Download - Carcinoma cervix
CARCINOMA CERVIX
AETIOLOGY
• Human Papilloma Virus(HPV)• High risk- types 16, 18, 31, 33• Low risk- types 6 and 11• HPV viral proteins interact with the tumour
suppressor gene p53
RISK FACTORS
• Young age at first intercourse• Multiple sexual partners• Cigarette smoking (both active and passive)• Increasing parity• Low socioeconomic status• Sexually transmitted diseases• Immunosuppression- HIV, autoimmune diseases
etc.• Oral contraceptive use
PREVENTION
• Safe sexual practices• Regular Pap smears- early detection• HPV vaccine
DOWNSTAGING
• Detection of cancer cervix at an earlier stage by nurses and other health workers using simple speculum and visual inspection of the cervix
HISTOLOGIC TYPES• Squamous cell carcinoma Large cell keratinizing tumours Large cell non- keratinizing tumours Small cell tumours• Adenocarcinoma Adenoma malignum Villoglandular papillary adenocarcinoma Clear cell carcinoma• Adenosquamous carcinoma• Neuroendocrine tumours• Sarcomas• Malignant melanoma
PATTERNS OF SPREAD
• Direct invasion- cervical stroma, parametrium, body of uterus, vagina, anteriorly to the bladder and posteriorly to the rectum and bowel
• Lymphatic spread- pelvic nodes and paraaortic nodes
• Haematogenous spread- lungs, bones and liver
SYMPTOMS
• Vaginal bleeding• Vaginal discharge• Pain• Asymptomatic• Advanced cases- weight loss, obstructive
uropathy
SIGNS
• General examination
Lymphadenopathy (supraclavicular and inguinal)
Cachexia and anaemia in advanced cases
Oedema of legs• Abdominal examination
Hepatomegaly
Ascites
• Speculum examination Cauliflower like growth Barrel- shaped cervix Ulcer Vaginal involvement• Bimanual examination Classic signs of malignancy- friability, induration,
bleeding on touch and fixity due to parametrial spread Enlarged uterus due to tumour invasion or a pyometra• Rectovaginal or rectal examination Induration laterally denoting parametrial spread Fixed mass indicates that the tumour has extended to
the pelvic side walls Thick rectovaginal septum Rectal mucosal involvement
INVESTIGATIONS• Colposcopy Abnormal blood vessels Irregular surface contour Change in colour tone• Examination under anaesthesia to assess parametrial
spread• Barium enema, proctoscopy and sigmoidoscopy if rectal
spread is suspected• Cystoscopy in locally advanced disease• Intravenous pyelogram• Chest X ray• Skeletal X rays if bone spread is suspected
MANGEMENTStage Management
1a1 Cone biopsy or Type 1 simple hysterectomy
1a2 Type 11 (modified radical) hysterectomy and pelvic lymphadenectomy
1b1 Type 111 (radical) hysterectomy and pelvic lymphadenectomy
1b2 and 11a Primary chemoradiation or type 111 (radical) hysterectomy with pelvic and para- aortic lymphadenectomy (former preferred)
11b onwards Primary chemoradiation (primary exenteration in some 1V a)
RADICAL HYSTERECTOMY
Type 3 radical hysterectomy• Pelvic lymphadenectomy (common iliac, external
iliac, internal iliac and obturator nodes)• Removal of uterosacral and cardinal ligaments and
thereby most of the parametrium• Removal of the uterus, cervix and upper one- third
of vagina
Advantages over Radiotherapy
• Ovaries can be conserved• Ovarian transposition can be done at surgery to
prevent ovarian destruction by subsequent radiation
• Vaginal shortening is less than following radiotherapy
• Avoidance of the chronic bowel and bladder problems of radiotherapy
• Surgical complications are easier to treat• Avoids the risk of radiation- induced malignancies
Complications
Immediate• Haemorrhage• Injury to ureter, blader or
bowel• Pulmonary embolism
Delayed• Bladder atony due to
denervation of bladder• Small intestinal
obstruction• Vesicovaginal fistulae
(1%)• Ureterovaginal fistulae
due to avascular necrosis or ureteral injury (1-2%)
• Lymphocyst formation
ADJUVANT THERAPY
Intermediate risk factors
• Size of lesion more than 2 cm
• Cervical stroma invasion to middle or deep third
• Lymphovascular space invasion
High risk factors• Margins positive for
tumour• Positive lymph nodes• Microscopic
parametrial involvement
PRIMARY RADIOTHERAPY
• Brachytherapy• External beam or teletherapy
Complications
Immediate• Perforation during
insertion of uterine tube
• Diarrhoea, abdominal cramps, nausea and frequent urination
• Rarely haematuria or bleeding per rectum
Delayed• Small bowel
obstruction and small bowel fistulas
• Vesicovaginal fistulas• Rectovaginal fistulas• Proctosigmoiditis and
bleeding per rectum
Results of treatment
• Stage 1- 85%• Stage 2- 60%• Stage 3- 45%• Stage 4- 18%
SURGERY RADIOTHERAPY
Survival 85% 85%
Vaginal length and coitus
Better Vaginal stenosis more
Ovarian function Can be preserved Usually destroyed
Fistulas 1-2% 1-5% and less treatable
Serious complications
Less More, especially bowel and bladder
Best candidates Young and in good health
Any patient
THANK YOU