Gynecologic Oncology Overview Staging updates and Soap Box Issues Andrew. Green, M.D. Gynecologic Oncology Northeast Georgia Physician s Group Gainesville, GA 1 Overview 1) Review recent changes to FIGO/TNM staging of Gynecologic Cancers 1) Cervical 2) Uterine 3) Ovarian 4) Vulvar 2) Review upcoming quality measures that will be tracked in Gynecologic Oncology 3) Soap Box issues (I can because you handed me the mic.) Cervical Cancer Cervical cancer staging has remained relatively constant and low tech. This is because the majority of these cases occur in low resource regions CT, PT, etc are very limited. This is why nodal status is not in the FIGO staging system. In many regions, women rarely have access to surgery. Staging is limited to physical exam, basic radiology (chest x ray, IVP) 1
Cervical Cancer 1A1 Microscopic disease. Measured stromal invasion 3.0 mm in depth and 7.0 mm in horizontal spread 1A2 Microscopic disease. Measured stromal invasion > 3.0 mm and 5.0 mm with a horizontal spread 7.0 mm 1B all visible lesions. No matter the size. 1B1 Measured stromal invasion > 3.0 mm and 5.0 mm with a horizontal spread 7.0 mm 1B2 Clinically visible lesion > 4.0 cm in greatest dimension Stage 2 Cervical cancer Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina 2A1 Clinically visible lesion 4.0 cm in greatest dimension 2A2 Clinically visible lesion > 4.0 cm in greatest dimension 2B Tumor with parametrial invasion 2
Stage 3 Cervical cancer Tumor extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or nonfunctional kidney 3A Tumor involves lower third of vagina, no extension to pelvic wall 3B Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctional kidney Stage 4 cervical cancer Tumor invades mucosa of bladder or rectum and/or extends beyond true pelvis (bullous edema is not sufficient to classify a tumor as T4) 4A Tumor invades mucosa of bladder or rectum (bullous edema is not sufficient to classify a tumor as T4) 4B Tumor extends beyond true pelvis ndometrial Cancer Stage 1A no invasion or invades <50% of the wall of the uterus. Stage 1B invades > 50% of the uterine wall 3
ndometrial Cancer Stage 2 invasive into the cervix ndometrial Cancer 3A Spread to ovary or tube 3B Vaginal or parametrial invasion 3C1 spread to pelvic nodes 3C2 spread to aortic nodes ndometrial Cancer Stage 4 A invasion of Bowel or Blader mucosa Stage 4B distant mets including intraabdominal, and inguinal lymph nodes 4
Ovarian Cancer Ovarian Cancer Ovarian Cancer Stage 3 disease outside of pelvis 3A microscopic disease in upper abdomen 3C Nodes or > 2 cm in the upper abdomen 3B 2 cm in the upper abdomen 5
Ovary Stage 4 disease in liver or above the diaphragm HPV what is it? Double stranded DNA virus HPV DNA found in > 99% of cervical cancers HPV derived oncogenes appear to be critical to the process of malignant transformation Due to how the DNA inserts into your DNA in your cells HPV 6
6 and 7 have a much higher binding affinity De regulate the host cell cycle No G0 arrest.cells re enter S phase Facilitates cell replication in a cell that should have exited the cell cycle Cell immortalization Genomic Instability Cell Transformation 6 and 7 Act as viral oncoproteins 6 binds the p53 tumor suprressor protein, leading to rapid degradation 7 binds to the retinoblastoma family of tumor suppressors and inactivates them De regulate host cell cycle No G1 arrest.cells enter S phase No apoptosis if DNA damage occurs Suboptimal DNA repair, genomic instability Facilitates viral replication in a terminally differentiated cell that has exited the cell cycle In high risk viral subtypes, 6 and 7 have a particularly high affinity for these proteins 7
7 oncoprotein: -binds and inactivates the retinoblastoma tumor suppressor protein and blocks its inhibitory role in the cell cycle 6 oncoprotein: -binds and inactivates the p53 tumor suppressor protein and blocks its inhibitory role in the cell cycle Pap smear screening: An ffective screening program All countries implementing pap smear screening programs have reduced mortality Success is proportional to intensity of screening efforts Unfortunately, difficult for poor countries to implement 8
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Cervix Cancer Best treatment is not to get it Pap smear one of biggest risk factors for cervix cancer is no recent (>7 years) pap smear HPV vaccine Holy Grail of cancer treatment Prevention HPV Vaccine What if I could give you 3 shots over 6 months that would 1) prevent (or dramatically decrease) at least 3 types of cancer 2) May decrease your heart attack risk by 15% or more * remember, your number one risk of death * 3) would decrease the number of times you had to see your GYN Cervical Cancer Prevention & HPV Vaccines 11
xtremely effective: Risk for persistent HPV 16 infection: Placebo group: 41 cases of persistent HPV 16 9 cases of HPV 16 related CIN Treatment group: NO cases of persistent HPV 16 NO cases of HPV 16 related abnormal pap smears Unfortuate controversies. Some consumer groups have taken issue with social stigma of the vaccine What age to vaccinate? Parental consent It is not as effective in previously exposed people Vaccines for males? New data in Head and neck cancers, anal cancers, and most importantly, heart attack Why not vaccinate everyone? We should, and are trying HPV Vaccine This is not an STD Vaccine!!!!! HPV is transmitted sexually but is also in the environment. This is a CANCR vaccine end of story. BTW it may decrease heart attacks too. Need to talk about this in the correct context 12
HPV Vaccine Unfortunately, it is not being discussed adequately, here or around the country ASK!!!! Guidelines 9 25 Male or Female It is ok to get with other shots Cervix/HPV summary asily preventable cancer Vaccine dramatically improves prevention ducation on this topic is key YOU are key 13