Invasive Cervical Cancer. Kathleen M. Schmeler, MD Associate Professor Department of Gynecologic Oncology

Transcription

1 Invasive Cervical Cancer Kathleen M. Schmeler, MD Associate Professor Department of Gynecologic Oncology

2 Cervical Cancer Etiology Human Papilloma Virus (HPV): Detected in 99.7% of cervical cancers Cancer develops years following HPV infection HPV is necessary but not sufficient to develop cancer Requires persistent disease Cofactors: HIV, immunosupression, smoking Walboomers et al., J. Pathol, 1999

3 Cervical Cancer Risk Factors Persistent HPV infection is the cause of preinvasive cervical neoplasia and invasive cancer Other risk factors (indirect measures of HPV infection): Lower socioeconomic status More sexual partners Lower age at first intercourse

4 Cervical Cancer Prevention Primary Prevention: HPV Vaccination Secondary Prevention (Screening): Cytology (Pap test) HPV DNA testing Visual inspection with acetic acid (VIA)

5 Invasive Cervical Cancer

6 Presenting Symptoms Early Stage Disease: Frequently asymptomatic Vaginal discharge Abnormal bleeding Post-coital Irregular menses Postmenopausal bleeding Late Stage Disease: Pelvic/back pain Sciatica/leg swelling Weight loss Uremia Fistula: Rectovaginal Vesicovaginal

7 Histology Squamous (70-80%) Adenocarcinoma (20-25%) Other (~5%): Adenosquamous Glassy Cell Carcinoid Neuroendocrine Small-cell

8 Cervical Cancer Diagnosis Cytology (Pap) suspicion of cancer Colposcopy with biopsy is required to confirm If a visible lesion -> directly to biopsy If abnormal Pap/biopsies with no visible lesion -> cervical conization/leep is required Cone Biopsy LEEP (Loop Electro Excisional Procedure)

9 Local: Patterns of Spread cervical stroma, vagina, parametrium Lymphatic: pelvic -> common -> para-aortic Hematogenous: Liver, lung

10 Cancer Cervical Staging Internacional Federation of Ginecology and Obstetrics (FIGO) Clinical staging (not surgical): Physical exam, cone/leep, cystoscopy, proctoscopy Chest x-ray, Intravenous pyelogram (IVP) Allows use of the same staging system for low and high-resource areas

11

12 Cervical Cancer Survival FIGO Stage 5y Overall Survival IA1 98% IA2 95% IB1 89% IB2 76% IIA 73% IIB 66% IIIA 40% IIIB 42% IVA 22% IVB 9%

13 Cervical Cancer Treatment

14 Treatment Microinvasive (Stage IA1): Simple (extrafascial) hysterectomy/cone Early Stage (IA2 or IB1): Radical hysterectomy/trachelectomy vs. chemoradiation Locally Advanced (IB2-IVA) Primary chemoradiation (cisplatinum) Distant Metastases (IVB) Palliative care/systemic chemotherapy

15 Treatment of Early Stage Disease Stage IA1-IB1

16 Surgical Options Early Stage Cancer Cervical Stage IA1 Simple hysterectomy Cervical conization (preserve fertility) Stage IA2-IB1 Radical hysterectomy with lymphadenectomy Radical trachelectomy with lymphadenectomy (preserve fertility)

17 Simple vs. Radical Hysterectomy

18 Radical Trachelectomy Fertility Preservation

19 Early Stage Disease Summary Stage IA1: Simple hysterectomy or conization Stage IA2-IB1: Radical hysterectomy of trachelectomy Primary RT if poor surgical candidate Post-operative chemort if high-risk disease Post-operative RT if intermediate-risk disease (Sedlis criteria)

20 Locally Advanced Disease Stage IB2-IVA Treatment is radiation therapy with weekly chemotherapy (chemoradiation) * Neoadjuvant chemotherapy followed by surgery and/or chemoradiation is an option if radiation is not available

21 Primary Chemoradiation Radiotherapy: External beam Whole pelvis Extended field if positive paraaortic nodes Intracavitary (Brachytherapy) Tandem and ovoids

22 Primary Chemoradiation Adding weekly chemotherapy with cisplatin to primary radiation therapy decreases rate of death by 30-50% Has been confirmed in several randomized trials and a meta-analysis NCI clinical announcement in concurrent cisplatinum-based chemotherapy and RT are standard of care in the treatment of locally advanced cervix cancer

23 Locally Advanced Disease Summary: Stage IB2-IVA Primary chemoradiation is the treatment of choice Neoadjuvant chemotherapy followed by surgery and/or chemoradiation is an option if RT not available

24 Treatment of Recurrent and Metastatic Disease

25 Recurrent Disease Localized Recurrent Disease: Surgery for those with previous radiation Radiation for those with previous surgery When curative surgery or XRT not possible- PALLIATION is the goal Supportive care Chemotherapy Clinical trials

26 Pelvic Exenteration Indication: central recurrence in patient with previous radiation Cure rate of 30-50% Removal: Pelvic reproductive organs Rectum and anus Bladder and distal ureters Entire pelvic floor Ileal conduit, colostomy and VRAM flap

27 Cervical cancer is preventable: Effective vaccines Treatable pre-invasive disease Early stage disease: Surgery (radical hysterectomy, trachelectomy) Locally advanced disease: Chemoradiation Recurrent disease: Pelvic exenteration only curative option Metastatic disease: Palliative chemotherapy Summary

28 Thank You