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

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

# Special Considerations

• 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.

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.

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

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

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

# Recurrent Cervical Cancer

- 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

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

Surgical Therapy ◎ Exenteration - 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

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

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.

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.

# Vaginal Carcinoma

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

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

Staging • FIGO staging of Vaginal Cancer Stage 0 Carcinoma in situ, intraepithelia carcinoma. Stage Ⅰ The carcinoma is limited to the vaginal wall. Stage Ⅱ The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall. Stage Ⅲ The carcinoma has extended to the pelvic wall. Stage Ⅳ The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. Stage Ⅳa Spread of the growth to adjacent organs. Stage Ⅳb Spread to distant organs.

Etiology & Screening ◎ Etiology ◎ Screening • 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.

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)

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

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

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

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

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

Survival • Primary Vaginal Carcinoma : 5-year Survival Stage No. of Patients No. Surviving 5 Years Percentage Ⅰ 172 118 68.6 Ⅱ 236 108 45.8 Ⅲ 203 62 30.5 Ⅳ 114 20 17.5 Total 725 308 42.5

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