Cervix. Lower part of the uterus Connects the body of the uterus to the vagina (birth canal)

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Rosemary Neal
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1 CERVICAL CANCER

2 Cervix Lower part of the uterus Connects the body of the uterus to the vagina (birth canal) Cervical cancer Begins in the lining of the cervix Cells change from normal to pre-cancer (dysplasia) and then to cancer

4 GLOBOCAN 2012 Incidence CA Cx 4 th most common CA in women 528,000 new cases in % of all female cancer 85% occur in less developing countries

5 Incidence Carcinoma cervix is the second commonest female cancer in Myanmar. It is also the leading cause of deaths of It is also the leading cause of deaths of Myanmar women due to cancer

6 Invasive cervical cancer Macroscopic (overt) cancer of the cervix. Surface is proliferative, fragile, and easily blee

7 Risk Factors 1. Age Age -- 2 peaks ( around 35 years, years In the past two decades the incidence has doubled in younger women under 40 years, the mortality has almost trebled in women under 34 years of age.

8 2. Early exposure to sexual intercourse 3. Multiple sexual partners 4. Low socioeconomic status

9 5. HPV virus; type 16,18,31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 ( high risk) % are caused by HPV 16 AND Herpes simplex Type II 7 HIV infection 8 Chlamydia infection

10 9. Smoking 10. OCP 11 Diet 12 Diethylstilbestrol (DES) 13 Family history

11 Prevention Avoiding the risk factors Help for low-income women Avoid early sexual exposure Advice condom use HPV vaccine Cervical cancer screening - Having the Pap Test - VIA - HPV testing.

12 PREDISPOSING HISTOLOGICAL STATES Basal cell hyperplasia Squamous cell metaplasia CIN II & III

13 Pathology A.Gross (1) Ectocervical - Fungating(polypoidal), Ulcerative (2) Endocervical - Infiltrative(barrel shaped Cx)

14 B. Histological types (1) Squamous cell carcinoma (80-90%) a)large cell nonkeratinizing type b)large cell keratinizing type c)small cell squamous type* d)verrucous carcinoma

15 (2) Adenocarcinoma (10-20%) a) endocervical type b) endometrioid type c) clear cell adenocarcinoma d) adenoid cystic carcinoma e) rare types: sarcoma, lymphoma

16 (3) Mixed type (4) Others - Sarcoma - Metastatic tu - Lymphoma

17 Histological grading I. Well differentiated II. Moderately differentiated III. Poorly differentiated

18 C. Spread of CA cervix (1) Direct spread inferiorly to vagina, superiorly to uterus, laterally to right and left parametria, anteriorly to urinary bladder and posteiorly to rectum

19 (2) Lymphatic spread Internal iliac nodes obturator, hypogastric, bifurcation nodes), external iliac nodes, common iliac nodes, para-aortic nodes, sacral, para-aortic

21 Lymphatic system of female genital tract Ovarian vessels: to paraaortic. Rt; to IVC Lt; to lt renal vein Ovarian vessels: Anastomosis to pelvic vessels Corpus: to intapelvic, common iliac and paraaortic Cervix: to pelvic Vulva, lower vagina: to pelvic and inguinal

22 (3) Blood spread Embolic metastases to ovary, brain, bones & lungs Vertebral venous plexus bypasses lungs

23 Diagnosis of CA Cervix by proper history taking, physical examination and necessary investigations

24 History taking Risk factors - age, - marital status, parity, age at first coitus, number of sexual partners, - socioeconomic status, - history of STD (HPV infection) - smoking

25 Symptoms Symptomless ( early stromal invasion and microcarcinoma ) Abnormal uterine bleeding - contact bleeding, postcoital, intermenstrual bleeding, menorrhagia Postmenopausal bleeding Pain during intercourse-dyspareunia

26 discharge per vagina (blood stained, foul smelling) creamy or white at first, dirty brown later Odour due to infection of necrotic tissue with saprophytes pain in advanced cases Loss of weight, loss of appetide, cachesia Features of metastatics- bone pain, haematuria, bleeding PR, lung signs

27 Physical Examination General cachesia anaemia if bleeding present Neck gland, supraclavicular L/N Systemic examination Abdomen- liver spleen kidneys

