Cervical and Vulvar Cancer in Early Stages: What Is the State-of-the-Art Treatment?

Cervical and Vulvar Cancer in Early Stages: What Is the State-of-the-Art Treatment?

Anastasios Liberis (2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece), Angelos Sioutas (BlueWhite Crossmed AB, Sweden & 2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece), Marius Moga (Clinic Department of Obstetrics and Gynecology, Faculty of Medicine, Transilvania University of Brasov, Romania) and Alexandros Daponte (Department of Obstetrics and Gynaecology, University of Thessaly, Larissa, Greece)
DOI: 10.4018/978-1-7998-4213-2.ch012

Abstract

Cervical and vulvar cancer represent two clinical entities whose diagnosis and management are often challenging. They are frequently diagnosed in the early stages, therefore leaving chances for optimal treatment and prognosis. The aim of this chapter is to answer two oncological issues concerning early stage cervical and vulvar cancer. First, is still room for surgical treatment for early stage cervical cancer or should we suggest chemoradiotherapy instead? Second, when is a limited surgical intervention sufficient for early stage vulvar cancer?
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Early Stage Cervical Cancer

Introduction

Cervical cancer is the third most common cancer that occurs in women after breast and colon cancer, with approximately 527,624 new cases and 265,653 deaths in 2012 (Ferlay, 2013). Concerning the five-year survival of European women with diagnosed cervical cancer, this was about 62% in 2000-2007 (Sant, 2015).

Cervix can be easily visualized and sampled or treated with little or no anesthesia. This has helped to better understand the natural history of cervical cancer along with the development of simple outpatient techniques of screening and prevention. The known factors that raise the risk of developing cervical cancer are human papilloma virus (HPV), low socio-economic status, smoking, marrying before the age of 18 years, young age at first sexual intercourse, multiple sexual partners, and multiple childbirths (Paul, 2011). Cervical cancer originates in the cells lining the cervix, mainly the lower part of the uterus known as the uterine cervix. There are mainly two types of cells covering the cervix, the glandular cells and the squamous cells which meet at a place called the transformation zone and this is the place where cervical cancer commonly originates. The location of the transformation zone changes with age. Normal cells become precancerous and subsequently turn cancerous and do not transform into cancer cells abruptly initially (American Cancer Society, 2015). Persistent infection with certain HPV types and especially with high-risk types has been documented as a causative factor for the development of cervical cancer (Walboomers, 1999). A study that evaluated the HPV infection in 10,575 histologically confirmed cases of invasive cancer from 38 countries in Asia, Europe, Latin America, Caribbean, North America, Oceania and Sub-Saharan Africa over a period of 60 years, found that 85% (8,977) of the cases were HPV DNA positive. HPV 16, 18 and 45 were the three most common types found in 61%, 10%, and 6% of the cases, respectively (de Sanjose, 2010).

The histopathologic types of cervical cancer are:

  • 1.

    Squamous cell carcinoma (keratinizing; non-keratinizing; papillary, bas-aloid, warty, verrucous, squamotransitional, lymphoepithelioma-like)

  • 2.

    Adenocarcinoma (endocervical; mucinous, villoglandular, endometrioid)

  • 3.

    Clear cell adenocarcinoma

  • 4.

    Serous carcinoma

  • 5.

    Adenosquamous carcinoma

  • 6.

    Glassy cell carcinoma

  • 7.

    Adenoid cystic carcinoma

  • 8.

    Adenoid basal carcinoma

  • 9.

    Small cell carcinoma

  • 10.

    Undifferentiated carcinoma (Bhalta, 2018)

Cervical cancer can be divided into three groups:

  • 1.

    Early Stage: Cervical carcinoma confined to the uterus. Tumors up to 4 cm. (FIGO IA-IB1).

  • 2.

    Local advanced Cervical Cancer (LACC), tumors that grow locally larger than 4 cm or with primary parametrial invation (FIGO stage IB2-IIB). and

  • 3.

    Advanced-stage cervical cancer, with tumors predominantly comprising pelvic structures or distant metastatic tumors (FIGO stage IIIA-IVB).

Although radiotherapy and radical surgery are equally effective for early stages, the latter strategy is generally accepted as a standard of care. On the other hand, concomitant chemoradiotherapy is used as first-line therapy for patients with advanced stage disease (FIGO stage IIIA-IVB) (Minig, 2014).

In general, the benefits of surgical treatment include: 1) the emotional satisfaction that the tumor has been removed, 2) the accuracy of the surgical staging, 3) the ability to maintain ovaries, 4) preventing the development of secondary endometrial cancer 5) complication that may occur are more easily treated . On the other hand, radiotherapy, in addition to being the treatment of choice for more advanced cancers, excels because it is applicable to most patients regardless of age or medical condition. In particular, patients with co-existing medical conditions who are not candidates for surgery can be successfully treated with radiotherapy or chemoradiotherapy (Photopulos, 1990).

In 1999, based on five randomized trials (RCTs), the National Cancer Institute recommends concomitant chemoradiotherapy rather than only radiatiotherapy for women with cervical cancer. This has led to the revision of the treatment of many women with cervical cancer (Keys, 1999; Morris, 1999; Peters, 2000; Rose, 1999; Whitney, 1999).

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