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Management of Cervical Cancers Dr. H. Osore Shesor Clinic Gaborone.

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Presentation on theme: "Management of Cervical Cancers Dr. H. Osore Shesor Clinic Gaborone."— Presentation transcript:

1 Management of Cervical Cancers Dr. H. Osore Shesor Clinic Gaborone

2 Cervical Cancer Causative Agents (old teaching) Smoking, hormones,infectionsSmoking, hormones,infections Cervical cancer is rare in virgins but more common in sexually active womenCervical cancer is rare in virgins but more common in sexually active women Cervical cancer more common in women who become sexually active at early ageCervical cancer more common in women who become sexually active at early age Highly sexually active women with multiple sexual partners or those in contact with partner who has multiple sexual partnersHighly 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 diseaseCancer Cervix is an infectious disease Therefore Preventable diseaseTherefore Preventable disease

4 Classification of HPV types by Oncogenic Risk HPV subtypes Risk category 16,18,45,56High 30,31,33,35,39, 51,52, 58,66 Intermediate 6,11,42,43,44,53,54, 55 Low

5 Cancer Cervix Magnitude of Problem 500,000 new cases diagnosed yearly500,000 new cases diagnosed yearly 80% of new cases occur in developing countries80% of new cases occur in developing countries More than 200,000 deaths each yearMore than 200,000 deaths each year Second most cancer amongst women world wideSecond most cancer amongst women world wide Botswana- Cancer cervix second commonest nationallyBotswana- 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 cancerTherefore high risk increase in developing intraepithelial neoplasia and more likely rapid progression to invasive cervical cancer HIV increases the risk of pre-invasive disease (2 to 12 times higher cytological abnormalities rate in HIV positive women)HIV increases the risk of pre-invasive disease (2 to 12 times higher cytological abnormalities rate in HIV positive women)

7 Cervical Cancer Magnitude of problem cont’d Women with HIV have a higher prevalence of HPV infection and are more likely to develop persitent infectionWomen with HIV have a higher prevalence of HPV infection and are more likely to develop persitent infection Treatment outcomes for patients with cervical cancer are poorer for positive HIV than for HIV negative womenTreatment 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) %Epithelial tumours-(Squamous Cancer) % Mesenchymal tissue tumours-( Adenocarcinoma, sarcoma, embryonal) %Mesenchymal tissue tumours-( Adenocarcinoma, sarcoma, embryonal) %

9 Cancer Cervix Symptoms: - Asymptomatic in early stages/preclinical stage Haemorrhage-Metrorrhagia /PostcoitalHaemorrhage-Metrorrhagia /Postcoital Bleeding is usually severe in cauliflower- like exophytic (growth) lesionsBleeding is usually severe in cauliflower- like exophytic (growth) lesions Discharge- watery, offensive, blood stainedDischarge- watery, offensive, blood stained

10 Cancer Cervix Clinical features- Cachexia( wasting) and pain in advanced lesions Signs:- -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 Cervix Signs:- Cervix usually indurated, hard, friable, easily bleeds on contact and its mobility may be restricted or lostCervix usually indurated, hard, friable, easily bleeds on contact and its mobility may be restricted or lost Endocervical growth- cervix is expanded, firm and feels barrel shapedEndocervical growth- cervix is expanded, firm and feels barrel shaped

12 Cervical Cancer Diagnosis Pap Smear examinationPap Smear examination ColposcopyColposcopy Biopsy:-Biopsy:- -Excisional biopsy preferred to Punch biopsy -Excisional biopsy preferred to Punch biopsy Schiller’s Test/Acetic Acid helps in selecting the biopsy site where growth may not be obvious Schiller’s Test/Acetic Acid helps in selecting the biopsy site where growth may not be obvious Cone biopsy-in early cases Cone biopsy-in early cases Endocervical curettageEndocervical curettage

13 Cancer Cervix Investigations Complete Physical Exam, Pelvic Exam, Rectal Exam- EUA to be doneComplete Physical Exam, Pelvic Exam, Rectal Exam- EUA to be done Abdominal/Pelvic UltrasoundAbdominal/Pelvic Ultrasound Chest X-rayChest X-ray IVP IVP CystoscopyCystoscopy ProctosigmoidoscopyProctosigmoidoscopy

14 Cancer Cervix Treatment Quandary Surgery Or Radiotherapy?

15 Cervical Cancer Staging-(Clinical for treatment Planning) (FIGO) O: Carcinoma-in-situO: Carcinoma-in-situ 1a: Micro-invasive <=3mmD,<=7mmW (Ia1,Ia2)1a: Micro-invasive <=3mmD,<=7mmW (Ia1,Ia2) 1b: Invasive (>5mm FIGO, >3mm SGO)1b: Invasive (>5mm FIGO, >3mm SGO) IIa: Upper 2/3 of vaginaIIa: Upper 2/3 of vagina IIb: Parametrial Involvement ( but Pelvic wall)IIb: Parametrial Involvement ( but Pelvic wall) IIIa: Lower 1/3 vaginaIIIa: Lower 1/3 vagina IIIb: Pelvic wall involvement or hydronephrosis/non- funtional kidneyIIIb: Pelvic wall involvement or hydronephrosis/non- funtional kidney IVa: Bladder or rectal mucosa involvementIVa: Bladder or rectal mucosa involvement IVb: Distant metastasesIVb: Distant metastases

