Janjira Petsuksiri, M.D

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Mervin Todd
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1 GYN malignancies Janjira Petsuksiri, M.D

2 Outlines Cervical cancer Endometrial cancer Ovarian cancer Vaginal cancer Vulva cancer 2

3 CA Cervix Epidemiology - Second most common female cancer Risk factors : - HPV 16, 18 - multiple partners, early sexual life, prior Hx of STD - smoking, low socioeconomic status Natural history and pattern of spread - severe dysplasia Cis Invasive carcinoma - Locoregional disease in the pelvis - Lymphatic spreading : paracervical, obturator, pelvic, iliac LNs - Risks of pelvic LNs : Stage IB 15%, IIB 25-30%, III B 50% - Others : Paraaortic LN, lung, SPC, bone 3

4 CA Cervix Clinical pres entations - Asymptomatic : PAP smear (VCE technique) - Symptomatic : Vaginal bleeding, abnormal vaginal discharge, pelvic pain : adjacent organs invasion --Bladder - hematuria, VV fistula --Rectum - bleeding per rectum, - RV fistula : compression -- obtructive uropathy 4 -- Deep vein thrombosis

5 CA Cervix Normal cervix Cervical cancer 5

6 CA Cervix Diagnostic work up : Clinical Staging - Hx, PE, PV, PR - Colposcopy, cervical biopsy - cystoscopy, proctoscopy - IVP, CT abdomen, CXR - Blood works : CBC, BUN, Cr., - PET scans 6

7 CA Cervix : Staging FIGO 2009 : Clinical s taging 7

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12 CA Cervix Pathology - SCC > 90% - AdenoCA 7-10% - Others Prognostic factors - staging, size of tumor - pathology : SCC better than AdenoCA 12

13 Stage Surgical treatments Radiation Cis Simple hysterectomy ( Conization) ICRT alone Stage IA1 Simple hysterectomy ICRT alone Stage IA2 Radical hysterectomy + Pelvic LN dissection (5%risk of LN involvement) ERT + ICRT Stage IB1 Radical hysterectomy + Pelvic LN dissection ERT + ICRT Stage IB2-IVA - ERT+ ICRT + concurrent chemotherapy Stage IVB Palliative chemotherapy and/or radiation therapy Postop ( High risks features : positive margins, deep stromal invasion, LVSI, tumor size> 4 cms) ERT + ICRT+ concurrent chemotherapy 13

14 Early stage cervical cancer Radical hysterectomy + LN dissection 14

position HDR : Ir 192 - LINAC 10 MV Dose

15 Locally advanced stage Concurrent Chemo Radiation ERT ICRT - AP/PA, supine position HDR : Ir LINAC 10 MV Dose : cgy x 4 F - WPRT 5000 cgy ( 200 cgy/ F) 15

16 External beam radiation therapy 16

17 CT Planning for Brachytherapy 17

18 CA Cervix Results : 5 yr survival Cis % Stage IA 90-95% Stage IB-II 70-80% Stage III 50-60% Stage IV 15-25% Side effects - Acute : Skin ( desquamation), GI ( N/V, diarrhea, proctitis), GU ( cystitis), BM suppression - Subacute - Late : Skin ( hyperpigmentation, telangiectasia), Subcutaneous tissue ( fibrosis), GU ( cystitis), GI ( bowel, rectum) 18 Femur (avascular necrosis)

19 Outlines Cervical cancer Endometrial cancer Ovarian cancer Vaginal cancer Vulva cancer 19

CA Endometrium Epidemiology - most common GYN cancer in western countries - incidence : peak in 50-70 y-o ( Postmenopausal)

20 CA Endometrium Epidemiology - most common GYN cancer in western countries - incidence : peak in y-o ( Postmenopausal) Risk factors - unopposed estrogen, tamoxifen - obesity, nulliparous, early menarche, late menopause(>52 y-o), - hypertension, DM 20

