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CERVICAL CANCER...
Diagnosis
＆
Treatment
CERVICAL CANCER...
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The most common malignancy in
gynecological oncology
Incidence: 7.8/100,000
Mortality: 2.7/100,000
Diagnosis: biopsy
Main modality of treatment: surgery and
radiation
Goal of treatment: cure, except stage 4b
Special Case
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38 yrs, G3/P1, nurse
C/O: postcoital bleeding for 2 months
Menstruation regular with 30 days cycle
and 5 days duration. Abnormal discharge
with bad smell. LMP: 12 days ago
Pap smear: squamous cell cancer
PV: Vulva : Normal,
Vaginal: yellowish discharge with bloody
stained,
Cervix: growth with ulceration and
contact bleeding.
Uterus: N/S, mobile.
Parametrium: thickening not to pelvic
sidewall on both side
CERVICAL CANCER…..
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How can we make a diagnosis?
How can we evaluate the patient?
How can we manage the patient?
How should we explain to the patient?
Can we prevent cervical cancer?
How can we make a diagnosis?
SYMPTOMS
 Abnormal vaginal bleeding
postcoital bleeding*
contact bleeding
 Abnormal vaginal discharge
 Asymptomatic, just abnormal
pap smear
SYMPTOMS
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The classic symptom is intermittent, painless
metrorragia or spotting only postcoitally or after
douching.
Probably the first symptom of early cancer of the
cervix is a thin, watery, blood-tinged vaginal
discharge that frequently goes unrecognized by the
patients.
As the maligancy enlarges, the bleeding episodes
become heavier and more frequent, and they last
longer.
SYMPTOMS
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Late symptom or indicators of more advanced disease
include the development of pain referred to the flank or leg.
Many patients c/o dysuria, hematuria or rectal bleeding or
obstipation resulting from bladder or rectal invasion.
Distant metastasis and persistent edema of one or both lower
extremities as a result of lymphatic and venous blockage by
extensive pelvic wall disease are late manifestation of
primary disease and frequent manifestations of recurrent
disease.
How can we make a diagnosis?
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SIGNS
Vagina: mucous,
fornix
Cervix:
erosion
growth
ulceration
barrel-shaped
Uterus: size,
mobility
Paramet: thickening
Gross appearence
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Three categories of gross lesions have
traditionally been described.
The most common is the exophytic lesion, which usually
arises on the ectocervix and ofter grows to form a large,
friable,polypoid mass, arises on the endocervical canal,
creating barrel-shaped lesion.
Little visible ulceration or exophytic mass like a stone-hard
cervix that regresses slowly with radiation therapy.
Ulcerative tumor,usually erodes a portion of the cervix or
replacing the cervix , erodes a portion of the upper vaginal
vault with a large crate.
How can we make a diagnosis?
CLINICAL TESTS:
 Pap smear
 Colposcopy and target biopsy
 Endocervical curettage (ECC)
 Cone biopsy
 Biopsy
Pap smear
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Pap smear is the most common
and effective screening method.
Exfoliated cervical cells are scraped from the cervix by
spatula. The entire T zone must be sampled. Incomplete
sampling could produce a false-negative smear.
The endocervical canal is also sampled with a swab or
cytobrush.
Cells are fixed immediately to avoid air-drying cytologic
artifacts
Pap Smear Show Squamous Cell Carcinoma
Colposcopy and directed biopsy
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A pap smear is only a screening test. A
definitive diagnosis requires inspection of
a well-visualized cervix with a colposcope.
The cervix is painted with 3% acetic acid solution to
enhance surface alterations and vascular changes.
The colposcope evaluation is considered adequate or
satisfactory if the complete T zone and full extent of the
lesions is visualized.
Areas of abnormality(e.g., White epithelium, mosaicism,
and punctation) are selectively punch biopsied.
Colposcopy Examination
Cone biopsy
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Indications for cone biopsy
1.The lesion cannot be fully visualized .
2.The ECC is positive
3.There is significant discrepancy between the Pap smear
and biopsy.
4.A biopsy reveals microinvasive squamous cell carcinoma
5.A biopsy reveals adenocarcinoma in situ
How can we make a diagnosis?
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pap smear is only a
screening test!
 Definitive diagnosis of
cervical cancer
requires a BIOPSY!
How can we evaluate the patient?
Histologic type:
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Squmous cell carcinoma ( SCC) 80%
Adenocacinoma
10%-15%
Others
5%-10%
Routes of spread
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Into the vaginal mucosa, extending microscopically
down beyond visible or palpable disease;
Into the myometrium of the low uterine segment and
corpus, particularlly with lesions arising from the
endocervix.
Into the paracervical lymphatics and from there to the
most common involved lymph nodes ( the obturator;
hypogastric, and external iliac nodes).
Direct extending into adjacent structures or parametria,
reaching to the obturator fascia and the wall of the
true pelvis
How can we evaluate the patient?
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Stage:
Pelvic examination,
Rectovaginal examination,
Intravenous pyelography(IVP)
Ultrasonography or CT
Staging is clinical, but can use IVP and CT
Cervical cancer is the only gynecologic
malignancy that is not surgically staged
Clinical Staging for
Cervical Carcinoma
 Stage
0
Carcinoma in-situ;
Confined to the epithelium only
Clinical Staging for
Cervical Carcinoma
 Stage
I
Invasion is strictly confined to
the cervix
• Ia: Invasive cancer identified only microscopically .
• Ia1: Minimal microscopically evident stromal
invasion <=3mm in depth and no wider than 7mm.
• Ia2: Microscopic invasion <=5mm in depth and no
wider than 7mm
Clinical Staging for
Cervical Carcinoma
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Stage I
Invasion is strictly confined to the cervix
• IB: All others preclinical lesions and clinical
lesions confined to the cervix.
