Cancer of the Uterine Corpus and Cervix David Toub, M.D. Medical Director Newton Interactive

ACS Statistics, 1992: Incidence corpus32,000 ovary21,000 cervix13,500 other4500 Mortality440013,

Risk Factors: Cervix u HPV, HPV, HPV... u Smoking u Immunosuppression u ?low beta-carotene intake Corpus u Hyperestrogenism u Nulliparity u Hypothyroidism u Obesity u Diabetes u Atypical Hyperplasia

Histopathology Cervix u Squamous Cell (85%) u Adenocarcinoma u Clear Cell u Mesonephric Corpus u Endometrioid AdenoCA(80%) u Papillary Serous AdenoCA u Clear Cell AdenoCA u Squamous Cell u Sarcomas (LMS,ESS,MMMT)

Staging: CervixClinicalCorpusSurgical

Cervical CA Staging: 0:Carcinoma-in-situ Ia:Microinvasive (Ia 1, Ia 2 ) Ib:Invasive (>5mm FIGO, >3mm SGO) IIa:Upper 2/3 of vagina IIb:Parametrial involvement (not to PSW) IIIa:Lower 1/3 of vagina IIIb:PSW or hydronephrosis/nonfunctional kidney IVa:Bladder or rectal mucosa IVb:Distant metastases

Cervical CA Staging Techniques: u Pelvic exam u CXR u SMA-7 u Cystoscopy u Proctoscopy u IVP  Not allowed: MRI, CT, lymphangiography, surgical findings

Preinvasive Lesions: Cervix u SIL (W/U by colposcopy) u Tx: CO 2 Laser, LEEP,Cryosurgery Corpus u Atypical Hyperplasia (W/U by EMBx, D+C/hyst s ) u Tx: Progestins, hysterectomy,?GnRH-a

Treatment of Cervical Cancer: u All stages: Radiation, but... u Microinvasive CA: Simple TAH, ?cone u Stage Ib,(some IIa), <45 yo: prefer rad hyst/LND u Bulky tumor > 3 cm RT (+/- chemo) u Recurrent dz:s/p RTExenteration s/p surgeryRT u Chemotx plays role as adjunct to RT or for palliation

Wake Up Slide

Radical Hysterectomy: u Removes corpus, cervix, parametria, upper third of vagina u Uterine arteries divided at origin u Ureters dissected through tunnel u Uterosacral ligaments divided near rectum u Typically combined with LND u Oophorectomy not mandated

Complications of Radical Hysterectomy/LND: u Bladder/rectal dysfunction u Lymphocyst/lymphedema u Urethral strictures u Ureterovaginal fistula

Complications of Radiation Tx: Acute: u Perforation u Fever u Diarrhea u Bladder spasm u Chronic: u Proctitis u Cystitis (a/w UTI) u Fistula u Enteritis

Five-Year Survival: Cervix from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988

Endometrial CA Staging: IaLimited to endometrium Ib<1/2 myometrial thickness Ic>1/2 myometrial thickness IIaCervical glandular involvement IIbCervical stromal involvement IIIaUterine serosa, positive washings, or adnexal involvement IIIbVaginal metastases IIIcPositive lymph nodes IVaBladder or bowel mucosa IVbDistant metastases (Add tumor grade to each stage)

Treatment of Endometrial Adenocarcinoma: u Surgical staging in majority of patients (Extrafascial TAH/BSO, washings, +/- LND) u No adjuvant RT if Ia, G1-2 (?Ib 1-2) with favorable histology u Adjuvant RT for high-risk pts u Progestins not useful for primary dz u Chemo does not appear to be helpful

High-Risk Patients: u Deep myometrial invasion u Positive nodes u Grade 3 tumor u Clear cell, papillary serous, squamous or undifferentiated histologies u Positive peritoneal cytology u Other extra-uterine spread

Primary Treatment of Uterine Sarcoma: u Surgical staging u Single-agent chemotx, depending on histology and stage (ADR for LMS, ESS; IFX for MMMT) u RT does not appear to alter survival

“Many physicians are discouraged with the results of cancer therapy. However, the opportunity is there for all physicians to make an early diagnosis in all the gynecologic cancers except those in thee tube and ovary. Stage for stage, little progress has been made in lowering mortality rates, but the overall mortality rate is decreasing because more patients are having their cancers diagnosed in early states of disease. This achievement is to the everlasting credit of the practicing doctors who have, by training and motivation, been successful in establishing early diagnosis as a protection for the women of the United States. Those women saved from the ravages of cancer shall call their physicians blessed.” Barber, 1980