Jacqui Morgan March 6, 2019

Transcription

1 Jacqui Morgan March 6, 2019

2 Case 1 25yo, G2P1 Here for WWE, no problems, healthy, needs refill on OCPs. Pap- Abnormal Glandular Cells-NOS Now What??

3 Case 1 Colposcopy What findings?

4 Case 1 ECC Cervical Biopsy HPV testing if not already done

5 Case 1 Bx and ECC- negative for abnormal glandular pathology Now What?

6 Case 1 Review cytology If AGC- NOS Cotest in 12 and 24 months If AGC favour neoplasia or AIS Conisation Endometrial sampling, Pelvic U/S

7 Case 2 37yo, G3P2 Here for WWE, Fluffy, Pre-diabetic Regular periods, every 4 months Pap- Abnormal Glandular Cells Now What??

8 Case 2 ECC Cervical Biopsy EMBx HPV testing

9 Case 2 ECC- Adenocarcinoma in situ Cervix biopsy CIN I-II EMBx- Proliferative endometrium

10 Case 2 Diagnostic Excisional Procedure Why can t I just have a partial hysterectomy

11 Case 2 Cannot diagnose ACIS from ECC alone Skip lesions Margins

12 ACIS 1/3 of patients with ACIS on cytology, will have an invasive carcinoma found on excisional procedure.

13 Case 2 Hysterectomy- Residual ACIS 6-25% of hysterectomy specimens performed for ACIS with negative margins will have residual ACIS

14 Case 3 29 yo seen in outside ER for fatigue, back pain. Hb 6.2 Cr 7.0 Non contrast CT- Poor image quality due to habitus and lack of contrast. Uterine mass, possible fibroid, recommend pelvic U/S. Bilateral hydronephrosis. Transferred to local facility with ICU.

15 Case 3 Transfused 3 U PRBC Dialysis catheter inserted Started on dialysis. Renal sono- hydonephrosis/hydroureters bilaterally Seen by medicine, nephrology, surgery Urology consulted for ureteric stent placement, they recommended

16 Case 3 Gyn consult, Day 4 in ICU

17 Case 3 History Postcoital bleeding for 3 months Heavy bleeding last 2 weeks to point that boss threatened to fire her for amount of time spent in bathroom/off work Last pelvic/pap, cant remember

18 Case 3 Exam 9cm friable mass replacing entire cervix. Extending to both sidewalls.

19 Case 3 Biopsy Poorly differentiated SCC Ureteric stents placed Stage? Treatment? Related pt- What happens when you live in a tent by the river with bilateral nephrostomy tubes?

20 Case 3 What stage? What treatment?

21 Case 3 What can be done if Urology were unable to insert stents?

22 Case 4 30yo G4P2 Pap HGSIL Colpo & Biopsy CIN II-III

23 Case 4 LEEP- CIN III and Invasive adenocarcinoma 2.5mm depth, 3mm lateral spread Stage? Treatment?

24 Case 5 47yo G 3 P3 referred from Family Physician HGSIL Pap Colposcopy- Acetowhite changes and mosaicism Biopsy CIN III What next?

25 Case 5 Exam- 1x1cm lesion on anterior cervix Plan?

26 Case 5 Excisional procedure Pathology- Squamous cell carcinoma. Depth of invasion 1.5mm. Lesion 5mm width. Margins negative for invasive disease. CIN III extending to ecto-cervical margin. Stage? Treatment plan?

27 Cervical Cancer Approx 14,000 cases annually in US 4,500 deaths Mean age 51 Internationally much higher incidence. Second most common cancer and leading cause of cancer death in women in developing world

28 Presentation Asymptomatic, pap only abnormality Abnormal bleeding Postcoital bleeding Vaginal discharge Pelvic pain Renal failure

29 Cervical Cancer Squamous Adenocarcinoma Adenosquamous Melanoma Clear cell Small cell Sarcoma Lymphoma etc

30 Staging Clinical, not surgical. Why?

31 Clinical staging Most disease is not treated surgically Limitations on imaging/testing to be applicable to areas with higher disease burden.

