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Invasive cervical cancer Background • Most common cancer of women in Africa, most common gynaecologic cancer, most common cancer of black and coloured women in SA • Probably always preventable: follows on SIL lesions and share epidemiology • Half of patients present in late stages • 80% squamous Ca, 20% adenocarcinoma Clinical • Ages: 45-60 (range 20-100!!) • Symptoms: none / + smear / BLEEDING / discharge. Pain is a LATE complaint • Signs: normal to cachectic. Paraneoplastic syndromes common: excessive anaemia, fever, cachexia • On cervix: ulcer / exophytic / endophytic growth Spread • 1 Direct: vagina, uterus then parametria then adjacent organs: bladder, rectum, vulva • 2 Lymphatic: pelvic nodes then para-aortic • 3 Hematogenous: late and rare: bone, lungs, liver Staging • Necessary to diagnose extent of cancer, to decide on appropriate therapy, to suggest prognosis • Staging is clinical but utilises special tests: – FBC, U&E, LFT, urine MCS – X ray chest – Ultrasound of bladder, ureters, upper abdomen and kidneys – Can do CT, MRI, Cystoscopy if needed Staging system • • • • • • • • IA: invisible, diagnosed on cone or LLETZ IB: Visible: <4cm = IBi, >4cm = IBii IIA: Cx + upper 2/3 of vagina IIB: Cx + parametria not to pelvic sidewall IIIA: Cx + entire vagina (lower 1/3) IIIB: Cx + parametria to pelvic sidewall IVA: pelvic organs: bladder, rectum IVB: distant organs Treatment options • Stage IA: LLETZ or cone is sufficient • Stage IB: RHND: radical hysterectomy and pelvic node dissection • Stage II, III: Radical radiotherapy to pelvis with added chemotherapy • Stage IV: chemotherapy plus pelvic irradiation Outcomes • Success of treatment is determined by stage, size, type, nodal status and general condition of patient including HIV status • Prognosis: 5year survival rates: – IA: =/- 100% – IB: - nodes: 85-90%; + nodes: 60-70% – II: 50-60% – III: 35-40% – IV: <10% Control of disease • Screening for precursors and treatment of HSIL • Early detection of invasive CaCx • Correct treatment per stage • Education education education Palliative care • Reasons for death: uraemia, bleeding, infection, general cachexia, HIV, metastases • When we cannot cure we still care • Cannot re-operate radically in most cases, cannot re-irradiate radically, can sometimes offer chemotherapy • Can relieve pain, look after normal needs, help, talk: at home, hospital, hospice