1/28

Ch. 31.Ch. 31.

Cervical and Vaginal CancerCervical and Vaginal Cancer

부산백병원 산부인과부산백병원 산부인과

R1 R1 손영실손영실

2/28

INDEX

# Special Considerations# Special Considerations1. Cervical Cancer during Pregnancy1. Cervical Cancer during Pregnancy

2. Others2. Others

# Recurrent Cervical # Recurrent Cervical CancerCancer1. Radiation Retreatment1. Radiation Retreatment

# Vaginal Carcinoma# Vaginal Carcinoma

2. Surgical Therapy2. Surgical Therapy

3/28

# Special Considerations# Special Considerations

4/28

• • The incidence of adenocarcinoma of the cervixThe incidence of adenocarcinoma of the cervix appears to be increasing relative to that of squamousappears to be increasing relative to that of squamous cancers.cancers.

• • 5% of all cervical cancers (in older report)5% of all cervical cancers (in older report) → → 18.5~27% of all cervical cancers (in newer report)18.5~27% of all cervical cancers (in newer report)

• • Adenocarcinoma has a poorer prognosis than forAdenocarcinoma has a poorer prognosis than for squamous cell carcinoma in every stage.squamous cell carcinoma in every stage. (by FIGO annual report)(by FIGO annual report)

• • Adenosquamous carcinoma has a poorer prognosisAdenosquamous carcinoma has a poorer prognosis than pure adenocarcinoma or squamous carcinoma.than pure adenocarcinoma or squamous carcinoma.

5/28

• • Diagnosis is often delayed during pregnancy,Diagnosis is often delayed during pregnancy,

because bleeding is attributed to pregnancy-because bleeding is attributed to pregnancy-relatedrelated

complications.complications.

• • Pap test should be performed on all pregnant Pap test should be performed on all pregnant patientspatients

at the initial prenatal visit, and any grossly at the initial prenatal visit, and any grossly suspicioussuspicious

lesions should be excised for biopsy.lesions should be excised for biopsy.

Cervical Cancer during Pregnancy

6/28

• • Less than 3mm of invasion and no lymphaticLess than 3mm of invasion and no lymphatic

involvementinvolvement

→ → may be followed to term and delivered vaginallymay be followed to term and delivered vaginally

→ → vaginal hysterectomy may be performed 6 weeksvaginal hysterectomy may be performed 6 weeks

postpartum (if further child is not desired)postpartum (if further child is not desired)

• • 3~5mm of invasion and lymph-vascular invasion3~5mm of invasion and lymph-vascular invasion

→ → also may be followed to term and delivered byalso may be followed to term and delivered by

cesarean sectioncesarean section

→ → followed immediately by modified radicalfollowed immediately by modified radical

hysterectomy and pelvic LN dissectionhysterectomy and pelvic LN dissection

Cervical Cancer during Pregnancy

7/28

• • More than 5mm invasionMore than 5mm invasion : Treatment depends on gestational age : Treatment depends on gestational age

and wish ofand wish of the patients.the patients. - After 28~32 weeks (75~90% survival - After 28~32 weeks (75~90% survival

rate),rate), recommended treatment is classic c/sec recommended treatment is classic c/sec

followedfollowed by radical hysterectomy with pelvic LN by radical hysterectomy with pelvic LN

dissection.dissection.

• • Stage Ⅱ to ⅣStage Ⅱ to Ⅳ - before GA 28 weeks : irradiation → - before GA 28 weeks : irradiation →

spontaneousspontaneous abortionabortion - after GA 28 weeks : delivered by classic - after GA 28 weeks : delivered by classic

cesareancesarean birth, followed a birth, followed a

radiotherapyradiotherapy

Cervical Cancer during Pregnancy

8/28

◎ ◎ Pyometra and HematometraPyometra and Hematometra • • An enlarged fluid-filled uterine cavity may beAn enlarged fluid-filled uterine cavity may be detected.detected. • • It should be drained, and given antibioticsIt should be drained, and given antibiotics (in pyometra)(in pyometra)

◎ ◎ Cervical Carcinoma after ExtrafascialCervical Carcinoma after Extrafascial HysterectomyHysterectomy - reoperation : involving a pelvic LN dissection,- reoperation : involving a pelvic LN dissection, radical excision of parametrial tissue,radical excision of parametrial tissue, cardinal ligaments, and vaginal stumpcardinal ligaments, and vaginal stump - radiotherapy- radiotherapy

Others

9/28

# Recurrent Cervical # Recurrent Cervical CancerCancer

10/28

- Treatment depends on the mode of primary - Treatment depends on the mode of primary therapytherapy

and the site.and the site.