• Ib1: Clinical lisions no greater than 4 cm.
• Ib2: Clinical lisions greater than 4 cm.
Clinical Staging for
Cervical Carcinoma
 Stage
II
Invasion is beyond the cervix but
not to the pelvic wall or lower third
of the vagina
• IIA Parametria is not involved
• IIB Parametria is involved
Clinical Staging for
Cervical Carcinoma
 Stage III
Invasion is to the pelvic wall or
lower third of vagina
• IIIA Pelvic wall is not involved
• IIIB Pelvic wall is involved;
hydronephrosis or nonfunctioning of
the kidney may occur because of
tumor
Clinical Staging for
Cervical Carcinoma
 Stage
IV
Invasion is beyond to the true pelvis
or to the mucosa of the bladder or
rectum.
• IVA Spread is to adjacent organs
• IVB Spread is to distant organs
How can we evaluate the patient?
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Age: treatment vary with the patient’s age
Marriage statue
Reproductive history：menstrual,
contraceptive, Gynecologic, Obstetric
Social history: sexually activity, social
statue
Family history: children, partner,parents
Past medical history
How can we evaluate the patient?
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General condition:
pulmonary (Chest-x-ray)
cardiac function (ECG)
liver function
renal function
Special disorders:
bleeding diseases,
diabetes mellitus, and infection
How can we manage the patient?
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Management of premalignant lesions:
make definitive diagnosis
selection of an appropriate mode of therapy
1. carbon dioxide laser
2. cryotherapy
3. electrocautery
4. loop electrodiathermy excision procedure
(LEEP）
5. Conization
6. hysterectomy
How can we manage the patient?
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Cervical Intraepithelial Neoplasia(CIN)
For CIN I-II:
observation(only for CIN I),
carbon dioxide laser
cryotherapy
electrocautery
loop electrdiathermy excision
procedure (LEEP)
How can we manage the patient?
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Cervical Intraepithelial Neoplasia (CIN)
For CIN III or CIS:
conization:
cold knife
carbon dioxide laser
diathermy and LEEP
simple hysterectomy
How can we manage the patient?
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For invasive cancer:
1 Simple hysterectomy (Ia1)
2 Modified radical hysterectomy (Ia2)
3 Radical hysterectomy and RPND
(Ib-IIa)
4 Radiotherapy (any stage, IIb III IV)
5 Chemotherapy
CERVICAL CANCER...
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Prognosis:
55% five-year survival
(all stage combined)
stage I
85%
stage II
60%
stage III
30%
stage IV
10%
How can we prevent cervical cancer?
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Risk factors
Education
Screening
program
Treatment of
premalignant
lesions
How can we prevent cervical cancer?
RISK FACTORS:
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early age of sexual
intercourse
multiple sexual partners
low socioeconomic
classes
early age of pregnancy
high parity
cigarette smoking
HPV (16,18）
immunocompromised
host
How can we prevent cervical cancer?
EDUCATION:
 Population
education
 Medical staff
education
How can we prevent cervical cancer?
SCREENING:
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committee
program:
onset of screening,
duration,
end of screening
methods for
screening pap
smear, CCT,
thin-rep, HPV typing
Case discussion
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27 yrs, G0/P0, married for 2 yrs
C/O: one episode of postcoital
bleeding for 2 weeks
Menstruation regular with 30 days
cycle and 5 days duration.
No abnormal discharge. LMP: 2
weeks ago
Pap smear: LSIL with HPV infection,
clue cell > 50%
PV: Vulva and vaginal: normal Cervix:
erosion with contact bleeding,Uterus:
N/S, mobile. Parametrium: clear
Wants to preserve her reproductive
function
Treatment strategy for
CIN
Pap smear result abnormal
Suspicion of CIN/SIL
Biopsy
Endocervical currettage
Repeat Pap smear
No suspicion of invasion
Suspicion of invasion
Leep (ectocervix),
CO2 laser therapy,
Cryotherapy
Cone biopsy,
cold knife cone, Laser cone,
LEEP cone (ecto and endocervix)
Case discussion
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48 yrs, G3/P1, midlife
C/O: postcoital bleeding for 4 months
Menstruation irregular with 30-60
days cycle and 5-20 days duration.
Abnormal discharge with bad smell.
LMP: 2 months ago
Pap smear: squamous cell cancer
PV: Vulva : Normal, vaginal: right
fornix involved by cervical growth.
Cervix: growth with ulceration and
contact bleeding.Uterus: N/S, mobile.
Parametrium: nodular thickening to
pelvic sidewall on right
Biopsy:SCC. IVP:nonfunctional kidney
Treatment strategy for
Invasive Cervical Cancer
Invasive cervical cancer
Staging
Microinvasive invasion
(less than 3mm)
Early Stage IB or IIA
Advanced or Bulky Disease
Cone Biopsy or
Simply hysterectomy
Radical Hysterectomy and
Pelvic Lymphadenectomy
or
Pelvic Radiation
Multimodality Therapy
Pelvic Radiation Therapy
or
Invastigational Protecols
How can we explain to the patient?
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What is cervical cancer?
How many treatment modes for cervical
cancer ?
Why we choose surgery or RT for the
patient?
What is the side-effect of the treatment?
What is the prognosis and survival rate?
Cervical cancer
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Cervical cancer is the most common
gynecologic malignancy.
The most common tumor type is squamous
cell carcinoma (80%)
A pap smear is only a screening test!
Definitive diagnosis of cervical cancer
requires a tumor BIOPSY!
Radiation and operation are both effective
treament .
Goal of the treatment: cure, except stage IV