Cervical Cancer

Introduction

• Third most common gynecologic cancer– Also 3rd cause of death in US– Second most common type in places where there

is no preventive screening– HPV is central to its development; detected 99.7%

Epidemiology

• 530,000 new case cases worldwide, and for 275,00 deaths in 2008.

• Mortality rate 52% worldwide• 75% decrease due to vaccination and

screening in the past 50 years.• In Women:– 10th most common type– developed country– 2nd most common type – developing countries

Risk Factors

1. Early onset of sexual activity – by 2 fold inc2. Multiple Sexual partners – by 2 fold inc3. Hx of STI (e.g., Chlamydia, genital herpes)4. Hx of Vulvar or vaginal squamous

intraepithelial neoplasia or cancer5. Immunosuppression (e.g., AIDS)6. Oral contraceptives, adenocarcinoma – (≥5 years' use versus never-use: RR 1.90, 95% CI

1.69-2.13).

Pathogensis

• Four major steps in cervical cancer development:– Oncogenic HPV infection of metplastic epithelium

at transformation zone– Persistence of HPV infection– Progression of a clone epithelial cells from

persistent viral infection to precancer– Development of carcinoma and invasion through

the basement membrane.

Oncogenic HPV

Histopathology

Route of Spread

• Can spread by – Direct extention: involve the uterine corpus,

vagina parametria, perotoneal cavity, bladder and recturm

– Lymphatic: obtruae lymph node pevlic side wall of common illiac, and then paraortic

– Hematogenous: lungs, liver, and bone. • Less frequent: bowel, adrenal glands, spleen and brain

Clinical Manifestations

• Early is frequently asymptomatic• Common symptoms at presentation:

– Irregular or heavy vaginal bleeding– Post-coital bleeding– Some present with vaginal discharge:

• Can be watery, purulent and malodorous– Non specific finding for vaginitis and cervicitis

• Advance disease:– Back pain radiate to posterior lower extremities– Bowel or urinary symptoms:

• Pressure related complaints, hematuria, hematochezia, vaginal passage of urine or stool (Uncommon and suggest advance)

• Asymptomatic women – can be discovered due to screen

Diagnosis

• By biopsy, colposcopy with direct biopsy• Physical:

– Pelvic exam: visualization of cervix upon speculum examination may reveal a visible lesion, or sometimes normal appearance• Lesion that is raised friable or has appearance of condyloma should be

biopsied.• Do not biopsy Nabothian Cyst

– Thorough pelvic exam, includes rectovaginal examination and assessment of tumour size and vaginal parametrial involvement for staging

• Cervical cytology – principal of screening (conjoined with HPV testing)

Colposcopy

Nabothian Cyst

• Endophytic tumors can result in an enlarged, indurated cervix whose surface is smooth, referred to as a “barrel shaped cervix”.

Staging: • Clinical preferred on surgical• Accurate pretreatment staging of cervical

cancer is critical, as it determines therapy (ie, surgery, chemoradiation, chemotherapy alone) and prognosis

• Diagnosis (histology) the extent of disease

Two parallel clinical stages:

• FIGO system:– based upon• physical examination• Endoscopic diagnostic procedures • Imaging studies

• TNM system:– “T" stages correspond to the FIGO stages with the

exception of carcinoma in situ– Includes a pathologic staging system (pTNM)

STAGING PROCEDURE• Physical examination

– Pelvic examination– Examination for distant metastases

• Cervical biopsy– Colposcopy with directed cervical biopsy– Endocervical curettage– Conization

• Endoscopy– Hysteroscopy– Cystoscopy– Proctoscopy

• Imaging studies– Intravenous pyelogram (IVP) … (CT, or MRI)– Imaging with a plain chest radiograph and radiograph of the skeleton

Adequacy of Colposcopy

• Must evaluate the entirety of the lesion– Can you follow the entire lesion?– Does it go past the SCJ and into the endocervix?– Does it move into the vagina?

• Must evaluate the entirety of the SCJ– Is it obscured by prior treatments?– Does it recede into the endocervix?– Proper evaluation of both the lesion and the SCJ is an adequate

colposcopy

Failure of either criteria is an inadequate colposcopy and leads to changes

Colposcop

STAGING PROCEDURE

STAGING PROCEDURE

Staging For Cervical Cancer

Stages of Cervical Cancer

Cervical CancerTreatment Modalities

1.Surgery , Radical Hysterectomy + PLND .

2. Chemo / Radiation Therapy , including :

A. Tele - therapy ( External Radiation) .

B. Brachy- therapy ( Intracavitary ) . C. Neo-adjuvant Chemotherapy .

Types Of Hysterectomies

Radical Hysterectomy

Complications:

Bleeding ! Bladder ! Bowel ! General !

Type I Type II Type III type IV

Radical Hysterectomy

Types Of Radical Hysterectomy

Radiation Therapy Complications

External : Abdominal

organs ! Bone Marrow ! Bowel ( Small /

Large). Skin !

Internal : Cystitis ! Proctitis ! Vaginal tissues !

Decision depends on : 1. Patient age . 2. Stage of disease . 3. Performance status

. 4. Other factors .

Cervical CancerTreatment Modalities

Work UpA chest X-ray looks for spread to the lungs. IVP can be used to look at the urinary

tract. A CT scan is necessary !!!The bladder and urethra are evaluated by

cystoscopy.The rectum is evaluated by a procto

signoidoscopy. Lymph nodes are evaluated by CT scans,

invasion of soft tissues is evaluated by MRI scans !

??? Distal metastases is evaluated by PET scans.