• • patients who have been treated initially with patients who have been treated initially with surgerysurgery

→ → should be considered radiotherapyshould be considered radiotherapy

• • patients who have had radiotherapypatients who have had radiotherapy

→ → should be considered for surgeryshould be considered for surgery

• • patients who are not curable by other two patients who are not curable by other two modalitiesmodalities

→ → chemotherapychemotherapy

11/28

• • Radiotherapy can be palliative with localizedRadiotherapy can be palliative with localized

metastatic lesions.metastatic lesions.

Radiation Retreatment

painful bony metastasespainful bony metastases

CNS lesionCNS lesion

severe urologic orsevere urologic or vena caval obstructionsvena caval obstructions

→ → specificspecific

indicationindication

12/28

- Surgical therapy for postirradiation recurrence is- Surgical therapy for postirradiation recurrence is

limited to patients with central pelvic disease.limited to patients with central pelvic disease.

◎ ◎ ExenterationExenteration - extension of the tumor to the pelvic sidewall is a- extension of the tumor to the pelvic sidewall is a

contraindication to exenterationcontraindication to exenteration

- clinical triad of unilateral leg edema, sciatic pain,- clinical triad of unilateral leg edema, sciatic pain,

ureteral obstruction is nearly always pathognomonicureteral obstruction is nearly always pathognomonic

of unresectable disease on the pelvic sidewallof unresectable disease on the pelvic sidewall

Surgical Therapy

13/28

1. Anterior Exenteration1. Anterior Exenteration

• • removal of bladder, vagina, cervix, and uterusremoval of bladder, vagina, cervix, and uterus

• • patients whom disease is limited to the cervix andpatients whom disease is limited to the cervix and

anterior portion of upper vaginaanterior portion of upper vagina

2. Posterior Exenteration2. Posterior Exenteration

• • removal of rectum, vagina, cervix, and uterusremoval of rectum, vagina, cervix, and uterus

• • rarely performed for recurrent cervical cancerrarely performed for recurrent cervical cancer

Surgical Therapy

14/28

3. Total Exenteration3. Total Exenteration

• • removal of both bladder and rectum with the vagina,removal of both bladder and rectum with the vagina,

cervix, and uteruscervix, and uterus

• • indicated when the disease extends down to lowerindicated when the disease extends down to lower

part of vaginapart of vagina

• • It leaves the patients with permanent colostomyIt leaves the patients with permanent colostomy

as well as a urinary conduit.as well as a urinary conduit.

Surgical Therapy

15/28

a. In selected patients, it may take above levatora. In selected patients, it may take above levator

muscle, leaving rectal stump that may bemuscle, leaving rectal stump that may be

anastomosed to the sigmoid, thus avoiding aanastomosed to the sigmoid, thus avoiding a

permanent colostomy.permanent colostomy.

b. The technique to establish continent urinaryb. The technique to establish continent urinary

diversion has helped improve a physicaldiversion has helped improve a physical

appearance after exenteration.appearance after exenteration.

→ → The associated psychological trauma is avoided.The associated psychological trauma is avoided.

Surgical Therapy

16/28

# Vaginal Carcinoma# Vaginal Carcinoma

17/28

• • Relatively uncommon tumorRelatively uncommon tumor

• • Only 1% to 2% of malignancy of the female genitalOnly 1% to 2% of malignancy of the female genital

tracttract

- primary vaginal cancer- primary vaginal cancer

- metastatic cancer to the vagina- metastatic cancer to the vagina

18/28

• • In the FIGO stagingIn the FIGO staging - a tumor that has extended to the vagina from cervix- a tumor that has extended to the vagina from cervix → → regarded as a cancer of the cervixregarded as a cancer of the cervix - a tumor that involves both the vulva and the vagina- a tumor that involves both the vulva and the vagina → → classified as a cancer of the vulvaclassified as a cancer of the vulva

• • Vaginal cancer is rare and treatment is generallyVaginal cancer is rare and treatment is generally by radiotherapyby radiotherapy → → there is very little informationthere is very little information (depth of invasion, LN invasion, size of lesion)(depth of invasion, LN invasion, size of lesion) → → FIGO staging does not include a category forFIGO staging does not include a category for microinvasive diseasemicroinvasive disease

Staging

19/28

• • FIGO staging of Vaginal CancerFIGO staging of Vaginal Cancer

Staging

Stage 0 Carcinoma in situ, intraepithelia carcinoma.