21 CA Endometrium Clinical pres entations - vaginal bleeding (Postmenopausal bleeding) (70-80%) - pelvic pain Diagnostic work up - Endometrial biopsy in post/peri menopausal bleeding (Diagnostic fractional curettage) - U/S, CT abdomen - tumor marker : CA 125 (60% sensitivity but not specific) 21

22 CA Endometrium Natural history - most : tumor confined in the uterus at the time of Dx - Direct extension : myometrium, cervix, vagina, parametrium, bladder, rectum - Lymphatic spreading : pelvic LN : PAN ( can be directly involved w/o pelvic LN metastases) - hematogenous spreading : uncommon 22

23 CA Endometrium Staging : FIGO : Surgical staging Surgery : TAH, BSO, : pelvic & PAN s ampling : peritoneal washing 23

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25 IA IB II IIIA IIIB FIGO 2009 IIIC IVA IVB 25

26 CA Endometrium Pathology - Endometrioid adenocarcinoma : most common (75-80%) Grading : I Well differentiated II Mod differentiated III Poorly differentiated - Others : Serous, Clear cell, Squamous : aggressive Prognostic factors - Clinical/Pathological staging (depth of myometrial invasion, lymph node involvement) - histology ( Endometrioid > Serous or clear cell), tumor grading, - presence of lymphovascular space invasion 26

27 CA Endometrium Treatment - Surgery : staging and treatment (TAH, BSO, pelvic & PAN sampling, peritoneal washing) - Adjuvant treatment : Radiation therapy - deep myometrial invasion, high grade histology - ERT (pelvic +/- P AN in s tag e IIIC) 5000 cgy + ICRT ( vaginal cuff RT) 500 c GY x 3F : Chemotherapy stage III, IV aggressive histology ( Clear cell, Serous carcinoma) Inoperable cases : ERT + ICRT!!! not comparable to Surgery + Postop RT 27

28 Radiation therapy for Endometrial cancer External beam RT - AP/PA, supine position ICRT (Intracavitary RT) HDR : Ir LINAC 10 MV - WPRT 5000 cgy ( 200 cgy/ F) 28

29 CA Endometrium Outcome : 5 yr survival - Stage I : 80-90% - Stage II: 50-85% - stage III : clinical 20-30% : pathological : 40-64% - Stage IV : 20-30% 29

30 Outlines Cervical cancer Endometrial cancer Ovarian cancer Vaginal cancer Vulva cancer 30

31 CA ovary Epidemiology : 4 th leading cause of death : worst prognosis : disease of older women ( y-o) : rarely seen in premenarche ( except ovarian germ cell tumor) Risk factors : nulliparous ( uninterrupted ovulatory cycles) : Oral contraceptive : protective effect : Hereditary syndrome : Lynch II, hereditary site specific ovarian cancer syndrome 31

32 CA ovary Clinical pres entation : Early stage : vague, adnexal mass : Advanced stage : pelvic/abdominal mass, pain, abdominal discomfort Diagnostic Work up : Hx & PE : U/S, CT abdomen, : Lab : CBC, BUN, Cr., : CA125 ( 80-85% sensitivity), CA 19-9(mucinous subtype), : b hcg & AFP ( germ cell tumors) 32

33 CA ovary Natural history : most common : Epithelial cancer : arise from ovarian surface epithelium : Others (10-15%) : primary germ cell ( pre menarche) : sex cord, stromal tumors : spreading : transcoelomic (peritoneal implant) : lymphatic (pelvic and PAN) : hematogenous spreading 33

34 CA ovary Staging : FIGO Require surgical staging : Tumor debulking, TAH, BSO, :peritoneal washing, peritoneal examination & samplings, omental biopsied :selective pelvic and PAN sampling Second look surgery ( Firstly inoperable) 34

