3 CERVICAL CANCER...The most common malignancy in gynecological oncologyIncidence: 7.8/100,000Mortality: 2.7/100,000Diagnosis: biopsyMain modality of treatment: surgery and radiationGoal of treatment: cure, except stage 4b
4 Special Case 38 yrs, G3/P1, nurse C/O: postcoital bleeding for 2 monthsMenstruation regular with 30 days cycle and 5 days duration. Abnormal discharge with bad smell. LMP: 12 days agoPap smear: squamous cell cancerPV: 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
5 CERVICAL CANCER….. 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?
6 How can we make a diagnosis? SYMPTOMSAbnormal vaginal bleeding postcoital bleeding* contact bleedingAbnormal vaginal dischargeAsymptomatic, just abnormal pap smear
7 SYMPTOMSThe 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.
8 SYMPTOMSLate 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.
9 How can we make a diagnosis? SIGNSVagina: mucous, fornixCervix: erosion growth ulceration barrel-shapedUterus: size, mobilityParamet: thickening
10 Gross appearenceThree 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.
15 How can we make a diagnosis? CLINICAL TESTS:Pap smearColposcopy and target biopsyEndocervical curettage (ECC)Cone biopsyBiopsy
16 Pap smear 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
18 Colposcopy and directed biopsy 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.
20 Cone biopsy Indications for cone biopsy 1.The lesion cannot be fully visualized .2.The ECC is positive3.There is significant discrepancy between the Pap smear and biopsy.4.A biopsy reveals microinvasive squamous cell carcinoma5.A biopsy reveals adenocarcinoma in situ
23 How can we make a diagnosis? A pap smear is only a screening test!Definitive diagnosis of cervical cancer requires a BIOPSY!
24 How can we evaluate the patient? Histologic type:Squmous cell carcinoma ( SCC) 80%Adenocacinoma %-15%Others %-10%
25 Routes of spreadInto 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
26 How can we evaluate the patient? Stage: Pelvic examination, Rectovaginal examination, Intravenous pyelography(IVP) Ultrasonography or CTStaging is clinical, but can use IVP and CTCervical cancer is the only gynecologic malignancy that is not surgically staged
27 Clinical Staging for Cervical Carcinoma Stage 0Carcinoma in-situ;Confined to the epithelium only
28 Clinical Staging for Cervical Carcinoma Stage IInvasion is strictly confined to the cervixIa: 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
29 Clinical Staging for Cervical Carcinoma Stage IInvasion is strictly confined to the cervixIB: 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.
30 Clinical Staging for Cervical Carcinoma Stage IIInvasion is beyond the cervix but not to the pelvic wall or lower third of the vaginaIIA Parametria is not involvedIIB Parametria is involved
31 Clinical Staging for Cervical Carcinoma Stage IIIInvasion is to the pelvic wall or lower third of vaginaIIIA Pelvic wall is not involvedIIIB Pelvic wall is involved; hydronephrosis or nonfunctioning of the kidney may occur because of tumor
32 Clinical Staging for Cervical Carcinoma Stage IVInvasion is beyond to the true pelvis or to the mucosa of the bladder or rectum.IVA Spread is to adjacent organsIVB Spread is to distant organs
33 How can we evaluate the patient? Age: treatment vary with the patient’s ageMarriage statueReproductive history：menstrual, contraceptive, Gynecologic, ObstetricSocial history: sexually activity, social statueFamily history: children, partner,parentsPast medical history
34 How can we evaluate the patient? General condition: pulmonary (Chest-x-ray) cardiac function (ECG) liver function renal functionSpecial disorders: bleeding diseases, diabetes mellitus, and infection
35 How can we manage the patient? Management of premalignant lesions:make definitive diagnosisselection of an appropriate mode of therapy carbon dioxide laser cryotherapy electrocautery loop electrodiathermy excision procedure (LEEP） Conization hysterectomy
36 How can we manage the patient? Cervical Intraepithelial Neoplasia(CIN)For CIN I-II: observation(only for CIN I), carbon dioxide laser cryotherapy electrocautery loop electrdiathermy excision procedure (LEEP)
37 How can we manage the patient? Cervical Intraepithelial Neoplasia (CIN)For CIN III or CIS: conization: cold knife carbon dioxide laser diathermy and LEEP simple hysterectomy
38 How can we manage the patient? For invasive cancer: Simple hysterectomy (Ia1) Modified radical hysterectomy (Ia2) Radical hysterectomy and RPND (Ib-IIa) Radiotherapy (any stage, IIb III IV) 5 Chemotherapy
39 CERVICAL CANCER...Prognosis: % five-year survival (all stage combined)stage I % stage II % stage III % stage IV %
40 How can we prevent cervical cancer? Risk factorsEducationScreening programTreatment of premalignant lesions
41 How can we prevent cervical cancer? RISK FACTORS:early age of sexual intercoursemultiple sexual partnerslow socioeconomic classesearly age of pregnancyhigh paritycigarette smokingHPV (16,18）immunocompromised host
42 How can we prevent cervical cancer? EDUCATION:Population educationMedical staff education
43 How can we prevent cervical cancer? SCREENING:committeeprogram: onset of screening, duration, end of screeningmethods for screening pap smear, CCT, thin-rep, HPV typing
44 Case discussion 27 yrs, G0/P0, married for 2 yrs C/O: one episode of postcoital bleeding for 2 weeksMenstruation regular with 30 days cycle and 5 days duration No abnormal discharge. LMP: 2 weeks agoPap smear: LSIL with HPV infection, clue cell > 50%PV: Vulva and vaginal: normal Cervix: erosion with contact bleeding,Uterus: N/S, mobile. Parametrium: clearWants to preserve her reproductive function
46 Case discussion 48 yrs, G3/P1, midlife C/O: postcoital bleeding for 4 monthsMenstruation irregular with days cycle and 5-20 days duration Abnormal discharge with bad smell. LMP: 2 months agoPap smear: squamous cell cancerPV: 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 rightBiopsy:SCC. IVP:nonfunctional kidney
47 Treatment strategy for Invasive Cervical Cancer
48 How can we explain to the patient? 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?
49 Cervical cancerCervical 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