Cervical Vulva r Cancer 2012
-
Upload
vaneciabella -
Category
Documents
-
view
222 -
download
0
Transcript of Cervical Vulva r Cancer 2012
-
8/10/2019 Cervical Vulva r Cancer 2012
1/63
The Management ofCervical , Vulvar and
Vaginal Cancers
Kerry J. Rodabaugh, M.D.
Division of Gynecologic OncologyUniversity of Nebraska Medical Center
-
8/10/2019 Cervical Vulva r Cancer 2012
2/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
3/63
United States Incidence
15,000 women diagnosed annually
4,800 annual deaths
-
8/10/2019 Cervical Vulva r Cancer 2012
4/63
Mortality Rates
-
8/10/2019 Cervical Vulva r Cancer 2012
5/63
Lifetime risk of developing
cervical cancer
5% - South America
0.7% - USA
-
8/10/2019 Cervical Vulva r Cancer 2012
6/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
7/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
8/63
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.
-
8/10/2019 Cervical Vulva r Cancer 2012
9/63
Clinical Presentation
CIN/CIS/ACISasymptomatic
Irregular vaginal bleeding
Vaginal discharge
Pelvic pain
Leg edema Bowel/bladder symptoms
-
8/10/2019 Cervical Vulva r Cancer 2012
10/63
Physical Findings
Exophytic, cauliflower like mass
Cervical ulcer, friable or necrotic
Firm barrel-shaped cervix
Hydronephrosis Anemia
Weight loss
-
8/10/2019 Cervical Vulva r Cancer 2012
11/63
-
8/10/2019 Cervical Vulva r Cancer 2012
12/63
Histology
Squamous 85-90%
Adenocarcinoma 10-15%
Lymphoma
Neuroendocrine/small cell
Melanoma
-
8/10/2019 Cervical Vulva r Cancer 2012
13/63
Route of Spread
Cervical cancer spreads by direct
invasion or by lymphatic spread
Vascular spread is rare
-
8/10/2019 Cervical Vulva r Cancer 2012
14/63
Staging
Physical exam
Cervical biopsies
Chest x-ray
IVP (Ct scan)
Barium enema, cystoscopy, proctoscopy Surgical staging
-
8/10/2019 Cervical Vulva r Cancer 2012
15/63
Staging
Stage Iconfined to the cervix
IA1
-
8/10/2019 Cervical Vulva r Cancer 2012
16/63
Staging
Stage III
IIIAlower 1/3 of vagina
IIIBextension to pelvic sidewall or
hydronephrosis
Stage IV
IVAbladder or rectal mucosa
IVBdistant metastases
-
8/10/2019 Cervical Vulva r Cancer 2012
17/63
-
8/10/2019 Cervical Vulva r Cancer 2012
18/63
5 year survival rates
Stage IA 90-100%
Stage IB 70-90%
Stage II 50-60%
Stage III 30-40%
Stage IV 5%
-
8/10/2019 Cervical Vulva r Cancer 2012
19/63
Therapy
Cervical conization
Simple hysterectomy
Radical hysterectomy
Radiation therapy withchemosensitization
-
8/10/2019 Cervical Vulva r Cancer 2012
20/63
-
8/10/2019 Cervical Vulva r Cancer 2012
21/63
-
8/10/2019 Cervical Vulva r Cancer 2012
22/63
-
8/10/2019 Cervical Vulva r Cancer 2012
23/63
5 year Survival
Stage I 70%
Stage II 51%
Stage III 33%
Stage IV 17%
-
8/10/2019 Cervical Vulva r Cancer 2012
24/63
Pros and Cons
Surgery
Bladder dysfunctionVesico/uretero fistula
Bowel obstruction
Ovarian preservation
Vaginal preservation
Radiation
SigmoiditisRectovaginal fistula
Bowel obstruction
Vesico/uretero fistula
Ovarian failure
-
8/10/2019 Cervical Vulva r Cancer 2012
25/63
Radiation Therapy
External BeamWhole pelvis or para-aortic window
4000-6000 cGyOver 4-5 weeks
Brachytherapy
Intracavitary or interstitial2000-3000 cGy
Over 2 implants
-
8/10/2019 Cervical Vulva r Cancer 2012
26/63
-
8/10/2019 Cervical Vulva r Cancer 2012
27/63
-
8/10/2019 Cervical Vulva r Cancer 2012
28/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
29/63
Recurrent Cervical Cancer
Radiation
Pelvic exenteration
Palliative chemotherapy
-
8/10/2019 Cervical Vulva r Cancer 2012
30/63
Vulvar Cancer
3870 new cases 2005
870 deaths
Approximately 5% of Gynecologic
Cancers
American Cancer Society. Cancer Facts & Figu res. 2004. Atlanta, GA; 2005
-
8/10/2019 Cervical Vulva r Cancer 2012
31/63
Vulvar Cancer
85% Squamous Cell Carcinoma
5% Melanoma
2% Sarcoma
8% Others
-
8/10/2019 Cervical Vulva r Cancer 2012
32/63
Vulvar Cancer
Biphasic Distribution
Average Age 70 years
20% in patients UNDER 40 and appears to
be increasing
-
8/10/2019 Cervical Vulva r Cancer 2012
33/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
34/63
Vulvar Cancer
Pagets Disease of Vulva
10% will be invasive
4-8% association with underlyingAdenocarcinoma of the vulva
-
8/10/2019 Cervical Vulva r Cancer 2012
35/63
-
8/10/2019 Cervical Vulva r Cancer 2012
36/63
-
8/10/2019 Cervical Vulva r Cancer 2012
37/63
Symptoms
Most patients are treated for other
conditions
12 month or greater time from symptoms todiagnosis
-
8/10/2019 Cervical Vulva r Cancer 2012
38/63
Symptoms
Pruritus
Mass
Pain Bleeding
Ulceration
Dysuria Discharge
Groin Mass
-
8/10/2019 Cervical Vulva r Cancer 2012
39/63
Symptoms
May look like:
Raised
Erythematous
Ulcerated
Condylomatous
Nodular
-
8/10/2019 Cervical Vulva r Cancer 2012
40/63
Vulvar Cancer
IF IT LOOKS ABNORMAL ON THE
VULVA
BIOPSY!