Stage Ⅰ The carcinoma is limited to the vaginal wall.

Stage ⅡThe 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.

20/28

◎◎ EtiologyEtiology • • The cause of squamous cell carcinoma of the vaginaThe cause of squamous cell carcinoma of the vagina is unknown.is unknown. • • VAIN (vaginal intraepithelial neoplasia)VAIN (vaginal intraepithelial neoplasia) : premalignant phase of vaginal cancer: premalignant phase of vaginal cancer : similar to cervical cancer: similar to cervical cancer • • Any new vaginal carcinoma developing at leastAny new vaginal carcinoma developing at least 5 years after the cervical cancer should be5 years after the cervical cancer should be considered a new primary lesion.considered a new primary lesion.

◎ ◎ ScreeningScreening - routine screening of all patients is inappropriate.- routine screening of all patients is inappropriate.

Etiology & Screening

21/28

• • Painless vaginal bleeding and dischargePainless vaginal bleeding and discharge

: most common symptoms: most common symptoms

• • With advanced tumorsWith advanced tumors

→ → urinary retention, bladder spasm, hematuria,urinary retention, bladder spasm, hematuria,

frequency of urinationfrequency of urination

• • Tumors on the posterior vaginal wallTumors on the posterior vaginal wall

→ → produce rectal symptomsproduce rectal symptoms

(tenesmus, constipation, bloody stool)(tenesmus, constipation, bloody stool)

Symptoms

22/28

• • The diagnostic workupThe diagnostic workup

- complete history and physical exam, - complete history and physical exam, carefulcareful

speculum exam, palpation of vagina, speculum exam, palpation of vagina, bimanualbimanual

pelvic and rectal exampelvic and rectal exam

• • The upper one third of the vaginal posterior The upper one third of the vaginal posterior wallwall

: most common site, but may be overlooked: most common site, but may be overlooked

→ → important to rotate the speculum to important to rotate the speculum to obtainobtain

a careful view of the entire vaginaa careful view of the entire vagina

Diagnosis

23/28

• • Squamous cell carcinomaSquamous cell carcinoma

- most common form, 80%~90% of vaginal cancers- most common form, 80%~90% of vaginal cancers

- occur in the upper posterior wall of vagina- occur in the upper posterior wall of vagina

- mean age : 60 years- mean age : 60 years

• • Malignant melanomaMalignant melanoma

- 2nd most common cancer of vagina- 2nd most common cancer of vagina

- 2.8%~5% of vaginal neoplasms- 2.8%~5% of vaginal neoplasms

• • Others : adenocarcinoma, sarcomaOthers : adenocarcinoma, sarcoma

Pathology

24/28

• • Based on the clinical exam, CT scan, chest x-ray, age,Based on the clinical exam, CT scan, chest x-ray, age,

and condition of the patientand condition of the patient

• • Most are treated by radiation therapy.Most are treated by radiation therapy.

• • Surgery is limited to highly selective cases.Surgery is limited to highly selective cases.

- stage Ⅰ (on upper posterior vagina)- stage Ⅰ (on upper posterior vagina)

→ → radical vaginectomy and pelvic lymphadenectomyradical vaginectomy and pelvic lymphadenectomy

Treatment

25/28

• • Radiation therapyRadiation therapy

: treatment of choice: treatment of choice

- Small lesion : intracavitary radiation alone- Small lesion : intracavitary radiation alone

- Larger lesion : external teletherapy to decrease- Larger lesion : external teletherapy to decrease

tumor volume and to treat regionaltumor volume and to treat regional

pelvic nodes → followed bypelvic nodes → followed by

intracavitary and interstitial therapyintracavitary and interstitial therapy

to the primary tumorto the primary tumor

Treatment

26/28

• • The proximity of the rectum, bladder, and urethraThe proximity of the rectum, bladder, and urethra

leads to a major complicationleads to a major complication

→ → radiation cystitis, proctitis, rectal strictures orradiation cystitis, proctitis, rectal strictures or

ulcerationsulcerations

• • Necrosis of vagina, vaginal fibrosis, stenosis, stricturesNecrosis of vagina, vaginal fibrosis, stenosis, strictures

: use of vaginal dilators, topical estrogen to maintain: use of vaginal dilators, topical estrogen to maintain

adequate vaginal functionadequate vaginal function

Sequelae

27/28

• • Primary Vaginal Carcinoma : 5-year SurvivalPrimary Vaginal Carcinoma : 5-year Survival

Survival

Stage

No. of PatientsNo. Surviving 5

YearsPercentage

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

28/28

감사합니다감사합니다 ..