Download Cervical cancer - Department of Obstetrics and Gynecology

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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
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Finland which has an advanced population
based screening program has one of the lowest
rates in the world.
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4-6 % of female genital cancers.
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40-50 years old
Risk factors and aetiology
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Coitus at
at young
young age:
age: <16
Coitus
<16years
yearsold
oldincreased
increasedrisk
riskby
by50%
50%
Number
of sexual
sexual partners: 66 sexual
Number of
sexual partners
partners or
or more
more increase
increaserisk
riskby
by
14.2
folds.
14.2 folds.
Smoking
Smoking
Smoking
1212
years
increase
thethe
riskrisk
by by
12.7
folds.
Smokingfor>
for>
years
increase
12.7
folds.
Male related
related risk
risk factors:
factors:
Male
number
the
partners
previous
relationships
numberofof
the
partners
previoussexual
sexual
relationshipsisisrelevant
relevant. .
cervical
risk
if if
partners
has
penile
cancer
cervicalcancer
cancer
riskincreased
increased
partners
has
penile
cancer
(circumcision)
(circumcision)
Previous
Previouswife
wifewith
withcervical
cervicalcancer.
cancer.
Previous CIN
CIN
Previous
Poor
uptake of
of screening program.
program.
Poor uptake
Long term
term use of the
Long
the contraceptive
contraceptive pill
pill increase the risk
risk due to increasing
increasing
exposure to seminal fluids.
fluids.
Barrier
method decrease the
Barrier method
the risk
risk (condan)
(condan)
Immuno suppresion
suppresion risk
riskincreased
increasedwith
withimmuno
immunosuppressed
suppressedrenal
renal
Immuno
transplant
in HIV
HIVpositive
positivewomen.
women.
transplant patients and in
HPV (Human
(Humanpapilloma
papillomavirus
virus) infection
) infectionmainly
mainly
16,18
HPV
16,18
thethe
main
aetiological
is infection
with
subtypes
of of
HPV
main
aetiological
is infection
with
subtypes
HPV(16,18)
(16,18)
Low socioecomic
socioecomic class
class of
Low
HPV 16,18
Smoking
Cervical cell
Male factors
Infhibation of CX
cellp53 tumour
suppression gyne
Protection against
tumour
development lifted
Cancer develops
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Multiparous.
Low socioeconomic class.
Poor hygiene.
Prostitutes.
Low incidence in Muslims and Jews.
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Cervical dysplasia.
(Cervical intraepithelial neoplasia)
CIN III / CARCINOMA IN SITU
THE LESION PROCEEDS THE INVASION BY
10-12 YEARS
Early 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.
Late symptoms
- Pain, leg oedema.
Urinary
and
symptoms
dysuria
haematuria
rectal bleeding
constipation
haemorrhoids
- Uraemia
rectal
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Squamous cell carcinoma- 90%.
Adenocarcinoma- 10%.
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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.
1- History.
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Many women are a symptomatic .
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Presented with abnormal routine cx smear
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Complain of abnormal vaginal bleeding
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I M bleeding
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post coital bleeding
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perimenopausal bleeding
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postmenopausal bleeding
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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.
Cytology
Histology
calposcopy
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o
o
o
o
o
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o
o
o
o
o
o
Review her history.
General examination:
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.
Best to follow FIGO system.
 Examination under anaesthesia.
 Bimanual palpation.
 P/V, P/R.
 Cervical biopsy, uterine biopsy.
 Cystoscopy, Proctoscopy, if necessary.
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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.
TO PLAN TREATMENT, A DOCTOR NEEDS
TO KNOW THE STAGE OF THE DISEASE.
Direct
Lymphatic
Dissemination
(late)
-
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.
Uteruq.
Vagina.
Parametrium.
Bladder and rectum.
B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Inguinal.
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Cervical ectropion.
Cervical tuberculosis.
Cervical syphilis, Schistosomiasis, and
Choriocarcinoma are rare causes.
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Surgical.
Radiotherapy.
Radiotherapy & Surgery.
Radiotherapy and Chemotherapy followed by
Surgery.
Palliative treatment.
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Fitness of the patients
Age of the patients
Stage of disease.
Type of lesion
Experience and the resources avalible.
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The classic surgical procedure is the
wertheim’s hystrectomy for stage Ib,IIa, and
some cases of IIb in young and fat patient
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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
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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
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Haemorrhage: primary or secondary.
Injury to the bladder, uerters.
Bladder dysfunction.
Fistula.
Lymphocele.
Shortening of the vagina.
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.
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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 -------
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For stage IV – individualized therapy.
Some suitable for palliative XRT ( usually intracavitary
Caesium).
Some suitable for extensive surgery.
Some suitable 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.
Depends on:
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Age of the patient.
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Fitness of the patient.
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Stage of the disease.
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Type of the tumour.
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Adequacy of treatment.
THE OVERALL 5 YEARS SURVIVAL
FOLLOWING THERAPY:
 Stage I -------80%
 Stage II-------50-60%
 Stage III-------30-40%
 Stage IV-------4%
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1. Local recurrence:
Radiation – if not used.
Pelvic exenturation.
2. Distant disease
Chemotherapy.
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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.
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.
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Cancer of the cervix is still quite common,
reduction in incidence depends on the quality
of the screening program.
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The aetiology appears to be multifactorial the
prime oncogenic agent is probably [HPV16,18].
Clinical presentation is with
inermenstrul,postcoital, postmenospausal
bleeding or following abnormal cytology.
Tumour spreads locally to involve the uterus
bladder , vagina, parametrium, ureters, rectum
and bone.
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Spread also to the internal and external iliac ,
obdurater and common iliac nodes then to
para- aortic nodes.
Blood borne metastasis spread to liver, lung
and bone occur .
Microinvasion squamous tumour carry a good
prognosis allowing conservative treatment
initially if required.
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Early invasive squamous cell disease (stage
Ib,IIa and in some cases of IIb) may be treated
by either a wertheimes hysterectomy or
radiotherapy as first line treatment.
Advanced stage (IIb, III,IV) treated by radio or
chemotherapy.
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Glandular tumours (adenocarcinomas) are not
detectable by screening are associated with
skip lesions and require radical surgery.