ca cervix (combined)
TRANSCRIPT
CARCINOMA CERVIXBY : SITI MUNIRAH KAMARUDINNOR ELYA FARHANA BINTI ABDUL RAZAK
OUTLINE INTRODUCTION EPIDEMIOLOGY ETIOLOGY DIAGNOSIS CLASSIFICATION MANAGEMENT PREVENTION
INTRODUCTION Cx ca is the most common gynecologic ca in women
Most of ca cx stem from infection with Human Papilloma Virus (HPV)
Dx : colposcopic examination and histologic evaluation of cervical biopsy
This ca is staged clinically the most important indicator of long term survival
Prevention lies mainly in early detection regular Pap smear screening
EPIDEMIOLOGY
1 million fresh cases/year across the globe
2nd commonest cancer in women (parkin 2005)
Incidence is decreasing in developed countries
Pap smear has reduced incidence by 80%& death by 70%
Most common CA in developing countries
Risk factors Early intercourse(<16yrs) High parity Early age of pregnancy Too many/ too frequent pregnancy Multiple sexual partners OCPills Smoking Lower socioleconomic
Pathogenesis Cx epithelium-> infection->hpv dna
integration to human genome-> up regulation of viral oncogenes-> expression of E6&E7 oncoproteins ->interference with tumor suppressor genes-> host cell immortalization, HPV induced euplastic transformation
HISTOPATHOLOGY Squamous cell carcinoma is the
commonest (80-90%) Well differentiated, moderately
differentiated, poorly differentiated Source- healing erosion, squamous
metaplasia of columnar epithelium, squamous cell rests in ectocx
HISTOPATHOLOGY Adenocarcinoma (10-15%) develops
from endocervical canal- from lining epithelium/glands
Occurs at young age 80% purely endocervical type Others- endometroid, clear,
adenosquamous, or mixed
DIAGNOSISSYMPTOMSEarly stage : watery , blood tinged p/v d/cirregular/continuos bleeding Offensive dischargeLower extremity edemaLow back painBladder, Rectal symptoms , Ureteral obstruction
P/SLesion may appear as
Exophytic or endophytic growth Polypoid mass Papillary tissue Barrel shaped cx Ulceration
invasive cervical cancer originating from the endocervix
Bimanual examination may palpate
indurated, friable, bleeding to touch thick, hard , irregular rectovaginal septum
Rectal examinationParametria involvement
Feel thick, irregular, firm , less mobile
FIGO Staging
• A clinical classification• According to:
– vaginal examination– rectal examination– cystoscopy
* FIGO – International Federation of Gynaecology and Obstetrics
• Stage 0 - CIN III(CIS)
Stage I – confined to the cervix
Ia - Microscopic
1a1 – Stromal invasion ≤ 3mm,
Width ≤ 7 mm
1a2 – stromal invasion 3 – 5 mm,
Width ≤ 7 mm
Ib – Macroscopic
1b1 – Lesion ≤ 4 cm
1b2 – Lesion > 4 cm
Stage II – extend beyond the cervix but not to the pelvic wall and lower third of the vagina
IIa
Extend to the upper two third of the vagina
IIb
Extend to the parametrium
Stage III – Extend to lower one third of vagina or pelvic wall
IIIa
Involvement of the lower one third of the vagina
IIIb
Involvement of the pelvic wall/ hydronephrosis or non-
functioning kidney
Stage IV – extend beyond true pelvis, involve bladder or rectum
IVa
Spread to adjacent organ
(bladder, rectum)
IVb
Spread to distant organ
MANAGEMENTSURGICAL RADIOTHERAPY CHEMOTHERAPY
Pre-invasive (Ca in situ, CIN III)
*** All women who have had CIN before should be followed up with annual smears for a minimum of 10 years.
Wertheim’s hysterectomy
Radical hysterectomy
Bilateral lymph node clearance+
Favoured in :
• Pre-menopausal women• Where the tumour is
small• When the future child bearing is not wished
Complications :• uriteric fistula or stricture
• bladder dysfunction• DVT and PE
Palliative-Pain control
-radioRx - bleeding
Prognosis
• Stage I - > 85%• Stage II – 50%• Stage III – 25%• Stage IV – 5%
• In patients with recurrent disease :– 50 % show recurrence within 1 year– 75% show recurrence within 2 years– 90% show recurrence in 5 years
STAGE SPREAD TREATMENT PROGNOSIS (5-year survival %)
I a
I b
II a
II b
III
IV
Cervix (micro-invasive)
Cervix (macro-invasive)
2/3rd upper vagina
Parametrium
1/3rd lower vagina, pelvic walls
Bladder, rectum or metastases
Local excision
Radical surgery
Radical surgery
Radiotherapy
Radiotherapy
Palliation
100
80
60
50
30
10
PREVENTION STRATEGIES
CERVICAL CYTOLOGY SCREENING
PROGRAMME
PROPHYLACTIC HPV VACCINE
Methods of Screening
• Pap smear• Colposcopy
How to take?