28 Cervix may appear normal as in stromal invasion, microcarcinoma and adenocarcinoma Cervix may be hard with a granular erosion which bleeds to touch may be ulcerative, polypoidal, fungating Barrel shape if infiltrative PR examination- parametrial, pelvic side wall involment

29 Investigations Biopsy of all cervical lesions (1) colposcopically directed biopsy, and cone biopsy for microscopic lesion (2) Punch or wedge biopsy for gross lesion (3) Examination under anaesthesia

30 FIGO Staging Stage 0 Carcinoma Insitu Stage I Invasive carcinoma confined to the cervix Ia1 Stromal invasion is less than 3 mm in depth and 7 mm in width Ia2 Stromal invasion between 3 and 5 mm with maximal lateral spread of 7mm

31 Ib All other stage 1 lesion Ib1 Clinical lesion no greater than 4 cm in size Ib2 Clinical lesion larger than 4 cm in size Ib1 lesion <4cm Ib2 lesion >4cm

32 Stage IICarcinoma extends beyond the cervix but not to the pelvic side-wall; and/or lower third of vagina IIa Carcinoma extend to upper two third of vagina IIa1 lesion < 4cm IIa2 lesion > 4cm

33 IIb Obvious parametrial involvement but not reaching pelvic side wall

34 Stage III Carcinoma extends to the pelvic sidewall and/or the lower third of the vagina is involved ; presence of hydronephrosis or non-functioining kidney IIIa extension to the lower third of vagina IIIb Extension to the pelvic sidewall or hydronephrosis or nonfunctioning kidney

35 Stage IV Carcinoma extends beyond the true pelvis or involves the bladder or rectum IVa Spread of tumour onto adjacent pelvic organs- bladder, rectum IVb Spread to distant organs

36 Ia Ib1 Ib2 IIa IIb IIIa IIIb Staging IVa IVb 16/05/2012 CIN and Carcinoma Cervix 36

37 Prognosis 5 year survival rate Stage I % Stage II % StageIII % Stage IV 8-14 %

38 Management Of Cervical CA For Diagnosis Cx biopsy for histology EUA and biopsy ( for clinical staging and diagnosis)

39 For staging CXR CT scan for information about extra-pelvic involvement, pelvic L/N involvement Magnetic resonance imaging (MRI) for size & extent of tumour, but small deposits can be missed Cystoscopy, IVU

40 Preoperative investigations Full blood count, ABO Rh grouping, BT CT urea and electrolytes, RBS Infection screen Unine RE Chest X-ray, ECG

41 Treatment options Surgery Radiotherpy Chemotherapy Combination

42 Therapeutic target for cervical cancer Spread to lateral side of retoroperitoneal space Radical (Type III) hysterectomy Cardinal ligament Parametrium/paracolpium Upperpart of vagina Pelvic lymphnodes

43 Treatment Options by stage Stage Ia1 Conization or TAH if no lymph vascular space invasion (for therapeutic conization, the surgical margin must be free of disease) If Lymphovascular involvement present lymphadenectomy is needed or Brachytherapy alternative to surgery

44 Stage Ia2 Radical surgery ( Wertheim's Radical hysterectomy and bilateral pelvic lymphadenectomy) Radical Trachelectomy and bilateral pelvic lymph adenectomy- (tumour <2 cm) to conserve reproductive life in young women EBRT alternative to surgery

45 Stage IBI, IIA1 Radical hysterectomy and pelvic lymph adenectomy To remove uterus cervical growth with adequate mangin, parametrium, upper1/3 or ½ of vagina Pelvic lymph node include obturator, internal iliac, external iliac, common iliac

46 EBRT + concurrent CT and Brachytherapy as alternative to surgery

47 Adjuvant RT/Chemoradiation Indications for adjuvant RT/ chemoradiation Lymph node positive Narrow margin Involvement of margin Parametrium infiltration Poor histology type

48 Stage IB2, IIA2 RT followed by simple hysterectomy Or Neoadjuvant CT followed by radical hysterectomy

49 Stage IIB -VA RT +CT Stage VB Palliative RT CT

50 Recurrent cases Previous surgery- RT Previous RT- surgery Exenteration operation for central radiorecurrent cases (anteral, posterior, total) Palliative

51 Radiotherapy For all stages of carcinoma cervix Curative in early stage, prognosis is similar with surgery Cancericidal dose of gamma-rays to all Cancericidal dose of gamma-rays to all areas of growth & likely areas *

