Transcript 5._Cervical_Cancer

Dr. Maryam B. MAHMMUD
Incidence:
 Cervical cancer is the most common form of
cancer in women in developing countries.
 Second most common form of carcinoma in
the world as a whole.
 Three-quarters of affected women live in
developing countries
 Its estimated that up to 450 000 new cases
of invasive cancer of the cervix occur per
year in these countries
 However,
the incidence of cervical cancer
has fallen in the UK since 1988 that is after
introduction of an effective call-recall
system for cervical screening and lead to 5%
reduction in mortality associated with this
form of cancer.
< 91.5
< 33.2
< 25.3
< 15.4
< 9.7 */100.000 women
 Although
cervical cancer is characterize by
rapid, uncontrolled growth of severely
abnormal cell on cervix, fortunately, when
detected at an early stage, cervical cancer is
highly curable.
 Columnar
epithelium is constantly changed
into squamous cells in an area of the cervix
called transformation zone.
 As a result of this natural process of change,
some cervical cells can become abnormal.
Infection can also cause abnormal cellular
change.

When abnormal cellular change persist over
times and become irreversible, these cells
may lead to development of cervical cancer.
 Epidemiological
studies demonstrates that
the major risk factor, indeed a necessary
event for the development of pre-invasive
and invasive carcinoma of the cervix, is
Human papillomavirus (HPV) infection
specially type 16 and 18.
 High
parity.
 Increasing number of sexual partner.
 Young age at first intercourse.
 Low socioeconomic status.
 Positive smoking history.
 Squamous
cell and adenosquamous
carcinoma comprise approximately 85% and
adenocarcinoma approximately 15% of
cervical cancer.
 Adenocarcinoma can be pure or mixed with
squamous cell carcinoma; adenosquamous
carcinoma or mixed carcinoma.
 The
tumors are locally infiltrative in the
pelvic area,
 via lymphatic
 in late stages via blood vessels.
 The
clinical presentation is variable.
 Many patients are a symptomatic and have
been diagnosed as an incidental finding after
a loop biopsy of the cervix or during routine
testing.
 Post
ciotal bleeding.
 Intermenstrual bleeding.
 Post-menopausal bleeding.
 Offensive vaginal discharge.
 Late
stage disease may presents with
backache, leg pain/edema, hematuria, bowel
changes, malaise and weight loss
 On
speculum examination: the cervix may
looks normal or there may be an abnormal
ulcer , mass or friable growth easily bleed on
touch.
A
full history and clinical examination is
undertaken. If diagnosis is suspected on
bases of clinical finding and abnormal Pap
smear then colposcopy should be performed.
Suspicious feature at colposcopy include
 intense acetowhiteness,
 atypical vessels,
 raised/ulcerated surface,
 contact bleeding,
 and atypical consistency on bimanual
examination.
 Diagnosis
is based on histology and
appropriate biopsies should be taken.
 This biopsy should be either wedge or cone
shaped to obtain sufficient material for
histological assessment.
 once
cancer has been diagnosed, it is
important to stage the disease so that
treatment can be planned appropriately, as
staging will give an idea about type of
treatment and prognosis.
 Staging should include an assessment of
disease extent and site of spread.
 Examination
under anesthesia which should
include a combined recto-vaginal
assessment.
 Biopsy of suspicious area, this should be
suitably large to make definitive diagnosis.
 Cystoscopy.
 Sigmoidoscopy.
 Chest
X-ray and IVU.
 Other imaging as indicated and according to
facilities available. These might include
computerized tomography CT and MRI
 Stage
I carcinoma confined to cervix
Ia microscopic lesion confined to
cervix
Ib visible cancer by naked eye but
confined to cervix
 Stage
2 carcinoma extends beyond the
cervix but not extend to lower third of
vagina or pelvic side wall
2a involving upper third of vagina
2b involving the parametrium.
 Stage
3 carcinoma involving the lower third
of vagina and/or extending to the pelvic side
wall
3a involving lower third of the vagina
3b extend to pelvic side wall or cause
non-functioning kidney.
(hydronephrosis)
 Stage
4 distance metastasis
4a carcinoma involve mucosa of
bladder or rectum
4b more distance metastasis.
Treatment is given depending on the
 stage of the disease
 the age
 fitness of the patient.