BIOPSY!
BIOPSY!
-
8/10/2019 Cervical Vulva r Cancer 2012
41/63
Tumor Spread
Very Specific nodal spread pattern
Direct Spread
Hematogenous
-
8/10/2019 Cervical Vulva r Cancer 2012
42/63
Staging
Based on TNM Surgical Staging
Tumor size
Node Status
Metastatic Disease
-
8/10/2019 Cervical Vulva r Cancer 2012
43/63
Staging
Stage I T1 N0 M0
Tumor 2cm
IA 1 mm depth of Invasion
IB 1 mm or more depth of invasion
-
8/10/2019 Cervical Vulva r Cancer 2012
44/63
Staging
Stage II T2 N0 M0
Tumor >2 cm
Confined to Vulva or Perineum
-
8/10/2019 Cervical Vulva r Cancer 2012
45/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
46/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
47/63
Staging
Stage IVB
Any T Any N M1
Any distal mets including pelvic nodes
-
8/10/2019 Cervical Vulva r Cancer 2012
48/63
Treatment
Primarily Surgical
Wide Local Excision
Radical Excision
Radical Vulvectomy with Inguinal Node
Dissection
Unilateral Bilateral
Possible Node Mapping, still investigational
-
8/10/2019 Cervical Vulva r Cancer 2012
49/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
50/63
Treatment
Special Tumor
Verrucous Carcinoma
Indolent tumor with local disease, rare metsUNLESS given radiation, becomes Highly
malignant and aggressive
Excision or Vulvectomy ONLY
-
8/10/2019 Cervical Vulva r Cancer 2012
51/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
52/63
Recurrence
Local Recurrence in Vulva
Reexcision or radiation and good prognosis if
not in original site of tumorPoor prognosis if in original site
-
8/10/2019 Cervical Vulva r Cancer 2012
53/63
Recurrence
Distal or Metastatic
Very poor prognosis, active agents include
Cisplatin, mitomycin C, bleomycin,methotrexate and cyclophosphamide
-
8/10/2019 Cervical Vulva r Cancer 2012
54/63
Melanoma
5% of Vulvar Cancers
Not UV related
Commonly periclitoral or labia minora
-
8/10/2019 Cervical Vulva r Cancer 2012
55/63
Melanoma
Microstaged by one of 3 criteria
Clarks Level
Chungs LevelBreslow
-
8/10/2019 Cervical Vulva r Cancer 2012
56/63
Melanoma Treatment
Wide local or Wide Radical excision with
bilateral groin dissection
Interferon Alpha 2-b
-
8/10/2019 Cervical Vulva r Cancer 2012
57/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
58/63
Vaginal Cancer
84% of cancers in vaginal area are
secondary
CervicalUterine
Colorectal
OvaryVagina
Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva,nd
-
8/10/2019 Cervical Vulva r Cancer 2012
59/63
Vaginal Carcinoma
Squamous Cell 80-85%
Clear Cell 10%
Sarcoma 3-4%
Melanoma 2-3%
-
8/10/2019 Cervical Vulva r Cancer 2012
60/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
61/63
Vaginal Cancer Etiology
Mimics Cervical Carcinoma
HPV 16 and 18
-
8/10/2019 Cervical Vulva r Cancer 2012
62/63
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
-
8/10/2019 Cervical Vulva r Cancer 2012
63/63
Treatment
Surgery with Radical Hysterectomy and
pelvic lymph dissection in selected stage I
tumors high in Vagina All others treated with radiation with
chemosensitization