52 Brachytherapy (BT) intrauterine and intravaginal Radium or Caesium to deal with the tumour and paracervical spread deliver Gy at Point A (2cm lateral to the midline, 2cm above the lateral fornix in the same saggital plane as the uterus),

53 External beam radiotherapy (EBRT) and 25% of the dose to Point B ( 5cm from the midline at the same level and the same plane) the external radiation ( preferably linear accelerator to deal with the pelvic lymphnodes and lymphatics deliver Gy to the pelvic sidewall

55 Chemotherapy Concurrent chemotherapy with Radiation - Cis-platin based chemotherapy enhanced the effect of radiation Neoadjuvant CT before surgery in bulky II Neoadjuvant CT before surgery in bulky II B stage

56 Indication for surgery Stage-I-IIa young patient ( to preserve ovarian function) patient's choice patient is contra-indicated to radiotherapy eg. PID, Myoma, radio-resistant tumour radio-recurrent tumour pregnancy

57 Complication of surgery A) Intra-operative Anaesthetic accident Injury to bladder, ureter, rectum, Haemorrhage

58 B) Post-operative Haemorrhage, Infection, Urinary retention, Ileus

59 Remote VVF, RVF, Ureteric fistula, Lymphocyst formation, Short vagina

60 Complications Of RT Morbidity during treatment GIT diarrhoea, abdominal cramps, nausea, bleeding from bowels Prescribe low-gluten, low-lactose, lowprotein diet Majority will have some permanent minor change in bowel habit

61 Bladder symptoms uncommon unless there is urinary infection, occasionally heamaturia Increased morbidity with PID, diverticulitis & previous surgery which causes adhesions of gut & increases the dose to a particular portion of the gut

62 Late Complications -Vaginitis, vaginal stenosis -Urinary tract injury ;cystitis, ulceration, VVF G.I. injury ; Enteritis, Rectal ulceration, RVF Radiation-induced menopause Coital difficulties Narrowing & shortening of vagina

63 Chemotherapy Cannot cure but can cause significant tumour regression Single agents used are Cisplatinum, Bleomycin, Ifosfamide, Methotrexate Neoadjuvant chemotherapy with bulky tumours preop & with radiotherapy Concurrent chemotherapy & radiotherapy with bulky & advanced cancer cervix

64 Follow -Up Timing every 3 months in the first 3 years 6 monthly for the next 2 years yearly thereafter

65 Assessment Analysis of symptoms & signs Cytology Renal function Chest X'ray IVU if there is pelvic mass or urinary symptoms CT scan at 6-12 months in operated cases Counselling for sexual dysfunction - HRT

66 CA Cervix and Pregnancy Usually Stage I or Stage II Relatively unfavourable prognosis The patient is relatively young. The hormonal and vascular changes in pregnancy encourage rapid growth and early dissemination The presence of pregnancy hinders treatments

67 Diagnosis is usually made by a colposcopy dirrected biopsy if the Pap smear test is positive. Diagnostic conization In the second trimester only if the Pap smear is strongly suggestive of invasive canaer. Carries a high risk of abortion.

68 Treatment Depends on The stage of the disease The period of gestation The wishes of the patient

69 Stage IA with no LVSI Delivered vaginally at term followed by hysterectomy 6 weeks later if no further childbearing is required. or Conization if it is.

70 Stage IA1 with LVSI and in Stage IA2 Delivery at term by caesarean section and modified radical hysterectomy with pelvic node dissection at the same time

71 Stage IB Delivery can be delayed for 4 weeks Delivered after 32 weeks by classical caesarean section and radical hysterectomy with pelvic lymph node dissection

72 Stage II IV Radiotherapy is treatment of choice. First trimester- Start with EBRT Second trimester the patient's wishes and the available facilities need to be taken into consideration.

73 Third trimester Classical caesarean section after fetal maturity is attained. External irradiation and intra-cavitary External irradiation and intra-cavitary therapy, commenced 4-21 days after delivery of the child.

74 Thanks

Cervical cancer presentation

Cervical cancer presentation Carcinoma of the cervix: Carcinoma of the cervix is the second commonest cancer among women worldwide, with only breast cancer occurring more commonly. Worldwide, cervical cancer accounts for about 500,000