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 • <2/100,000: 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

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 – <3mm depth of invasion IA2 – stromal invasion 3-5mm in depth or <7 mm in width IB1- tumor < 4 cm IB2 - tumor > 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

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

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

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 • Paget’s Disease of Vulva • 10% will be invasive • 4-8% association with underlying Adenocarcinoma of the vulva

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 >2 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 < 5mm can be observed • 3 or more or >5mm 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