Cervical Cancer
Etiology:-The main cause of cervical cancer is infection with HPV. HPV have many strains, those that important in cervical cancer:-
High risk:- 16 , 18
Low risk:- 6 , 11( cause genital warts )
HPV infection alone does not lead to cancer other cofactors need to be present for malignant changes to occur:-
Smoking
HIV
Immunodeficiency (ex:- renal transplant )
Pregnancy
Oral contraceptive pills ( but barrier method decreases the risk)
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.
That is why vaccination is indicated for men.
Epidemiology:-
It's the most common gynecological cancer (4-6 % of female genital tract cancers). The age of onset is 40s-50s.
The disease is more common in those with low socioeconomic state, poor hygiene and is less common in Muslims and Jews.
Pathogenesis:-
HPV infection can result in cervical dysplasia, this is followed by a precancerous lesion cervical intraepithelial neoplasia (CIN) and it had been classified according to the depth of invasion of cervical epithelium into:-
CIN 1:- involvement of one third of the mucosa
CIN 2 :- involvement of two thirds of the mucosa
CIN 3 ( carcinoma in situ ) :- all mucosa involved
THE LESION PROCEEDS THE INVASION BY 10-12 YEARS
Cervical carcinoma is mostly a squamous cell carcinoma (90%). HPV infection alone and CIN I are grouped together as ‘low – grade squamous intraepithelial lesions' (LSIL) and CIN II and CIN III as ‘high –grade SIL' (HSIL).Clinical features:-
Early:- asymptomatic
Thin watery vaginal discharge
Vaginal bleeding
Foul smelling blood stained vaginal discharge
Late:- Due to spread:-
painLymph nodes:- Leg edema
Bladder:- Dysurea, hematuria
Rectum:- Rectal bleeding, constipation, hemorrhoids
Ureter:- uremia ( a cause of death ).
Obstruction of cervical canal:- pyometria
On examination:- may be normal or show a mass ( fungating/ulcerating).
Do bimanual exam to:- asses the size of the uterus, adnexeal mass and mobility of the cervix.
PR/PV are very helpful.
Differential diagnosis:-
Cervical ectropion.
Cervical tuberculosis.
Cervical syphilis, Schistosomiasis, and Choriocarcinoma are rare causes.
Investigations:-
The definitive diagnosis is by biopsy done on colposcopy which also enables staging of the disease.
Then asses the eligibility of the patient for surgery:-
CBC, RFT, LFT, CXR, IVU
U/s to asses the state of the uterus
MRI to asses site and metastases
Treatment:-
Only stage Ia and Ib are resectable
Stage IIa is only sometimes resectable
The operation is called wertheim’s hystrectomy which is a radical hysterectomy (the whole uterus, tubes, parametrium, upper one third of vagina, and lymph nodes are removed).
Note:- In squamus cell carcinoma, the ovaries can be preserved since no metastases occur to ovaries, while in adenocarcinoma the ovaries must be removed.
Why surgery?
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 accurate staging and prognsis
Complications of surgery:-
Haemorrhage: primary or secondary.
Injury to the bladder, uerters.
Bladder dysfunction.
Fistula.
Lymphocele.
Shortening of the vagina.
Indications of radiotherapy:-
Positive pelvic lymph nodes.
Tumor close to resection margins and/or parametrial extension.
Irresectable tumors (> IIa)
In some cases of stage IIa or b radio and chemotherapy to be given then followed by simple hysterectomy to decrease the size of the tumor
Prognosis:-
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.
Preventing cervical cancer
Avoiding exposure to HPV
Current screening guidelines
The new HPV vaccines
Method of screening:-
The most important method is the pap smear.
It is a screening tool but not diagnostic (low sensitivity).
Recently a new test called liquid pap test was presented, it decreases errors rate and can test for HPV infection in the specimen.
Cervical Cancer Screening Guidelines
First screen 3 years after first intercourse or by age 21
Screen annually with regular Paps or every 2 years with liquid-based tests
After three normal tests, can go to every three years
Stop at 65-70 years with history of negative tests
Still need annual check-ups
Endometrial carcinoma
Epidemiology:
fifth leading cancer in the women
it’s the most common gynaecological cancer but in developing countries it’s surpassed by cervical cancer.
Mean age of presentation is 56 years
Aetiology:
indiscriminate use of oestrogen.
un opposed oestrogen.
Theca granulosa cell tumours.
Risk factors:-
Nullipara or low parity
Middle or upper social class
Overweight and obese patients
Early menarche and late menopause
Associated factors:
Diabetes or abnormal glucose tolerance test.
Hypertension.
Fibroids.
Polycystic ovarian syndrome.
Infertility, Arthritis, and Thyroid disease.
Use of TAMOXIFEN.
Previous pelvic irradiation.
Positive family history of breast, ovarian, and to lesser extent colon cancer.
Protective factors:
Smoking !
Use of oral contraceptive.
Use of progesterone.
Predisposing factors:
Complex Atypical adenomatous hyperplasia 25% (10 - 60%) to progress to cancer
It is classified into endometriod adenocarcinoma ( most common ) and non endometriod types
Clinical features:-
Symptoms:-
Postmenopausal bleeding or staining( this symptom should be assumed to be caused by carcinoma of the endometrium until proved otherwise), only 10% of PMB have endometrial carcinoma.
Perimenopausal menstrual irregularities.
Blood stained vaginal discharge.
Heavy and irregular vaginal bleeding
Examination:-
it should include palpation of supraclavicular and inguinal lymph nodes
DO Bimanual vaginal examination assesses uterine size, and mobility, state of parametria and adnexa
Bimanual recto-vaginal examination.
Spread :
Invasion through the myometrium and by filling the uterine cavity.
Invasion to the cervix with subsequent lymphatic spread involving the iliac and para-aortic nodes.
From upper uterus may spread to round ligament to the deep inguinal nodes.
In advanced cases, the blood-stream spread may carry to the lungs, liver, and to the bone.
Investigations For diagnosis:-
Pap smear
Vaginal U/S
Endometrial biopsy
MRI to localize the lesion and asses for invasion
Proctoscopy , cytoscopy, Sigmoidoscopy, bone scan to asses for metastases
Then prepare her for surgery:- CBC, LFT, RFT, CXR .....
Treatment:-
Endometriod:-
If < 50% of the myometrium is involved we do total abdominal hysterectomy and bilateral sapingo-oopherectomy, peritoneal washing, and ?lymph node biopsy. (TAH+BSO+PW+LNB ).
If > 50% of the myometrium is involved then radiotherapy
Non endometriod:- Radiotherapy
Indications for post operative radiotherapy:
Moderate or poor differentiation(G2,G3).
Other histological type than adenocarcinoma as papillary or clear cell carcinoma.
Invasion of myometrium of> 1/2.
Positive peritoneal wash.
Positive lymph nodes
adjuvant hormonal therapy:
Medroxyprogesterone acetate (200- 400 mg daily)
Gn RH analogues
The rule of chemotherapy is limited
Anthracycline
Doxorubine.
platinum drugs
All are effective drugs can be used in a single course.