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17 Cervical Cervix Treatment Options Stage 1a-1 (<1mm)Stage 1a-1 (<1mm) -Conisation -Conisation -Simple hysterectomy-abdominal/vaginal approach -Simple hysterectomy-abdominal/vaginal approach Stage 1a-2 (1-3mm, lymph node -1%)Stage 1a-2 (1-3mm, lymph node -1%) -Modified radical hysterectomy-removal of medial ½ of uterosacral and cardinal ligaments with smaller vagina margin -Modified radical hysterectomy-removal of medial ½ of uterosacral and cardinal ligaments with smaller vagina margin

18 Cervical Cancer Treatment –Options: Recurrent disease:- as per previous treatmentRecurrent disease:- as per previous treatment -DXT > Exenteration -DXT > Exenteration -Surgery- DXT -Surgery- DXT Stage III and IV-Radiation/!!ExenterationStage III and IV-Radiation/!!Exenteration Radiation, as primary treatment is an option in all stagesRadiation, as primary treatment is an option in all stages Chemotherapy- as adjunct to DXT or for palliationChemotherapy- 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 lymphadenectomyStage Ib & IIa -Type III hysterectomy (radical hysterectomy with removal of most uterosacral and cardinal ligament, upper 1/3 of vagina, pelvic lymphadenectomy -Postop DXT -Postop DXT Bulky lesions and stage IIb Bulky lesions and stage IIb -Full irradiation followed 3-4 weeks later by type II hysterectomy -Full irradiation followed 3-4 weeks later by type II hysterectomy

20 Cancer Cervix Radical hysterectomy Removes corpus, Cervix, parametria, upper 1/3 of vaginaRemoves corpus, Cervix, parametria, upper 1/3 of vagina Uterine arteries divided at originUterine arteries divided at origin Ureters dissected through tunnelUreters dissected through tunnel Uterosacral ligament divided near rectumUterosacral ligament divided near rectum LymphadenectomyLymphadenectomy Oophorectomy not mandatoryOophorectomy not mandatory

21 Cervical Cancer Treatment Complications Acute:- FeverFever PerforationPerforation DiarrhoeaDiarrhoea Bladder spasmsBladder spasmsChronic:- ProctitisProctitis Radiation CystitisRadiation Cystitis FistulaFistula EnteritisEnteritis Femoral head necrosisFemoral head necrosis Rectal strictureRectal stricture

22 Cancer Cervix Follow-up At 2-3 months interval for 2 yearsAt 2-3 months interval for 2 years At 3-4 months interval – next 2-4 yearsAt 3-4 months interval – next 2-4 years At 6 months interval- Rest of the lifeAt 6 months interval- Rest of the life Tumour markers- CEA

23 Cervical Cancer Grigsby, P.W., et.al Radiother Oncol 12:289, 1988 Grigsby, P.W., et.al Radiother Oncol 12:289, 1988 Five-Year Survival: -

24 Cervical Cancer Special Cases –Difficulty to deal with Invasive cancer on cone biopsyInvasive cancer on cone biopsy Cervical stump carcinomaCervical stump carcinoma Invasive carcinoma found after simple hysterectomyInvasive carcinoma found after simple hysterectomy Cervical carcinoma in pregnancyCervical carcinoma in pregnancy Large barrel shaped lesionLarge barrel shaped lesion

25 Cancer Cervix Adenocarcinorma Has poorer prognosis stage by stage relative to squamous cancerHas poorer prognosis stage by stage relative to squamous cancer Tends to grow endophytically thus more often undetected until large tumour volume is presentTends to grow endophytically thus more often undetected until large tumour volume is present

26 Cancer Cervix Summary Prevention is the best curePrevention is the best cure Must carry out evaluation and Proper staging prior to treatmentMust carry out evaluation and Proper staging prior to treatment Surgery and radiotherapy are complimentary-(Surgeon and Radiotherapist together)Surgery and radiotherapy are complimentary-(Surgeon and Radiotherapist together) Mortality still high stage for stageMortality still high stage for stage Overall mortality is decreasing as cancers are diagnosed earlyOverall mortality is decreasing as cancers are diagnosed early

27 Cervical Cancer Vaccines & Cervical Cancer Gardasil – manufactured by Merck & Co. in USAGardasil – manufactured by Merck & Co. in USA the first vaccine developed to prevent genital lesions and genital warts due to human papillomavirus (HPV) types 6, 11 (warts), 16 and 18 (cervical cancer).the 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 age HPV types 16 and 18, cause approximately 70 percent of cervical cancers and against HPV types 6 and 11, cause approximately 90 percent of genital wartsHPV 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)Gardasil is a recombinant vaccine (contains no live virus) Given as three injections over a (6/12)six-month periodGiven as three injections over a (6/12)six-month period Females are not protected if they have been infected with that HPV type(s) prior to vaccinationFemales are not protected if they have been infected with that HPV type(s) prior to vaccination Immunization before potential exposure to the virusImmunization before potential exposure to the virus

29 Cervical Cancer Gardasil 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.Gardasil 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 Cancer Cervarix- second vaccine being researchedCervarix- second vaccine being researched Studies suggest that the vaccine may prevent infection against HPV-31 and HPV-45 in addition to HPV strains 16 and 18.Studies 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 StatesVaccine has not yet been approved for use in the general population in the United States.

31 Thank You Shesor Clinic Caring for women


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