Presentation on theme: "Management of Cervical Cancers"— Presentation transcript:
1 Management of Cervical Cancers Dr. H. OsoreShesor ClinicGaborone
2 Cervical Cancer Causative Agents (old teaching) Smoking, hormones,infectionsCervical cancer is rare in virgins but more common in sexually active womenCervical cancer more common in women who become sexually active at early ageHighly sexually active women with multiple sexual partners or those in contact with partner who has multiple sexual partners
3 Cancer Cervix Cancer Cervix is an infectious disease Therefore Preventable disease
4 HPV subtypes Risk category 16,18,45,56 High 30,31,33,35,39, Classification of HPV types by Oncogenic RiskHPV subtypesRisk category16,18,45,56High30,31,33,35,39,51,52, 58,66Intermediate6,11,42,43,44,53,54,55Low
5 Cancer Cervix Magnitude of Problem 500,000 new cases diagnosed yearly 80% of new cases occur in developing countriesMore than 200,000 deaths each yearSecond most cancer amongst women world wideBotswana- Cancer cervix second commonest nationally
6 Magnitude of the Problem Cont’d Therefore high risk increase in developing intraepithelial neoplasia and more likely rapid progression to invasive cervical cancerHIV increases the risk of pre-invasive disease (2 to 12 times higher cytological abnormalities rate in HIV positive women)
7 Cervical CancerMagnitude of problem cont’dWomen with HIV have a higher prevalence of HPV infection and are more likely to develop persitent infectionTreatment outcomes for patients with cervical cancer are poorer for positive HIV than for HIV negative women
8 Cervical Cancer Types of Cervical Cancers (histopathologically) Epithelial tumours-(Squamous Cancer) %Mesenchymal tissue tumours-( Adenocarcinoma, sarcoma, embryonal)-10-20%
9 Cancer Cervix Symptoms: - Asymptomatic in early stages/preclinical stageHaemorrhage-Metrorrhagia /PostcoitalBleeding is usually severe in cauliflower-like exophytic (growth) lesionsDischarge- watery, offensive, blood stained
10 Cancer CervixClinical features- Cachexia( wasting) and pain in advanced lesionsSigns:--Obvious lesion or growth may or may not be present-when obvious lesion growth present, it may be exophytic cauliflower-like or endophytic, ulcerative and scirrhous-
11 Cancer CervixSigns:-Cervix usually indurated, hard, friable, easily bleeds on contact and its mobility may be restricted or lostEndocervical growth- cervix is expanded, firm and feels barrel shaped
12 Cervical Cancer Diagnosis Pap Smear examination Colposcopy Biopsy:- -Excisional biopsy preferred to Punch biopsySchiller’s Test/Acetic Acid helps in selecting the biopsy site where growth may not be obviousCone biopsy-in early casesEndocervical curettage
13 Cancer Cervix Investigations Complete Physical Exam, Pelvic Exam, Rectal Exam- EUA to be doneAbdominal/Pelvic UltrasoundChest X-rayIVPCystoscopyProctosigmoidoscopy