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37 CA ovary : FIGO surgical staging Stage I IA IB IC Tumor limited to ovaries (one or both) Tumor limited to one ovary; capsule intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings* Tumor limited to both ovaries; capsules intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings.* Tumor limited to one or both ovaries with any of the following: capsule ruptured, tumor on ovarian surface, malignant cells in ascites, or peritoneal washings* Stage II IIA IIB IIC Tumor involves one or both ovaries with pelvic extension* Extension and/or implants on uterus and/or tube(s). No malignant cells in ascites or peritoneal washings. Extension to other pelvic tissues. No malignant cells in ascites or peritoneal washings. Pelvic extension (2a or 2b) with malignant cells in ascites or peritoneal washings Stage III IIIA IIIB IIIC Tumor involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis and/or regional lymph node metastasis Microscopic peritoneal metastasis beyond pelvis Macroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest dimension Peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node metastasis 37

38 CA Ovary Prognostic factors : - Tumor stage - volume of postoperative residual disease - tumor grade - overall 5 yr survival for stage I : 90%, II : 80% III : 15-20% IV < 5% 38

39 CA Ovary Treatment Surgery (Primary treatment) - surgical staging tumor debulking (cytoreductive surgery) Adjuvant treatment : chemotherapy **** (invade capsule, malignant ascites) : Radiation therapy :WART (no gross residual dz) : intraabdominal isotope(p32) : (22.5Gy/18F) Toxic!!!! - second look surgery 39

40 CA Ovary Roles of RT in ovarian cancer -- localized disease in the pelvis -- recurrent disease in the inguinal nodes Tumor directed RT -- rarely use of Whole abdominal RT 40

41 Outlines Cervical cancer Endometrial cancer Ovarian cancer Vaginal cancer Vulva cancer 41

42 CA Vagina Natural history - most : post wall of the upper third of the vagina - Lymphatics : upper vagina : pelvic LN : lower vagina : inguinofemoral LN Clinical pres entations - abnormal vaginal bleeding, discharge - dysuria, pelvic pain Diagnositic work up - Hx, PE, PV, PR - Tissue biopsy 42

43 CA Vagina Staging : FIGO clinical s taging Stage I Stage II IIA IIB : confined to vaginal mucosa : submucosal infiltration into parametrium, not extending out to pelvic wall : subvaginal infiltration, not into parametrium : Parametrial infiltration, not extending to pelvic wall Stage III : Tumor extend to pelvic wall Stage IV : Tumor extend to bladder or rectum 43

44 CA Vagina Pathology - Epithelial carcinoma : >90% ( 85% SCC, 5% AdenoCA) Treatment - Early stage (I) upper post wall of vagina Surgery - Locally advanced disease ERT + ICRT+ concurrent chemotherapy Radiation : Treat whole vagina ( Skip lesions) ERT 5000 cgy whole pelvis +/- Inguinal LN ICRT ( vaginal cylinders) 44

45 RT for CA Vagina 45

46 Outlines Cervical cancer Endometrial cancer Ovarian cancer Vaginal cancer Vulva cancer 46

47 CA Vu lva Natural history - Uncommon, elderly - Rich lymphatics : inguinofemoral LN - Hematogenous : rare - associated with HPV infection Clinical pres entations : - mass Diagnostic work up - Hx, PE, - Biopsy - CT pelvis : (Inguinal, pelvic LNs) 47

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49 CA Vu lva Treatment Early stage - radical vulvectomy + inguinal LN dissection ( uni/bilat) - adjuvant RT : positive margins, +LN Locally advanced - concurrent chemoradiation : organ preservation Prognostic factors : - depth of tumor invasion - LN involvement - margins 49

50 RT for CA Vulva 50

Staging and Treatment Update for Gynecologic Malignancies

Staging and Treatment Update for Gynecologic Malignancies Bunja Rungruang, MD Medical College of Georgia No disclosures 4 th most common new cases of cancer in women 5 th and 6 th leading cancer deaths