Transcript Cervical Ca by DR YUSUF

CANCER OF THE CERVIX
Dr Yusuf Muhammad
WHY IS CANCER OF THE CERVIX
SO IMPORTANT?
• 400,000 new cases are identified each year.
• 80% of the new cases occur in the developing countries
• At least 200,000 women die of cancer of the cervix world
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wide
Now, cancer of the cervix is the 3rd common cancer
world wide
In Korle-Bu teaching Hospital, a study in mid 1990s
showed the commonest female genital tract cancer to be
cancer of the cervix. It accounts for 58% of all female
genital tract cancer.
WHO GETS CANCER OF THE
CERVIX
Although cancer of the cervix is reported in
all ages, even at birth, it is not common
before the age of 40 years. There after
the risk rises progressively to reach a
maximum at 55-59 years and then
diminishes. It is essentially a sexually
transmitted disease.
WHAT FACTORS INCREASE THE CHANCE OF
A WOMAN GETTING CACX?
• Sex
• Multiple sexual partners
• Sexually transmitted disease – Human papilloma virus
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infection; Herpes simplex virus infection.
High parity
Smoking
Immunosuppression –HIV infection, Steroid use.
The use of hormonal contraceptives
Social class.
SIGNS AND SYMPTONS
• Initially asympptomatic.
• Vaginal discharge – The discharge is at first creamy or
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white but subsequently resembles dirty brown water. It
has a particularly offensive odour. The odour is due to
infection of the dead cervical tissue
Irregular vaginal Bleeding.
Contact bleeding – Any cervix which bleeds when
touched is suspect.
Any other symptoms usually occur so late that are to be
regarded more as evidence of impending death; They
include;
SIGNS AND SYMPTONS cont.
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Frequency of micturition
Dysuria
Urinary incontinence
Rectal pain
Oedema of legs
Loss of weight
Anorexia
Low back pain
NATURAL HISTORY OF CANCER OF
THE CERVIX
• It starts as high-grade dysplasia, which
may progress to cancer of the cervix over
a period of up to 10 years.
• Tobacco use may influence whether a
woman with dysplasia is likely to develop
cancer of the cervix
IS CANCER OF THE CERVIX
PREVENTABLE ?
• The cervix is uniquely placed for screening as a
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means of preventing cancer of the cervix
It is easily accessible.
Cells are constantly being shed from it. These
cells can be viewed under microscope to identify
early pre-cancerous changes (dysplasia).
There is a long period of about 10 years
between when precursor (pre-cancerous) lesion
appears and when cancer occurs.
WHAT SCREENING TEST IS
AVAILABLE?
• A pap smear (named after its inventor Dr.
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George Papanicolou), also known, as cervical
smear is a cytological test designed to detect
abnormal cervical cells.
THE PROCEDURE: The procedure involves
scrapping cells from the cervix and then fixing
them on a glass slide. The slides are then sent
to a cytology laboratory and evaluated by a
trained cytologist.
DIAGNOSIS
Cervical Biopsy for microscopic examination
TREATMENT
• Surgery (Weatheim’s Hysterectomy) – Up
to stage 2a
• Radiotherapy
• Combined
STAGING
Stage 0
• The cancer is limited to the epithelium
(carcinoma in situ)
Stage 1
• The cancer is invasive but is strictly to the
cervix or the uterus
• 1a – Pre-clinical invasion
• 1b- Clinically diagnoses
Stage 2
• 2a – Cervix + upper 2/3 of vagina
• 2b-Cervix + parametra but not reaching
the pelvic side wall
Stage 3
• 3a-Cervix + lower 1/3 of vagina
• 3b- Cervix + pelvic side wall
Stage 4
• Extra pelvis or
• Pelvic bones or
• Bladder or
• Rectum
COMPONENTS OF WERTHEIM’S
HYSTERECTOMY
• Removal of uterus and appendages
• The upper half of vagina
• Broad ligament together with their cellular
tissue
• The lymph nodes around the iliac vessels
and on the lateral pelvic walls
PROGNOSIS
• The extent of growth at the time of treatment.
