Cervical/Vulvar/Vaginal Cancer

Cervical/Vulvar/Vaginal Cancer
By:Steve Remmenga, M.D.
The McClure L Smith Professor of Gynecologic Oncology
Division of Gynecologic Oncology, Department of OB/GYN
University of Nebraska Medical Center

Cervical Cancer

Cervical CA
* International estimates
Pap Smear
* With the advent of the Pap smear, the incidence of cervical cancer has dramatically declined

Cervical CA Etiology
* Cervical cancer is a sexually transmitted disease.
* HPV DNA is present in virtually all cases of cervical cancer and precursors.
* Some strains of HPV have a predilection to the genital tract and transmission is usually through sexual contact (16, 18 High Risk).
* Little understanding of why small subset of women are affected by HPV.
* HPV may be latent for many years before inducing cervical neoplasia.

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

Prevention
* Educate all providers, men and women regarding HPV and the link to cervical cancer.
* Adolescents are an especially high-risk group due to behavior and cervical biology.
* Delay onset of sexual intercourse.
* Condoms may help prevent sexually transmitted disease.

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.

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.

Symptoms of Invasion
* May be silent until advanced disease develops
* Post-coital bleeding
* Foul vaginal discharge
* Abnormal bleeding
* Pelvic pain
* Unilateral leg swelling or pain
* Pelvic mass
* Gross cervical lesion

Cell Type
* Squamous Cell Carcinoma 80-85%
* AdenoCarcinoma 15%
* Adenosquamous
* Others

Staging
* Clinical Staged Disease
o Physical Exam
o Blood Work
o Cystoscopy
o Proctoscopy
o IVP

Staging Cervical Cancer
* Stage I Confined to Cervix
Microscopic Disease
* Squamous carcinoma of the cervix that has <3mm invasion from the basement membrane
* The diagnosis must be based on a cone or hysterectomy specimen.
* No lymph-vascular invasion
* May be successfully treated with fertility preservation in selected patients
* These patients should all be referred for consultation.





Staging

* Stage III Lower 1/3 Vagina, Sidewall or ureteral involvement
* IIIA Lower 1/3 of Vagina
* IIIB Sidewall or Ureteral Involvement
* Stage IV Bladder, Rectal or Distal Spread
* IVA Bladder or Rectal Involvement
* IVB Distal Spread

Treatment of Early Disease
* Conization or simple hysterectomy (removal of the uterus) - microinvasive cancer
* Radical hysterectomy - removal of the uterus with its associated connective tissues, the upper vagina, and pelvic lymph nodes. Ovarian preservation is possible.
* Chemoradiation therapy

Advanced Disease
* Chemoradiation is the mainstay of treatment

What is Standard Therapy for
Stage IB2 - IVA Cervical Carcinoma?
* External beam pelvic radiation (4,000 to 6,000 cGy)
* Brachytherapy (8,000 to 8,500 cGy to Point A)
* I.V. Cisplatin chemotherapy

Symptoms of Recurrence
* Weight loss, fatigue and anorexia
* Abnormal vaginal bleeding
* Pelvic pain
* Unilateral leg swelling or pain
* Foul discharge
* Signs of distant metastases
* NOTE: must distinguish radiation side effects from recurrent cancer

Management of Recurrence
* Chemoradiation may be curative or palliative, especially in women who have not received prior radiation therapy.
* Isolated soft tissue recurrence may occasionally be treated by resection with long-term survival.
Topotecan in Recurrent Cervical Cancer – Overview of Phase II Studies
Reference Regimen Evaluable Prior CT ORR Median OS
Survival
By Treatment Group
Proportion Surviving
Vulvar Cancer
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
* Paget’s Disease of Vulva
Symptoms
* Most patients are treated for “other” conditions
* 12 month or greater time from symptoms to diagnosis
* Pruritus
* Mass
* Pain
* Bleeding
* Ulceration
* Dysuria
* Discharge
* Groin Mass
* May look like:
o Raised
o Erythematous
o Ulcerated
o Condylomatous
o Nodular
* IF IT LOOKS ABNORMAL ON THE VULVA
* BIOPSY!
Tumor Spread
* Very Specific nodal spread pattern
* Direct Spread
* Hematogenous

Treatment
* Primarily Surgical
o Wide Local Excision
o Radical Excision
o Radical Vulvectomy with Inguinal Node Dissection
+ Unilateral
+ Bilateral
+ Possible Node Mapping, still investigational

* Local advanced may be treated with Radiation plus Chemosensitizer
* Positive Nodal Status
* Special Tumor
o Verrucous Carcinoma

Vulva 5 year survival
* Stage I 90
* Stage II 77
* Stage III 51
* Stage IV 18

Recurrence
* Local Recurrence in Vulva
o Reexcision or radiation and good prognosis if not in original site of tumor
o Poor prognosis if in original site
Melanoma
Melanoma Treatment
Clear Cell Carcinoma
Treatment

Cervical/Vulvar/Vaginal Cancer.ppt