ca cervix (combined)

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CARCINOMA CERVIX BY : SITI MUNIRAH KAMARUDIN NOR ELYA FARHANA BINTI ABDUL RAZAK

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Page 1: CA Cervix (Combined)

CARCINOMA CERVIXBY : SITI MUNIRAH KAMARUDINNOR ELYA FARHANA BINTI ABDUL RAZAK

Page 2: CA Cervix (Combined)

OUTLINE INTRODUCTION EPIDEMIOLOGY ETIOLOGY DIAGNOSIS CLASSIFICATION MANAGEMENT PREVENTION

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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

Page 4: CA Cervix (Combined)

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

Page 5: CA Cervix (Combined)

Risk factors Early intercourse(<16yrs) High parity Early age of pregnancy Too many/ too frequent pregnancy Multiple sexual partners OCPills Smoking Lower socioleconomic

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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

Page 7: CA Cervix (Combined)

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

Page 8: CA Cervix (Combined)

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

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DIAGNOSISSYMPTOMSEarly stage : watery , blood tinged p/v d/cirregular/continuos bleeding Offensive dischargeLower extremity edemaLow back painBladder, Rectal symptoms , Ureteral obstruction

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P/SLesion may appear as

Exophytic or endophytic growth Polypoid mass Papillary tissue Barrel shaped cx Ulceration

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invasive cervical cancer originating from the endocervix

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Bimanual examination may palpate

indurated, friable, bleeding to touch thick, hard , irregular rectovaginal septum

Rectal examinationParametria involvement

Feel thick, irregular, firm , less mobile

Page 13: CA Cervix (Combined)

FIGO Staging

• A clinical classification• According to:

– vaginal examination– rectal examination– cystoscopy

* FIGO – International Federation of Gynaecology and Obstetrics

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• Stage 0 - CIN III(CIS)

Page 15: CA Cervix (Combined)

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

Page 16: CA Cervix (Combined)

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

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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

Page 18: CA Cervix (Combined)

Stage IV – extend beyond true pelvis, involve bladder or rectum

IVa

Spread to adjacent organ

(bladder, rectum)

IVb

Spread to distant organ

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MANAGEMENTSURGICAL RADIOTHERAPY CHEMOTHERAPY

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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.

Page 21: CA Cervix (Combined)

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

Page 22: CA Cervix (Combined)

Palliative-Pain control

-radioRx - bleeding

Page 23: CA Cervix (Combined)

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

Page 24: CA Cervix (Combined)

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

Page 25: CA Cervix (Combined)

PREVENTION STRATEGIES

CERVICAL CYTOLOGY SCREENING

PROGRAMME

PROPHYLACTIC HPV VACCINE

Page 26: CA Cervix (Combined)

Methods of Screening

• Pap smear• Colposcopy

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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

Page 28: CA Cervix (Combined)

• 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%

Page 29: CA Cervix (Combined)

Speculum

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Insert Speculum

• Spread labia• Keep labia apart• Blades remain closed

until fully inserted

Page 31: CA Cervix (Combined)

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

Page 32: CA Cervix (Combined)

Ayre’s Spatula

Page 33: CA Cervix (Combined)

Sample Cervix

• Use concave end • Rotate 360 degrees• Don’t use too much force

(bleeding, pain)• Don’t use too little force

(inadequate sample)

Page 34: CA Cervix (Combined)
Page 35: CA Cervix (Combined)

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

Page 36: CA Cervix (Combined)

Cervical Intraepithelial Neoplasia

CIN I Mild dysplasiaCIN II Moderate displasia

Severe dysplasiaCIN III

Carcinoma in situ

Page 37: CA Cervix (Combined)

CIN I

Alterations are limited to the lower third of the cervical epithelium

Page 38: CA Cervix (Combined)

CIN II

The cell polarity is disturbed in the lower two thirds of the epithelium

Page 39: CA Cervix (Combined)

CIN III

Dyspolarity is present in more than two-third or all layers of the epithelium.

Page 40: CA Cervix (Combined)
Page 41: CA Cervix (Combined)

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%

Page 42: CA Cervix (Combined)

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)

Page 43: CA Cervix (Combined)

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

Page 44: CA Cervix (Combined)
Page 45: CA Cervix (Combined)

Colposcopy

• Technique of viewing cervix using binocular microscope with low magnification to determine the source of abnormal cells

• Indication: abnormal finding on Pap smear

Page 46: CA Cervix (Combined)
Page 47: CA Cervix (Combined)
Page 48: CA Cervix (Combined)

Procedure• Position patient in lithotomy position

1. LOOK• Using the speculum to visualize the cervix

Page 49: CA Cervix (Combined)

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

Page 50: CA Cervix (Combined)

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.

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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).

Page 52: CA Cervix (Combined)

3. BLOOD VESSEL PATTERN• Using the green filter to improve the ability to identify the vascular patterns (mosaic, punctation, atypical)

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VACCINES

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Star – 21st July 2009

Page 55: CA Cervix (Combined)
Page 56: CA Cervix (Combined)

Cumulative Incidence of Any HPV InfectionCumulative Incidence of Any HPV Infection

Page 57: CA Cervix (Combined)

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

Page 58: CA Cervix (Combined)

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

Page 59: CA Cervix (Combined)

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.

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Vaccine Available

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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.

Page 62: CA Cervix (Combined)

star– 21st July 2009

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THANK YOU

Page 64: CA Cervix (Combined)

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