cervical cancer pdf - dr. maad

gynecology

Total Lectures :19

Dr. Maad

Cervical cancer

Lec . 4

Done by :

Ali Faleh

2016-2017

مكتب اشور لالستنساخ

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

Cervical cancer

Introduction :

• Cancer of the cervix is the most common female genital cancer in developing

countries every year about 500,000 women , acquire the disease and 75% are
from frame developing countries.

• About 300,000 women also die from the disease annually and of these 75% are

from developing countries

• Finland which has an advanced population based screening program has one of

the lowest rates in the world.

Incidence :

• 4-6 % of female genital cancers.

• Age : 40-50 years old

Risk factors and aetiology

• Coitus at young age: <16 years old increased risk by 50%

• Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.

• Smoking for > 12 years increase the risk by 12.7 folds.

• Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

• Previous CIN

• Poor uptake of screening program.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

• Long term use of the contraceptive pill increase the risk due to increasing

exposure to seminal fluids.

• Barrier method decrease the risk (condan)

• Immuno suppresion risk increased with immuno suppressed renal transplant

patients and in HIV positive women.

• HPV (Human papilloma virus ) infection mainly 16,18 the main aetiological is

infection with subtypes of HPV (16,18)

• Low socioecomic of PATIENT .

HPV 16,18

Smoking

Cervical cell

Male factors

Infhibation of CX cellp53 tumour

suppression gyne

Protection against

tumour

development lifted

Cancer develops

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

Type of suspected patients :

• Multiparous. + Low socioeconomic class.

• Poor hygiene.

• Prostitutes. + Low incidence in Muslims and Jews.

Predisposing factors:

1- Cervical dysplasia. 2- (Cervical intraepithelial neoplasia)

3- CIN III / CARCINOMA IN SITU

• THE LESION PROCEEDS THE INVASION BY 10-12 YEARS

Symptoms:

Early symptoms

Late symptoms

- None.

- Thin, watery, blood tinged vaginal

discharge frequently goes unrecognized

by the patient.

- Abnormal vaginal bleeding

Intermenstrual

Postcoital

Perimenopausal

Postmenopausal

- Blood stained foul vaginal discharge.

- Pain, leg oedema.

- Urinary and rectal symptoms

dysuria

haematuria

rectal bleeding

constipation

haemorrhoids

- Uraemia

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

Pathology type

Squamous cell carcinoma- 90%. Adenocarcinoma- 10%.

Types of growth

• Exophytic: is like cauliflower filling up the vaginal vualt.

• Endophytic: it appears as hard mass with a good deal of induration.

• Ulcerative: an ulcer in the cervix.

DIAGNOSIS

1- History :

• Many women are a symptomatic .

• Presented with abnormal routine cx smear

• Complain of abnormal vaginal bleeding

• I M bleeding

• post coital bleeding

• perimenopausal bleeding

• postmenopausal bleeding

• blood stain vaginal discharge

2- Examination:

• Mainly vaginal examination using cuscu’s speculem nothing is found in early stage

• Mass ,ulcerating fungating in the cervix

• P/V P/R is very helful.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

Preoperative evaluation

• Review her history.

General examination witch involve :

Anaemia.

Lymphadenopathy-Supraclavicular LN.

Renal area.

Liver or any palpable mass.

Oedema.

Laboratory tests:

CBC, LFT, RFT, Urine analysis.

Tumour markers.

Chest X- ray, abdominal X- ray, IVU.

CAT, MRI, if necessary.

Ultrasound.

Lymphography, if necessary.

Staging

Best to follow FIGO system.

• Examination under anaesthesia.

• Bimanual palpation.

• P/V, P/R.

• Cervical biopsy, uterine biopsy.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

• Cystoscopy, Proctoscopy, if necessary.

• Carcinoma of the cervix uteri.

•

Stage I

The carcinoma is strictly confined to the cervix (extension to the

corpus would be disregarded)

• IA Invasive carcinoma which can be diagnosed only by microscopy, with

deepest invasion ≤5 mm and largest extension≥7mm IA1 Measured stromal
invasion of≤3.0 mm in depth and extension of≤7.0 mm

• IA2 Measured stromal invasion of 3.0 mm and notN5.0 mm with an extension

of notN7.0 mm

• IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers

greater than stage IA⁎

• IB1 Clinically visible lesion≤4.0 cm in greatest dimension

• IB2 Clinically visible lesionN4.0 cm in greatest dimension

•

Stage II

Cervical carcinoma invades beyond the uterus, but not to the pelvic

wall or to the lower third of the vagina

• IIA Without parametrial invasion

• IIA1 Clinically visible lesion≤4.0 cm in greatest dimension

• IIA2 Clinically visible lesionN4 cm in greatest dimension

• IIB With obvious parametrial invasion

•

Stage III

The tumor extends to the pelvic wall and/or involves lower third of the

vagina and/or causes hydronephrosis or non-functioning kidney

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

• IIIA Tumor involves lower third of the vagina, with no extension to the pelvic

wall

• IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning

kidney

• Stage IV The carcinoma has extended beyond the true pelvis or has involved

(biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such,
does not permit a case to be allotted to Stage IV

• IVA Spread of the growth to adjacent organs

• IVB Spread to distant organs⁎

STAGES OF CANCER CERVIX

• Once cancer cervix is found (diagnosed), more tests will be done to find out if the

cancer cells have spread to other parts of the body. This testing is called staging.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

• PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

SPREAD:

Direct

Lymphatic

Dissemination (late)

- Uterus
body.

