Ch. 31. Cervical and Vaginal Cancer

1. Ch. 31. Cervical and Vaginal Cancer 부산백병원 산부인과 R1 손영실

2. INDEX # Special Considerations 1. Cervical Cancer during Pregnancy 2. Others # Recurrent Cervical Cancer 1. Radiation Retreatment 2. Surgical Therapy # Vaginal Carcinoma

3. # Special Considerations

4. • The incidence of adenocarcinoma of the cervix appears to be increasing relative to that of squamous cancers. • 5% of all cervical cancers (in older report) → 18.5~27% of all cervical cancers (in newer report) • Adenocarcinoma has a poorer prognosis than for squamous cell carcinoma in every stage. (by FIGO annual report) • Adenosquamous carcinoma has a poorer prognosis than pure adenocarcinoma or squamous carcinoma.

5. Cervical Cancer during Pregnancy • Diagnosis is often delayed during pregnancy, because bleeding is attributed to pregnancy-related complications. • Pap test should be performed on all pregnant patients at the initial prenatal visit, and any grossly suspicious lesions should be excised for biopsy.

6. Cervical Cancer during Pregnancy • Less than 3mm of invasion and no lymphatic involvement → may be followed to term and delivered vaginally → vaginal hysterectomy may be performed 6 weeks postpartum (if further child is not desired) • 3~5mm of invasion and lymph-vascular invasion → also may be followed to term and delivered by cesarean section → followed immediately by modified radical hysterectomy and pelvic LN dissection

7. Cervical Cancer during Pregnancy • More than 5mm invasion : Treatment depends on gestational age and wish of the patients. - After 28~32 weeks (75~90% survival rate), recommended treatment is classic c/sec followed by radical hysterectomy with pelvic LN dissection. • Stage Ⅱ to Ⅳ - before GA 28 weeks : irradiation → spontaneous abortion - after GA 28 weeks : delivered by classic cesarean birth, followed a radiotherapy

8. Others ◎ Pyometra and Hematometra • An enlarged fluid-filled uterine cavity may be detected. • It should be drained, and given antibiotics (in pyometra) ◎ Cervical Carcinoma after Extrafascial Hysterectomy - reoperation : involving a pelvic LN dissection, radical excision of parametrial tissue, cardinal ligaments, and vaginal stump - radiotherapy

9. # Recurrent Cervical Cancer

10. - Treatment depends on the mode of primary therapy and the site. • patients who have been treated initially with surgery → should be considered radiotherapy • patients who have had radiotherapy → should be considered for surgery • patients who are not curable by other two modalities → chemotherapy

11. Radiation Retreatment • Radiotherapy can be palliative with localized metastatic lesions. painful bony metastases CNS lesion severe urologic or vena caval obstructions → specific indication

12. Surgical Therapy - Surgical therapy for postirradiation recurrence is limited to patients with central pelvic disease. ◎ Exenteration - extension of the tumor to the pelvic sidewall is a contraindication to exenteration - clinical triad of unilateral leg edema, sciatic pain, ureteral obstruction is nearly always pathognomonic of unresectable disease on the pelvic sidewall

13. Surgical Therapy 1. Anterior Exenteration • removal of bladder, vagina, cervix, and uterus • patients whom disease is limited to the cervix and anterior portion of upper vagina 2. Posterior Exenteration • removal of rectum, vagina, cervix, and uterus • rarely performed for recurrent cervical cancer

14. Surgical Therapy 3. Total Exenteration • removal of both bladder and rectum with the vagina, cervix, and uterus • indicated when the disease extends down to lower part of vagina • It leaves the patients with permanent colostomy as well as a urinary conduit.

15. Surgical Therapy a. In selected patients, it may take above levator muscle, leaving rectal stump that may be anastomosed to the sigmoid, thus avoiding a permanent colostomy. b. The technique to establish continent urinary diversion has helped improve a physical appearance after exenteration. → The associated psychological trauma is avoided.

16. # Vaginal Carcinoma

17. • Relatively uncommon tumor • Only 1% to 2% of malignancy of the female genital tract - primary vaginal cancer - metastatic cancer to the vagina

18. Staging • In the FIGO staging - a tumor that has extended to the vagina from cervix → regarded as a cancer of the cervix - a tumor that involves both the vulva and the vagina → classified as a cancer of the vulva • Vaginal cancer is rare and treatment is generally by radiotherapy → there is very little information (depth of invasion, LN invasion, size of lesion) → FIGO staging does not include a category for microinvasive disease

19. Staging • FIGO staging of Vaginal Cancer

20. Etiology & Screening ◎ Etiology • The cause of squamous cell carcinoma of the vagina is unknown. • VAIN (vaginal intraepithelial neoplasia) : premalignant phase of vaginal cancer : similar to cervical cancer • Any new vaginal carcinoma developing at least 5 years after the cervical cancer should be considered a new primary lesion. ◎ Screening - routine screening of all patients is inappropriate.

21. Symptoms • Painless vaginal bleeding and discharge : most common symptoms • With advanced tumors → urinary retention, bladder spasm, hematuria, frequency of urination • Tumors on the posterior vaginal wall → produce rectal symptoms (tenesmus, constipation, bloody stool)

22. Diagnosis • The diagnostic workup - complete history and physical exam, careful speculum exam, palpation of vagina, bimanual pelvic and rectal exam • The upper one third of the vaginal posterior wall : most common site, but may be overlooked → important to rotate the speculum to obtain a careful view of the entire vagina

23. Pathology • Squamous cell carcinoma - most common form, 80%~90% of vaginal cancers - occur in the upper posterior wall of vagina - mean age : 60 years • Malignant melanoma - 2nd most common cancer of vagina - 2.8%~5% of vaginal neoplasms • Others : adenocarcinoma, sarcoma

24. Treatment • Based on the clinical exam, CT scan, chest x-ray, age, and condition of the patient • Most are treated by radiation therapy. • Surgery is limited to highly selective cases. - stage Ⅰ (on upper posterior vagina) → radical vaginectomy and pelvic lymphadenectomy

25. Treatment • Radiation therapy : treatment of choice - Small lesion : intracavitary radiation alone - Larger lesion : external teletherapy to decrease tumor volume and to treat regional pelvic nodes → followed by intracavitary and interstitial therapy to the primary tumor

26. Sequelae • The proximity of the rectum, bladder, and urethra leads to a major complication → radiation cystitis, proctitis, rectal strictures or ulcerations • Necrosis of vagina, vaginal fibrosis, stenosis, strictures : use of vaginal dilators, topical estrogen to maintain adequate vaginal function

27. Survival • Primary Vaginal Carcinoma : 5-year Survival

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