14 Cancer CervixTreatment QuandarySurgery Or Radiotherapy?
15 Cervical Cancer Staging-(Clinical for treatment Planning) (FIGO) O: Carcinoma-in-situ1a: Micro-invasive <=3mmD,<=7mmW (Ia1,Ia2)1b: Invasive (>5mm FIGO, >3mm SGO)IIa: Upper 2/3 of vaginaIIb: Parametrial Involvement ( but Pelvic wall)IIIa: Lower 1/3 vaginaIIIb: Pelvic wall involvement or hydronephrosis/non-funtional kidneyIVa: Bladder or rectal mucosa involvementIVb: Distant metastases
17 Cervical Cervix Treatment Options Stage 1a-1 (<1mm) -Conisation -Simple hysterectomy-abdominal/vaginal approachStage 1a-2 (1-3mm, lymph node -1%)-Modified radical hysterectomy-removal of medial ½ of uterosacral and cardinal ligaments with smaller vagina margin
18 Cervical Cancer Chemotherapy- as adjunct to DXT or for palliation Treatment –Options:Recurrent disease:- as per previous treatment-DXT > Exenteration-Surgery- DXTStage III and IV-Radiation/!!ExenterationRadiation, as primary treatment is an option in all stagesChemotherapy- as adjunct to DXT or for palliation
19 Cancer Cervix Options: Stage Ib & IIa -Type III hysterectomy (radical hysterectomy with removal of most uterosacral and cardinal ligament, upper 1/3 of vagina, pelvic lymphadenectomy-Postop DXTBulky lesions and stage IIb-Full irradiation followed 3-4 weeks later by type II hysterectomy
20 Cancer Cervix Radical hysterectomy Removes corpus, Cervix, parametria, upper 1/3 of vaginaUterine arteries divided at originUreters dissected through tunnelUterosacral ligament divided near rectumLymphadenectomyOophorectomy not mandatory
21 Cervical Cancer Treatment Complications Acute:-FeverPerforationDiarrhoeaBladder spasmsChronic:-ProctitisRadiation CystitisFistulaEnteritisFemoral head necrosisRectal stricture
22 Cancer Cervix Follow-up At 2-3 months interval for 2 years At 3-4 months interval – next 2-4 yearsAt 6 months interval- Rest of the lifeTumour markers- CEA
23 Cervical Cancer Five-Year Survival: - The extent of reduction in cervical cancer mortality is in proportion to the number of women being screened, with no decrease in incidence or mortality in unscreened populations.The reasons for the reduction in cervical cancer mortality in screened populations are not clear. Although identification of invasive cancer at an earlier and more curable stage certainly contributes to the lower rate, most of the benefit is thought to be the result of identification and treatment of precancerous cervical lesions, thereby preventing invasive disease.Grigsby, P.W., et.al Radiother Oncol 12:289, 1988
24 Cervical Cancer Special Cases –Difficulty to deal with Invasive cancer on cone biopsyCervical stump carcinomaInvasive carcinoma found after simple hysterectomyCervical carcinoma in pregnancyLarge barrel shaped lesion
25 Cancer Cervix Adenocarcinorma Has poorer prognosis stage by stage relative to squamous cancerTends to grow endophytically thus more often undetected until large tumour volume is present
26 Cancer Cervix Summary Prevention is the best cure Must carry out evaluation and Proper staging prior to treatmentSurgery and radiotherapy are complimentary-(Surgeon and Radiotherapist together)Mortality still high stage for stageOverall mortality is decreasing as cancers are diagnosed early
27 Cervical Cancer Vaccines & Cervical Cancer Gardasil –manufactured by Merck & Co. in USAthe first vaccine developed to prevent genital lesions and genital warts due to human papillomavirus (HPV) types 6, 11 (warts), 16 and 18 (cervical cancer).Vaccine is approved for use in females 9-26 years of ageHPV types 16 and 18, cause approximately 70 percent of cervical cancers and against HPV types 6 and 11, cause approximately 90 percent of genital warts.
28 Cervical Cancer HPV Vaccine cont’d.. Gardasil is a recombinant vaccine (contains no live virus)Given as three injections over a (6/12)six-month periodFemales are not protected if they have been infected with that HPV type(s) prior to vaccinationImmunization before potential exposure to the virus
29 Cervical CancerGardasil does not protect against less common HPV types not included in the vaccine, therefore routine and regular Pap screening remain critically important to detect precancerous changes in the cervix to allow treatment before cervical cancer develops.
30 Cervical CancerCervarix- second vaccine being researchedStudies suggest that the vaccine may prevent infection against HPV-31 and HPV-45 in addition to HPV strains 16 and 18.Vaccine has not yet been approved for use in the general population in the United States.
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