- Vagina.

-
Parametrium.

- Bladder and
rectum.

A- primary node:

parametrial.

Paracervical.

Vesicovaginal.

Rectovaginal.

Hypogastric.

Obturator and external iliac

- parametrial spread causes
obstruction of the ureters,
many deaths occur due to
uraemia.

- Obstruction to the cervical
canal results in pyometria.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

B-Secondary nodes:

Common iliac

Sacral

Vaginal

Paraaortic + Inguinal.

DIFFERENTIAL DIAGNOSIS

• Cervical ectropion.

• Cervical tuberculosis.

• Cervical syphilis, Schistosomiasis, and Choriocarcinoma are rare causes.

TREATMENT

• Surgical….. or Radiotherapy or both .

• Radiotherapy and Chemotherapy followed by Surgery.

• Palliative treatment.

• The choice of treatment will depend on :

• Fitness & age of the patients

• Stage of disease.

• Type of lesion

• Experience and the resources avalible.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

Surgical procedure

• The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and

some cases of IIb in young and fat patient

• Werthemeim’s hystrectomy

• Total abdominal hystrectomy including the parametrium.

• Pelvic lymphadenectomy

• 3 cm vaginal cuff

• The original operation conserved the ovaries ,since squamouss cell carcinoma

does not spread dirctly to the ovaries.

• Oophorectomy should be performed in cases of adenocarcinoma as there is 5-

10% of ovarian metastosis

• Surgery offers several advantage

• It allows presentation of the ovaries (radiotherapy will destroythem).

• There is better chance of preserving sexual function.

• (vaginal stonosis occur in up 85% of irradiates.

• Psychological feeling of removing the disease from the body .

• More accute staging and prognsis

COMPLICATIONS OF SURGERY

1- Haemorrhage: primary or secondary. 2- Injury to the bladder, uerters.

3- Bladder dysfunction. 4- Fistula.

5- Lymphocele. 6- Shortening of the vagina.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

INDICATIONS OF P/O XRT FOLLOWING WERTHEIM’S
HYSTERECTOMY (STAGE I , IIa):

• Positive pelvic lymph nodes.

• Tumour close to resection margins and/or parametrial extension.

Radiotherapy

• Stage IIb and III

• Radical Radiotherapy

• External irradiation (Teletherapy).

• Intracavitary radiation (Brachytherapy).

• In some cases of stage IIa or b radio and chemotherapy to be given then followed

by simple hysterectomy -------

Palliative therapy

• For stage IV – individualized therapy.

• Some suitable for palliative XRT ( usually intracavitary Caesium).

• Some suitable for extensive surgery & some for chemotherapy

• Good nursing care.

• Analgesia-must be used in sufficient amount to ----- pain (Codein sulfate,

Pethidine, Morphine, Diamorphine).

• Antiemetic if necessary.

• IV drip, entral, and parentral feeding.

• Urinary Catheterization.

• Other measures for symptom relief.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

PROGNOSIS

Depends on:

1- Age & Fitness of the patient.

Stage of the disease.

3- Type of the tumour. 4- Adequacy of treatment.

THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY:

• Stage I -------80%

• Stage II-------50-60%

• Stage III-------30-40%

• Stage IV-------4%

MANAGEMENT OF RECURRENT DISEASE

• 1. Local recurrence:

Radiation – if not used.

Pelvic exenturation.

• 2. Distant disease

Chemotherapy.

Follow up policy

• On completion of treatment all patients are given a vaginal dilator to use until

vaginal mucosa healed, this prevents vaginal stenosis.

• Premenopausal patients commenced on HRT:

• post hysterectomy-Extraderm skin patches 50 meg twice weekly.

• No hysterectomy- Cycloprogyn 1mg daily.

• The patient to be seen 1/12 post-treatment.

Cervical cancer Dr. Maad

[Year]

By : Ali Faleh

• 3 monthly for 2 years.

• 4 monthly for 3rd year.

• 6 monthly until 5years.

• Then yearly all her life.

• Patients with stage I and II disease treated with radical radiotherapy will be

assessed by EUA approximately 3 months after completing treatment.