1 / 69

Cervical/Vulvar/Vaginal Cancer

Cervical/Vulvar/Vaginal Cancer. 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. Estimated incidence and mortality in the United States (2007)¹

risa-caldwell
Download Presentation

Cervical/Vulvar/Vaginal Cancer

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cervical/Vulvar/Vaginal Cancer 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

  2. Cervical Cancer • Estimated incidence and mortality in the United States (2007)¹ • 11,150 new cases • 3,670 deaths • 1:168 Lifetime risk 1. American Cancer Society. Cancer Facts & Figures. 2007. Atlanta, GA; 2007

  3. Cervical Cancer • <2% of all cancer deaths in women (twice as deadly in African-American women) • 5-year survival: 71% 1. American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

  4. Cervical CA • International estimates • Approximately 570,000 cases expected worldwide each year • 275,000 deaths • Number one cancer killer of women worldwide

  5. Pap Smear • With the advent of the Pap smear, the incidence of cervical cancer has dramatically declined

  6. Cervical Cancer

  7. 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.

  8. 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

  9. 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.

  10. 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

  11. 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.

  12. 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

  13. Cell Type • Squamous Cell Carcinoma 80-85% • AdenoCarcinoma 15% • Adenosquamous • Others

  14. Staging • Clinical Staged Disease • Physical Exam • Blood Work • Cystoscopy • Proctoscopy • IVP

  15. Staging Cervical Cancer • Stage I Confined to Cervix • Ia1 <3 mm deep, < 7 mm wide • Ia2 >3 <5 mm deep, • Ib1 < 4cm • Ib2 > 4 cm

  16. 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.

  17. Staging • Stage II Upper 2/3 vagina or Parametrial involvement • IIA Upper 2/3 vagina with no Parametrial • IIB Parametrial Involvement

  18. Staging • Stage III Lower 1/3 Vagina, Sidewall or ureteral involvement • IIIA Lower 1/3 of Vagina • IIIB Sidewall or Ureteral Involvement

  19. Staging • Stage IV Bladder, Rectal or Distal Spread • IVA Bladder or Rectal Involvement • IVB Distal Spread

  20. 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

  21. Advanced Disease • Chemoradiation is the mainstay of treatment • 4-5 weeks of external radiation • Two or more implants (brachytherapy) • Concurrent Cisplatin-based chemotherapy significantly improves the chances of survival • Radiation treats the primary tumor and adjacent tissues and lymph nodes • Chemotherapy acts as a radiation sensitizer and may also control distant disease

  22. 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 • Cisplatin 40mg/m2 (Max dose 70mg) IV q wk during RT (6wks) GOG 120-NEJM 340(15):1144, 1999

  23. 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

  24. 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.

  25. Recurrent Cervical Cancer: GOG 169 Moore DH et al. J Clin Oncol 22:3113-3119. 2004

  26. Topotecan in Recurrent Cervical Cancer – Overview of Phase II Studies Reference Regimen Evaluable Prior CT ORR Median OS (n) Single Agent (dailyx5): Bookman 1.5mg/m2/d 40 85% 13% 6.6 mo Muderspach 1.5mg/m2/d 43 None 19% 6.4 mo Noda 1.2mg/m2/d 22 82% 18% NR Combinations: Fiorica Topo + cisplatin 32 None 28% 10 mo Tiersten Topo + paclitaxel 13 33% 54% 8.6 mo • Bookman MA et al. Gynecol Oncol 2000; 77: 446-449. . Muderspach LI, et al., Gynecologic Oncology 2001;81: 213-215. Noda K, et al. Proc Am Soc Clin Oncol 1996;15:280 [Abstract 754]. Fiorica J, et al. Gynecol Oncol 2002;85:89-94. Tiersten AD, et al. Gyn Oncol 2004;92:635-638

  27. Recurrent Cervical Cancer:GOG 179 Regimen I Cisplatin 50 mg/m² Cervix Cancer Stage IV B or Regimen II Recurrent Topotecan 0.75 g/m²/d1-3 Cisplatin 50 mg/m² d 1 R A N D O M I Z E Long HJ, et al. Gynecol Oncol 2004; 92:397(SGO)

  28. SurvivalBy Treatment Group 1.0 Rx Group Alive Dead Total Cisplatin 17 129 146 Cis+Topo 29 118 147 0.9 0.8 0.7 Proportion Surviving 0.6 0.5 0.4 0.3 0.2 0.0 0.1 Months on Study 0 12 24 36 GOG 179

  29. GOG Protocol 179 Response rates based on previous cisplatin therapy (with RT) No Prior PlatinumPrior Platinum CDDP arm 20% 8% CDDP/Topo arm 39% 15%

  30. Comparing GOG 169 to 179 • Studies from two different eras • 169 before Chemo-RT • 179 during transition to Chemo-RT • Both showed no QoL disturbance with more aggressive regimens • In the new era chemo/RT • Response rate to CDDP less • Survival after single agent CDDP less • Survival advantage when add Topotecan • Survival Advantage when add Paclitaxel?

  31. Survival

  32. Vulvar Cancer • 3870 new cases 2005 • 870 deaths • Approximately 5% of Gynecologic Cancers American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

  33. Vulvar Cancer • 85% Squamous Cell Carcinoma • 5% Melanoma • 2% Sarcoma • 8% Others

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

  35. 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

  36. 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

More Related