32 Tissue Diagnosis Biopsy required Cytology not sufficient from Pap Tischler biopsy LEEP Glove Monsel s Pressure Cautery Packing if needed

33 Imaging PET/CT or CT alone Used as substitute for cystoscopy, barium enema and IVP

34 FIGO 2009 Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded) IA Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion <5 mm and the largest extension >7 mm IA1 Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mm IA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mm IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA IB1 Clinically visible lesion <4.0 cm in greatest dimension IB2 Clinically visible lesion >4.0 cm in greatest dimension Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina IIA Without parametrial invasion IIA1 Clinically visible lesion <4.0 cm in greatest dimension IIA2 Clinically visible lesion >4.0 cm in greatest dimension IIB With obvious parametrial invasion

35 FIGO 2009 Stage III The tumour extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidney IIIA Tumour involves lower third of the vagina, with no extension to the pelvic wall IIIB Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to Stage IV IVA Spread of the growth to adjacent organs IVB Spread to distant organs

36 Early Stage Disease Surgical Mx over Primary chemoradiation if a suitable surgical candiate Lymph node dissection if above stage IA1 Ovaries Squamous vs adenocarcinoma

37 Stage IA1 <3mm depth, 7mm width. Negative margins on excisional specimen Cervical conisation if fertility desired Extrafascial hysterectomy

38 Stage IA 2 3-5mm depth, 7mm width No visible lesion Modified Radical hysterectomy and pelvic lymph node assessment If fertilty desired- Radical trachelectomy and LNs

39 Stage IB1 Confined to cervix, 4cm or less tumor Radical hysterectomy and pelvic LNs Equivalent survival with chemoradiation, but different long term toxicities.

40 Radical Hysterectomy Incorporation of parametrial tissues, cardinal ligaments, uterosacral ligaments and upper vagina Initially assess lymph nodes, any suspicious nodes assessed intraoperatively. If nodal disease, abort procedure. Assess parametrial tissue for disease What spaces are developed?

41 Radical Hysterectomy 3 separate studies have identified decreased PFS with robotic approach in cervical cancer Uterine cancer showed no such difference in surgical approach Open approach standard of care

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43 Paravescial space Obliterated umbilical artery Obturator internus Cardinal ligament Pubic symphysis

44 Pararectal space Rectum Hypogastric artery Cardinal ligament Sacrum

45 Radical Hysterectomy

46 Radical Hysterectomy

47 Stage IB2 and above Or Not a surgical candidate Pelvic radiation Concurrent cisplatin chemotherapy +/- paraaortic radiation Radiation will rapidly control bleeding Initial fractions given at higher dose, then more detailed planning can be performed.

48 Pelvic Radiation 5-6 weeks external beam treatments Fractions 3-5 internal brachytherapy treatments

49 Radiation toxicity GI- diarrhea, urgency, nausea, colitis, fistula GU- Frequency, pain, dysuria, fistula Sexual function- Ovarian ablation, atrophy, vaginal stenosis General- fatigue Bone- sacral insufficiency fractures Heam- bone marrow suppression Lymph- lymphedema Secondary malignancies

50 Concurrent Cisplatin Chemotherapy IV weekly treatment during radiation Toxicity Renal impairment Substitute carboplatin if elevated Cr. Nausea Myelosuppresion Neurotoxicity Hypokalemia, Hypomagnesemia

51 Distant metastatic Disease Systemic chemotherapy Carboplatin/Paclitaxel/Bevacizumab Palliative radiation Potential benefit to still treatment pelvic disease with radiation Palliative only care

52 Cervical cancer Most advanced disease presents in unscreened or inadequately screened population No matter how frequent pap screening is performed, some rapid developing disease will arise between tests.