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Cervical Cancer DR KHALID H. WALI SAIT (FRCSC) ASSOCIATE PROFESSOR OF GYNECOLOGICAL ONCOLOGY King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

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Presentation on theme: "Cervical Cancer DR KHALID H. WALI SAIT (FRCSC) ASSOCIATE PROFESSOR OF GYNECOLOGICAL ONCOLOGY King Abdulaziz University Hospital, Jeddah, Saudi Arabia."— Presentation transcript:

1 Cervical Cancer DR KHALID H. WALI SAIT (FRCSC) ASSOCIATE PROFESSOR OF GYNECOLOGICAL ONCOLOGY King Abdulaziz University Hospital, Jeddah, Saudi Arabia

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3 Cancer in Women World Wide Breast Colo-rectal Cervix and Uterus Lung Leukemia- Lymphoma Ovary Saudi Breast Thyroid Leukemia – Lymphoma Colo-rectal Ovary Liver Cervix Uterus

4 Female Genital Tract Malignancy World Wide Uterus Cervix Ovary Vulva Vagina F.Tube Saudi Ovary Cervix Uterus Vulva Vagina F.Tube

5 Pathogenesis HPV are etiological agent for cancer cervix HPV DNA can be found in 99.7 % of all cervical carcinoma Type 16, 18, 45 and 31 most frequent.

6 HPV >100 types identified 2 ~30–40 anogenital 2,3 ~15–20 oncogenic*,2,3 types, including 16, 18, 31, 33, 35, 39, 45, 51, 52, 58 4 HPV 16 (54%) and HPV 18 (13%) accounted for the majority of worldwide cervical cancers. 5 Nononcogenic ** types include: 6, 11, 40, 42, 43, 44, 54 4 HPV 6 and 11 are most often associated with external genital warts Howley PM. In: Fields Virology. Philadelphia, Pa: Lippincott-Raven; 1996:2045– Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930– Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S Muñoz N, Bosch FX, de Sanjosé S, et al. N Engl J Med. 2003;348:518– Clifford GM, Smith JS, Aguado T, Franceschi S. Br J Cancer. 2003:89;101–105. Nonenveloped double- stranded DNA virus 1 *High risk; ** low risk

7 Infectious Virus Particle of HPV 1,2 Capsid proteins: L1L2 Viral DNA Viral exterior Viral interior 1. Baker TS, et al. Biophys J. 1991;60:1445– Chen XS, et al. Mol Cell. 2000;5:557–567.

8 Pathogenesis P53

9 Spectrum of Changes in Cervical Squamous Epithelium Caused by HPV Infection 1 Normal Cervix HPV Infection / CIN* 1 CIN 2 / CIN 3 / Cervical Cancer *CIN = cervical intraepithelial neoplasia 1. Adapted from Goodman A, Wilbur DC. N Engl J Med. 2003;349:1555–1564. Copyright © 2003 Massachusetts Medical Society. All rights reserved. Adapted with permission.

10 0–1 Year0–5 Years1–20 Years Invasive Cervical Cancer Cleared HPV Infection 1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362. CIN 1 Initial HPV Infection Continuing Infection CIN 2/3 Natural History of HPV Infection and Potential Progression to Cervical Cancer 1

11 HPV Clearance In women years of age ~80% of HPV infections are transient Gradual development of cell-mediated immune response presumed mechanism In a study of 608 college women, 443 infected, 70% of new infections cleared within 1 year and 91% within 2 years Mean duration of infection - 8 months HPV 16 and 18 infections persist longer

12 Cervical Cancer Prevention Education About early symptom of cancer cervix Avoid Risk Factors Screening and Vaccine

13 Risk Co Factor: HIV HPV 16,18 SMOKING MULTIPPLE SEXUAL PARTNER ?BCP

14 Cancer Cervix Has an easily identified pre-invasive disease and be diagnosed and treated before become an invasive disease Screening Test

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18 THIN PREP Liquid based cytology

19 Q7

20 Recommendations of ACS(2004)

21 False negative ( 30%) GOOD SCREENING ?

22 Ideal (not essential) Patient s Conditions For Screening No vagina douching for 48 hours Avoided use of contraceptive creams or jellies for 48 hours No intercourse for 24 hours Not recommended during menstruation, mid cycle smear is optimum Patient should be required to provide her LMP

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24 Changes in Terminology L SILHPV CIN I HPV Mild Dysplasia H SILCIN IIModerate Dysplasia H SILCIN IIISevere Dysplasia Carcinoma insitu

25 Management Of Pap Smear Result Pap smear is simply a lab test it is the responsibility of the physician to interpret the result in the context of a given patient and her particular circumstances

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27 Objective Of Colposcopy Exclude invasive disease Select the most appropriate area for biopsy

28 Original squamocolumnar junction Present squamocolumnar junction Transformation zone Endocervical canal IS COLPOSCOPY SATISFACTORY ? Detailed Colposcopic Exam.

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30 a grape-like or "sea-anemone"

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32 RCT

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34 Cancer of the Cervix Clinical presentation Abnormal vaginal bleeding Postmenopausal Vaginal bleeding Vaginal discharge Pain Asymptomatic

35 Invasive Disease

36 Cancer of the Cervix Histological types Squamous cell ca Adenocarcinoma Other

37 Cancer of the Cervix Mode of spread Direct Lymphatic Hematogenous

38 Cancer of the Cervix I nvestigations EUA Complete blood count Liver function test Renal function tests CXR/IVP or CT Cystoscopy Sigmoidoscopy

39 Cancer of the Cervix FIGO Staging ( clinical ) I - Tumour confined to the cervix II- Upper 2/3 vagina / parametrium. III- Lower 1/3 vagina / pelvic side wall or hydronephrosis IV- Adjacent organ / Distant metastasis

40 Cancer of Cervix Prognostic Factors

41 Cancer of the Cervix Treatment of patients Radical Hysterectomy and lymphadnectomy Radiation Therapy and chemotherapy

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43 Pelvic Radiation EBR and Brachytherapy Chemotherapy

44 What is: Radiotherapy

45 How Radiotherapy works ?

46 Follow up

47 RECURRENT CERVICAL CANCER Treatment depends on: Site of recurrence Mode of primary therapy

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49 Cancer of the Cervix stage/survival

50 Prophylactic Vaccine Virus – neutralization antibodies to prevent infection Generate antibodies in genital tract epithelium directed against the L1 and L2 capsid proteins

51 Commercial HPV Vaccines GSK vaccine (Harper 2004) 16/18(100% efficacy) Merck vaccine (villa 2005) 6/11/16/18 ( 88% efficacy (RCT PLACEBO) 0,1,6 months y old

52 Gardasil: Quadrivalent HPV Vaccine 0.5 ml IM, day 0, month 2, and month 6 COST ~$130 each vaccine dose Storage: 2-8 o C, should not be frozen, protect from light. *NEED TO PRESERVE THE COLD CHAIN* Contraindications: hypersensitivity to the active substances or components Precautions: May not be effective Not for use in active warts, cervical cancer, CIN VIN, VAIN Does not provide protection against none vaccine HPV types Not recommended for use in pregnancy, Category B

53 Who? Women 9-26 Do not need to have pap smear before vaccination Testing for HPV is not recommended prior to vaccination Sexually active women can be vaccinated, may be less effective in women who have been previously exposed to HPV

54 Cervical Cancer DR KHALID H. WALI SAIT (FRCSC) ASSOCIATE PROFESSOR OF GYNECOLOGICAL ONCOLOGY King Abdulaziz University Hospital, Jeddah, Saudi Arabia


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