal Cancer Etiology
  • Mimics Cervical Carcinoma
  • HPV 16 and 18

62
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

63
Treatment
  • Surgery with Radical Hysterectomy and pelvic
    lymph dissection in selected stage I tumors high
    in Vagina
  • All others treated with radiation with
    chemosensitization
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