Download primary vaginal cancer

Ch. 31.
Cervical and Vaginal Cancer
부산백병원 산부인과
R1 손영실
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INDEX
# Special Considerations
1. Cervical Cancer during Pregnancy
2. Others
# Recurrent Cervical Cancer
1. Radiation Retreatment
2. Surgical Therapy
# Vaginal Carcinoma
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# Special Considerations
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• 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.
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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.
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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
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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
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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
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# Recurrent Cervical Cancer
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- 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
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Radiation Retreatment
• Radiotherapy can be palliative with localized
metastatic lesions.
painful bony metastases
CNS lesion
severe urologic or
vena caval obstructions
→ specific
indication
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Surgical Therapy
- 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
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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
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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.
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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.
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# Vaginal Carcinoma
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• Relatively uncommon tumor
• Only 1% to 2% of malignancy of the female genital
tract
- primary vaginal cancer
- metastatic cancer to the vagina
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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
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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.
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Etiology & Screening
◎ Etiology
• 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.
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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)
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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
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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
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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
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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
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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
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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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감사합니다.
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