cervical cancer... diagnosis treatment treatment

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CERVICAL CANCER... Diagnosis Diagnosis Treatment Treatment

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Page 1: CERVICAL CANCER... Diagnosis Treatment Treatment

CERVICAL CANCER...

Diagnosis Diagnosis && TreatmentTreatment

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CERVICAL CANCER...

The most common malignancy in gynecological oncology

Incidence: 7.8/100,000 Mortality: 2.7/100,000 Diagnosis: biopsy Main modality of treatment: surgery and

radiation Goal of treatment: cure, except stage 4b

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Special Case

38 yrs, G3/P1, nurse C/O: postcoital bleeding for 2 months Menstruation regular with 30 days cycle and 5

days duration. Abnormal discharge with bad smell. LMP: 12 days ago

Pap smear: squamous cell cancer PV: 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

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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?

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How can we make a diagnosis?

SYMPTOMS Abnormal vaginal bleeding postcoita

l bleeding* contact bleeding Abnormal vaginal discharge Asymptomatic, just abnormal pap s

mear

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SYMPTOMS

The 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.

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SYMPTOMS

Late 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.

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How can we make a diagnosis?

SIGNS Vagina: mucous,

fornix Cervix:

erosion growth ulceration barrel-shaped

Uterus: size, mobility Paramet: thickening

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Gross appearence

Three 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.

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How can we make a diagnosis?

CLINICAL TESTS: Pap smear Colposcopy and target biopsy Endocervical curettage (ECC) Cone biopsy Biopsy

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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

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Pap Smear Show Squamous Cell CarcinomaPap Smear Show Squamous Cell Carcinoma

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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.

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Colposcopy ExaminationColposcopy Examination

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Cone biopsy

Indications for cone biopsy 1.The lesion cannot be fully visualized .

2.The ECC is positive

3.There is significant discrepancy between the Pap smear and biopsy.

4.A biopsy reveals microinvasive squamous cell carcinoma

5.A biopsy reveals adenocarcinoma in situ

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How can we make a diagnosis?

A pap smear is only a screening test!

Definitive diagnosis of cervical cancer requires a BIOPSY!

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How can we evaluate the patient?

Histologic type: Squmous cell carcinoma ( SCC) 80% Adenocacinoma 10%-15% Others 5%-10%

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Routes of spread

Into 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

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How can we evaluate the patient?

Stage: Pelvic examination, Rectovaginal examination, Intravenous pyelography(IVP) Ultrasonography or CT

Staging is clinical, but can use IVP and CT Cervical cancer is the only gynecologic

malignancy that is not surgically staged

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Clinical Staging for Cervical Carcinoma

Stage 0Carcinoma in-situ; Confined to the epithelium only

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Clinical Staging for Cervical Carcinoma

Stage I Invasion is strictly confined to the cervix• Ia: 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

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Clinical Staging for Cervical Carcinoma

Stage I Invasion is strictly confined to the cervix• IB: All others preclinical lesions and clinical lesion

s confined to the cervix.• Ib1: Clinical lisions no greater than 4 cm. • Ib2: Clinical lisions greater than 4 cm.

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Clinical Staging for Cervical Carcinoma

Stage IIInvasion is beyond the cervix but not to the pelvic wall or lower third of the vagina•IIA Parametria is not involved•IIB Parametria is involved

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Clinical Staging for Cervical Carcinoma

Stage IIIInvasion is to the pelvic wall or lower third of vagina• IIIA Pelvic wall is not involved• IIIB Pelvic wall is involved;

hydronephrosis or nonfunctioning of the kidney may occur because of tumor

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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 organs•IVB Spread is to distant organs

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How can we evaluate the patient?

Age: treatment vary with the patient’s age

Marriage statue Reproductive history : menstrual,

contraceptive, Gynecologic, Obstetric Social history: sexually activity, social

statue Family history: children, partner,parents Past medical history

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How can we evaluate the patient?

General condition: pulmonary (Chest-x-ray) cardiac function (ECG) liver function renal function

Special disorders: bleeding diseases, diabetes mellitus, and infection

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How can we manage the patient?

Management of premalignant lesions: make definitive diagnosis selection of an appropriate mode of therapy

1. carbon dioxide laser 2. cryotherapy 3. electrocautery 4. loop electrodiathermy excision procedure (LEEP ) 5. Conization 6. hysterectomy

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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)

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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

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How can we manage the patient?

For invasive cancer: 1 Simple hysterectomy (Ia1) 2 Modified radical hysterectomy (Ia2) 3 Radical hysterectomy and RPND (Ib-IIa) 4 Radiotherapy (any stage, IIb III IV) 5 Chemotherapy

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CERVICAL CANCER...

Prognosis: 55% five-year survival (all stage combined)

stage I 85% stage II 60% stage III 30% stage IV 10%

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How can we prevent cervical cancer?

Risk factors Education Screening

program Treatment of

premalignant lesions

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How can we prevent cervical cancer?

RISK FACTORS: early age of sexual

intercourse multiple sexual partners low socioeconomic

classes early age of pregnancy high parity cigarette smoking HPV (16,18 ) immunocompromised

host

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How can we prevent cervical cancer?

EDUCATION: Population

education Medical staff

education

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How can we prevent cervical cancer?

SCREENING: committee program:

onset of screening, duration, end of screening

methods for screening pap smear, CCT, thin-rep, HPV typing

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Case discussion

27 yrs, G0/P0, married for 2 yrs C/O: one episode of postcoital bleeding

for 2 weeks Menstruation regular with 30 days cycle

and 5 days duration. No abnormal discharge. LMP: 2 weeks ago

Pap smear: LSIL with HPV infection, clue cell > 50%

PV: Vulva and vaginal: normal Cervix: erosion with contact bleeding,Uterus: N/S, mobile. Parametrium: clear

Wants to preserve her reproductive function

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Treatment strategy for CIN

Leep (ectocervix),CO2 laser therapy,

Cryotherapy

No suspicion of invasion

Cone biopsy,cold knife cone, Laser cone,

LEEP cone (ecto and endocervix)

Suspicion of invasion

BiopsyEndocervical currettage

Repeat Pap sm ear

Suspicion of CIN/S IL

Pap sm ear result abnorm al

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Case discussion

48 yrs, G3/P1, midlife C/O: postcoital bleeding for 4 months Menstruation irregular with 30-60 days

cycle and 5-20 days duration. Abnormal discharge with bad smell. LMP: 2 months ago

Pap smear: squamous cell cancer PV: 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 right

Biopsy:SCC. IVP:nonfunctional kidney

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Treatment strategy for Invasive Cervical Cancer

Cone Biopsy orSim ply hysterectom y

M icroinvasive invasion (less than 3m m )

Radical Hysterectom y andPelvic Lym phadenectom y

orPelvic Radiation

Early Stage IB or IIA

M ultim odality TherapyPelvic Rad iatio n T h erap y

o r In vastig atio n al Pro teco ls

Advanced or Bulky Disease

Staging

Invasive cervical cancer

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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?

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Cervical cancer

Cervical 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 tum

or BIOPSY! Radiation and operation are both effective treament . Goal of the treatment: cure, except stage IV

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