• Explain to the patient/consent• Not during menstruation• The best time is on D10 - D20• Avoid douching, using spermicidal gel.• Avoid sex 24 hours prior to the procedure
• Patient in dorsal/lithotomy position • using the Cusco’s bivalve speculum to visualize
the cervix • Place the wooden spatula (Ayre’s spatula) on
the cervix and rotate 360° clockwise and make sure cover all the transformation zone
• Immediately smear it on the glass slide • Fix the slide with fixative agent either spray or
ethanol 95%
Speculum
Insert Speculum
• Spread labia• Keep labia apart• Blades remain closed
until fully inserted
Squamo-Columnar Junction
• Junction of pink cervical skin and red endocervical canal
• Inherently unstable • Key portion of the cervix
to sample• Most likely site of
dysplasia
Ayre’s Spatula
Sample Cervix
• Use concave end • Rotate 360 degrees• Don’t use too much force
(bleeding, pain)• Don’t use too little force
(inadequate sample)
How to interpret?
• Dyskaryosis - abnormal nucleus of individual the cell.
• Dysplasia - abnormality in organised growth of the cell.
• CIN – refers to a lesion in epithelium of the cervix
• New technique – Bethesda system
Cervical Intraepithelial Neoplasia
CIN I Mild dysplasiaCIN II Moderate displasia
Severe dysplasiaCIN III
Carcinoma in situ
CIN I
Alterations are limited to the lower third of the cervical epithelium
CIN II
The cell polarity is disturbed in the lower two thirds of the epithelium
CIN III
Dyspolarity is present in more than two-third or all layers of the epithelium.
Natural history of CIN 1-2
**(100 prospective studies)
STAGE/PROGRESS Regress Persist CIN III Cancer
CIN I 57% 32% 11% 1%
CIN II 43% 35% 22% 5%
Bethesda System
• Specimen adequacy– Satisfactory for evaluation– Unsatisfactory for evaluation …… (specify reason)– Specimen rejected/not processed …(specify
reason)– Specimen processed and examined but
unsatisfactory for evaluation … (specify reason)
When to start?• Within 3 years of 1st coitus or by age 21How frequent• Every two years provided the last smear is
normalWhen to stop?• No limit
Colposcopy
• Technique of viewing cervix using binocular microscope with low magnification to determine the source of abnormal cells
• Indication: abnormal finding on Pap smear
Procedure• Position patient in lithotomy position
1. LOOK• Using the speculum to visualize the cervix
2. ACETIC ACID• Apply 3-5% acetic acid for at least 60sec prior to
inspecting for changes• Acetic acid dissolves mucous and accentuates
atypical areas (white epithelium, punctation, mosaic and atypical vessels) by causing cellular dehydration and coagulation of cellular protein.
• The effect of the acetic acid peaks in ~ 2 min and fades in ~ 5 min. Re-apply the acetic acid solution several times.
• Biopsy the acetowhite epithelium
A. Benign surface vessels viewed through a colposcope using usual white light source.
B. Use of a blue-green (red-free) light filter provides higher contrast and definition of vascular patterns.
A. Cervix after application of acetic acid. Several areas of acetowhite change adjacent to the squamocolumnar junction are apparent.
B. Same cervix after application of Lugol iodine solution. Non-staining of the lesions at the 10 to 11 o'clock positions is seen (black arrow) while there is partial iodine uptake of acetowhite areas along the posterior SCJ (white arrow).
3. BLOOD VESSEL PATTERN• Using the green filter to improve the ability to identify the vascular patterns (mosaic, punctation, atypical)
VACCINES
Star – 21st July 2009
Cumulative Incidence of Any HPV InfectionCumulative Incidence of Any HPV Infection
What is HPV ?• HPV is short for human
papillomavirus
• HPVs are a groups of over 100 related viruses
• Each HPV virus in the group is given a number, which is called an HPV type.
American Cancer Society, Inc 2008
Human Papillomavirus Types and Disease Association
nonmucosal/cutaneous(~60 types)
skin warts (hands and
feet)
mucosal/genital(~40 types)
high-risk types16, 18, 31, 45 low-risk types
6, 11
•low grade cervical abnormalities
•cancer precursors•genital cancers
•low grade cervical abnormalities•genital warts
•laryngeal papillomas
How is HPV related to cervical cancer?
53.5
2.3
2.2
1.4
1.3
1.21.0
0.7
0.6
0.50.3
1.24.4
2.6
17.2
6.7
2.9
0 10 20 30 40 50 60 70 80 90 100
XOther
827368395156593558523331451816
Almost all (more than 99 %) cervical cancers are related to HPV. Almost all (more than 99 %) cervical cancers are related to HPV. Of these, about 70% are caused by HPV types 16 or 18.Of these, about 70% are caused by HPV types 16 or 18.
American Cancer Society, Inc 2008American Cancer Society, Inc 2008
Muñoz N et al. Int J Cancer 2004; 111: 278–85.
Vaccine Available
When, Why, HowWHEN can you prescribe CervarixTM?
• Prescribe now for girls and women, as they remain at riskof infection from oncogenic HPV throughout their lives.
WHY prescribe CervarixTM?CervarixTM, with its novel adjuvant AS04, provides strong and
sustained protection against cervical cancer.1,3,4,25-32Induces antibody levels that start high and stay high for both HPV 16/18.
HOW do you administer CervarixTM?Give 3 doses of CervarixTM at 0, 1, 6 months.
Vaccination is by intramuscular injection into the deltoid area.
star– 21st July 2009
THANK YOU
Referrence• Gynaecology companion, Dr Mohd Azhar Mohd Noor• Clinical Practice Guidelines (CPG), Management of Cervical Ca 2003• Gynaecology by Ten Teachers, 18th edition• Quick Management Guide in Gynaecology, Lee Say Fatt, UM 2008