The Management of

Cervical , Vulvar and

Vaginal Cancers

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

United States Incidence

15,000 women diagnosed annually
4,800 annual deaths

Mortality Rates
<2/100,000:

Finland, France, Greece,

Israel, Japan, Korea, Spain, Thailand

2.7/100,000:

USA

12-15.9/100,000:

Mexico

Chile, Costa Rica,

Lifetime risk of developing

cervical cancer
5% - South America
0.7% - USA

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

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

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.

Clinical Presentation
CIN/CIS/ACIS

asymptomatic
Irregular vaginal bleeding
Vaginal discharge
Pelvic pain
Leg edema
Bowel/bladder symptoms

Physical Findings
Exophytic,

cauliflower like mass

Cervical ulcer, friable or necrotic
Firm barrel-shaped cervix
Hydronephrosis
Anemia
Weight

loss

Histology
Squamous
85-90%
Adenocarcinoma
10-15%
Lymphoma
Neuroendocrine/small cell
Melanoma

Route of Spread
Cervical cancer spreads by direct
invasion or by lymphatic spread
Vascular spread is rare

Staging
Physical

exam
Cervical biopsies
Chest x-ray
IVP (Ct scan)
Barium enema, cystoscopy,
proctoscopy
Surgical staging

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

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

5 year survival rates

Stage IA
Stage IB
Stage II
Stage III
Stage IV

90-100%
70-90%
50-60%
30-40%
5%

Therapy
Cervical conization
Simple hysterectomy
Radical hysterectomy
Radiation therapy with
chemosensitization

5 year Survival
Stage

I
Stage II
Stage III
Stage IV

70%
51%
33%
17%

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

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

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

Recurrent Cervical Cancer

Radiation
Pelvic exenteration
Palliative chemotherapy

Vulvar Cancer
3870

new cases 2005

870 deaths
Approximately 5% of Gynecologic
Cancers

American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

Vulvar Cancer
85%

Squamous Cell Carcinoma

5% Melanoma
2% Sarcoma
8% Others

Vulvar Cancer
Biphasic

Distribution
Average Age 70 years
20% in patients UNDER 40 and appears to
be increasing

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

Vulvar Cancer
Pagets

Disease of Vulva

10% will be invasive

4-8% association with underlying
Adenocarcinoma of the vulva

Symptoms
Most

patients are treated for other

conditions
12 month or greater time from symptoms to
diagnosis

Symptoms

Pruritus
Mass
Pain
Bleeding
Ulceration
Dysuria
Discharge
Groin Mass

Symptoms
May

look like:

Raised
Erythematous
Ulcerated
Condylomatous
Nodular

Vulvar Cancer
IF

IT LOOKS ABNORMAL ON THE VULVA

BIOPSY!
BIOPSY!
BIOPSY!

Tumor Spread
Very

Specific nodal spread pattern

Direct Spread
Hematogenous

Staging
Based

on TNM Surgical Staging

Tumor size
Node Status
Metastatic Disease

Staging
Stage

I T1 N0 M0

Tumor 2cm

IA
IB

1 mm depth of Invasion
1 mm or more depth of invasion

Staging
Stage

II T2 N0 M0

Tumor >2 cm
Confined to Vulva or Perineum

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

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

Staging
Stage

IVB

Any T Any N M1

Any distal mets including pelvic nodes

Treatment
Primarily

Surgical

Wide Local Excision

Radical Excision
Radical Vulvectomy with Inguinal Node Dissection

Unilateral
Bilateral
Possible Node Mapping, still investigational

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

Treatment
Special

Tumor

Verrucous Carcinoma

Indolent tumor with local disease, rare mets UNLESS

given radiation, becomes Highly malignant and
aggressive
Excision or Vulvectomy ONLY

Vulva 5 year survival

Stage

I
Stage II
Stage III
Stage IV

90
77
51
18

Hacker and Berek, Practical Gynecologic Oncology

4th Edition, 2005

Recurrence
Local

Recurrence in Vulva

Reexcision or radiation and good prognosis if not

in original site of tumor
Poor prognosis if in original site

Recurrence
Distal

or Metastatic

Very poor prognosis, active agents include

Cisplatin, mitomycin C, bleomycin, methotrexate
and cyclophosphamide

Melanoma
5%

of Vulvar Cancers
Not UV related
Commonly periclitoral or labia minora

Melanoma
Microstaged

by one of 3 criteria

Clarks Level
Chungs Level
Breslow

Melanoma Treatment
Wide

local or Wide Radical excision with

bilateral groin dissection
Interferon Alpha 2-b

Vaginal Carcinoma
2140

new cases projected 2005

810 deaths projected 2005
Represents 2-3% of Pelvic Cancers

American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

Vaginal Cancer
84%

of cancers in vaginal area are

secondary

Cervical
Uterine
Colorectal
Ovary
Vagina

Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva,

Vaginal Carcinoma
Squamous
Clear

Cell
Sarcoma
Melanoma

Cell

80-85%
10%
3-4%
2-3%

Clear Cell Carcinoma

Associated

with DES Exposure In Utero

DES used as anti abortifcant from 1949-1971

500+ cases confirmed by DES Registry
Usually occurred late teens

Vaginal Cancer Etiology

Mimics

Cervical Carcinoma

HPV 16 and 18

Staging
Stage

I
Stage II

Confined to Vaginal Wall

Subvaginal tissue but not
to pelvic sidewall
Stage III Extended to pelvic
sidewall
Stage IVA
Bowel or Bladder
Stage IVB
Distant mets

Treatment
Surgery

with Radical Hysterectomy and

pelvic lymph dissection in selected stage I
tumors high in Vagina
All others treated with radiation with
chemosensitization