The Management of

Cervical , Vulvar and

Vaginal Cancers
Kerry J. Rodabaugh, M.D.
Division of Gynecologic Oncology
University of Nebraska Medical Center

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: Chile, Costa Rica,

Mexico

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,

nd

Vaginal Carcinoma

Squamous Cell
Clear Cell
Sarcoma
Melanoma

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