• Site – an endocervical growth is more dangerous than one
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which grows on the vaginal surface because it is diagnosed
relatively late, and it spreads to the broad ligaments and to
lymph nodes relatively early.
Naked eye appearance – The hypertrophic, florid, massive
growth filling the upper vagina generally carries a bad
prognosis – even if it does not appear to have spread much
beyond the cervix.
Histological type – An adenocarcinoma is unfavorable because
it is usually endocervical in site. Among the squamous cell
growths the wall differentiated are to be preferred because
they grow slowly and metastasize late.
Age – the younger the patient the more likely is the growth to
be fulminating in type and the worse the outlook
HOW IMPORTANT IS PRETREATMENT ASSESSMENT?
• Preliminary examination under anaethesia is
generally desirable in order to estimate the
extent of the disease, the size of the uterus,
vaginal fornices and to obtain material for
histopathological study.
• Anemia and malnutrition should be corrected,
even at the expense of delaying treatment. A
health blood picture improves the results of
radiotherapy considerably, possibly because it
means better oxygenation of malignant tissues.
RADIOTHERAPY
• This is the treatment of choice and is applicable to all
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stages of the disease.
It aims at giving cancericidal dose of gamma – rays to all
areas where there is growth or where there is likely to
be growth.
Gamma-rays act by damaging the nuclear structures is
actively dividing cells.
Radio sensitivity depends to a large extent on whether
the tumour receives a good blood supply from its bed.
In favourable cases the tumour disappears within 6
weeks.
If the initial course of treatment is adequate,
radiotherapy should never be used again even if the
growth recurs. IT CAN ONLY DO HARM.
Radioactive material used
– Radium – The most commonly used
– Cesium
– Cobalt
COMPLICATIONS OF RADIOTHERAPY
Major complications are caused by
overdose and by technical errors; but many
are unavoidable.
IMMEDIATE COMPLICATIONS
• Malaise, Anorexia, Vomiting, Pyrexia
• Enteritis, Proctitis, Cystitis, Pyelonephritis,
Cellulites, Peritonitis
• Pyometra
• Pelvic abscess
• Vaginal and skin burns
• Septicemia
MEDIUM TERM COMPLICATION
• Vaginal and cervical atresia secondary to
burns
• Hydronephrosis secondary to ureteric
stricture due to scaring in the broad
ligament.
LONG TERM COMPLICATIONS
• A state of aseptic cellulites in which all the
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tissues become “frozen” 3 month after
treatment.
Ischaemic rectal injury occurs in 10-15% cases
and usually makes itself manifest 6-18 month
after treatment
A similar reactions occur in the bladder in 5-10%
cases and tend to appear even later than those
in the rectum’. It presents as frequency, dysuria
and haematuria.
Necrosis of the pelvic part of the ureter followed
by fistula formation or by stricture.
Spontaneous fracture of the neck of the femur.
TREATMENT OF ABOVE LATE RADIATION REACTION
• The treatment of late radiation rectal
reactions in the acute phase is by means
of warm baths and suppositories
containing analgesics and cortisone.
• Bladder reactions can be treated by
antispasmodics and a liberal fluid intake.
COMPLICATIONS OF WERTHEIM’S OPERATIONS
IMMEDIATE COMPLICATIONS
• Haemorrhage
• Shock
• Peritonitis
• Ileus
• Intestinal obstruction
• Direct injury to pelvic structures, notably
– Bladder
– Ureters
– Rectum
LATE COMPLICATIONS
• Fistula forms 7-14 days after the in 1-15%
• Atony of bladder, incomplete emptying,
cystitis and pyelitis complicate 80% of
operation, and there is generally a need
for prolonged post-operative bladder
drainage.
• Stress incontinence
• Recurrent cancer
COMBINED RADOTHERAPY AND HYSTERECTOMY
• Here we are concern with combined
therapy as a planned primary procedure,
not with the resort to one when the other
has failed of appears to be failing.
• For this purpose various combinations are
used; Radiotherapy may follow surgery.
But ordinarily, however, the plan is to use
radiotherapy initially and to proceed to
wertheim’s hysterectomy 6 weeks later.