Ideally all cancer patients should be
discussed within the context of a
multidisciplinary team of doctors (surgeons,
radiotherapists, radiologists, and pathologist)
and nurses, so that the most appropriate
treatment can be offered.
 The
fitness of the patient is crucial before
embarking on treatment as radical surgery
may not be appropriate in an unfit patient.
 Pre-clinical
lesions: stage Ia
 Small lesions need to have clear margin of
excision, but also the pre-invasive disease
(CIN) must also be completely excised. This
treatment enables fertility to be preserved
and hysterectomy to be avoided.
 Clinical
invasive cervical carcinoma: stage
Ib-2a
 Here the tumor volumes are much greater in
patients with stage Ia disease and the
fertility-preserving treatment for this group
of patient is usually not an option.
 When
the disease is stage Ib, then radical
hysterectomy and pelvic node dissection
(Wertheim’s hysterectomy) should be
considered in pre-menopausal patients.
 This
operation involves the removal of the
whole uterus and cervix, upper third of
vagina, and paramaterial tissue.
 Pelvic lymph node removal includes the
obturator, internal and external iliac nodes.
The ovaries in premenopausal women can be
spared
 Advantage
of operation:
 Cure rate is high.
 Ovarian tissue can be preserved.
 Avoid complication of radiotherapy.
 Disadvantage:
 Bladder atony.
 Lymphoedama.
 Higher
stage disease 2a and above:
 Usually is treated with radiation and
chemotherapy, but sometimes surgery is
employed if cervical cancer comes back after
it has already been treated.
 Radiation
therapy is another option besides
surgery for early stage cervical cancer; and
in more advanced cervical cancer.
 Surgery and radiotherapy have been shown
to be equivalent treatments for early stages
cervical cancers, and radiation can be used
instead of surgery when patient are unfit for
surgery.
 Advantage:
 It
can treat all the disease in the radiation
field including the involved lymph nodes
 Radiotherapy is divided into 2 types either its
external source (external beam radiation) or
an internal source (Brachytherapy).
 The
external radiation is requiring several
treatment fractions as an outpatient over 4
weeks. Although this treatment is given daily,
the time of each fraction is no more than 10
minutes.
 Brachytherapy
is a radiotherapy technique
where the radiation is delivered internally to
the patient.
 The rode is inserted into the uterus under,
and then attached to the radiotherapy
source and the patient receive radiotherapy
in isolation to protect the staff
 Complications:
 Lethargy.
 Bladder
and bowel urgency.
 Skin erythema-like sunburn
 Bowel perforation, rare.
 Vaginal fibrosis and stenosis.
 Interstitial cystitis
 Chemotherapy
is ideally given in conjunction
with the radiotherapy as this combination
increases cure rates more than when
radiotherapy is used in isolation.
 It probably works by enhancing the effects of
radiotherapy and might also address micro
metastases which are outside the radiation
field.
 The most widely used drug is Cisplatin,
although 5-FU and Paclitaxil may also be
employed
 When
it is not possible to offer curative
treatment then palliation of the symptoms
becomes important. Patient may be
experiencing a number of symptoms from
local infiltration of the pelvis by the cancer.
 Malignant pain, recto-and/or vasicovaginal
fistula and bleeding may occur.
 Radiotherapy may be used in bone
metastasis.
 is
very difficult to be treated but some time
pelvic exenteration may be used, this is
drastic operation that involves removal of
uterus, ovaries, fallopian tubes, vagina,
bladder, rectum and part of the colon. Now
rarely used.
 The
presentation is usually by abnormal
vaginal bleeding
 both Pap smear and colposcopy are safe
during pregnancy.
 Early stage disease Ia can allow the
pregnancy to go to term and treated after
that but this require close follow-up.
 In
more advanced stages, time of treatment
depends on gestational age, if its far from
viability treatment is given immediately and
after giving the first dose of radiation the
baby will abort and if its near term we can
do caesarean hysterectomy and continue
treatment as in non pregnant.
GOOD LUCK AND SEE
YOU NEXT IN SIX YEAR
IN SHA ALLAH