Download HPV

Cervical Cancer
Xin LU
OB/GYN Hospital
Fudan University
Contents
General information
 CINs
 Spread pattern
 FIGO staging
 Clinical signs
 Diagnosis and differential diagnosis
 Principle for treatment
 Prevention
 Surveillance

Key words








Cervical cancer (Cxca)
Human Papillomavirus (HPV)
Radical Hysterectomy (RH)
Radiotherapy (RT)
Chemotherapy (CT)
Neoadjuvant chemotherapy (NACT)
Concurrent chemo-radiotherapy (CCCR)
Radical Trachelectomy
Female Reproductive Anatomy
Cervical Cancer
子宫颈癌

World report:
 Account for 1/3 female malignancies
 New cases: 529 800
 Death: 275 100
 85% developing country

The 4th most common cause of death
from malignancy in women.
Cxca Progression
HPV infection
CINs
Carcinoma in situ
≈10-15yr
Cervical cancer
Etiology
High-risk factors
HR-HPV
 Use of oral contraceptives
 Smoking
 Multiple sexual partners
 History of herpes infection
 History of STD

Human Papillomavirus , HPV
人乳头瘤状病毒

1972：Harald zur Hausen Zur
Hausen

1995：High-risk HPV by
International Agency for
Research on Cancer，IARC

90% cervical cancer with HPV
infection
HPV








High risk HPV（HR-HPV）
oncogenic HPV
HPV 16,18,31,33,35,39,45, 51,52,56,58,59,68,73,82
HSIL, Cxca
Low risk HPV（LR-HPV）
non-carcinogenic HPV
HPV 6,11,42,43,44,54,61,70,72,81
LSIL
Precursors
CIN: Cervical Intraepithielial Neoplasm
 CIN I：mild dysplasia，1/3
 CIN II：moderate dysplasia，1/3-2/3
 CIN III：severe dysplasia , 3/3

CIS : carcinoma in situ
Precursors ---CINs
Cervical cancer
Histological Types
Squamous carcinoma 80-85%
Adenocaricinoma 15-20%
Endometrial carcinoma
Clear cell carcinoma
Adenosquamous 3-5%
Undifferentiated carcinoma
Minimal deviation adenocarcinoma (MDA)
Neuroendocrine tumor (small cell) <5%
Spread pattern

Transcelomic
 most common

Lymphatic
 retroperitoneal ( pelvic and paraaortic ) LN
spreading is common in advanced- stage

Hematogenous
 uncommon
FIGO
stage
FIGO Staging
I The carcinoma is strictly confined to the cervix (extension to the uterine corpus should be disregarded).
IA Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a
maximum depth of 5mmb and no wider than 7mm. (All gross lesions even with superficial invasion are
Stage IB cancers.)
IA1: Measured invasion of stroma ≤3mm in depth and ≤7mm width.
IA2 : Measured invasion of stroma >3mm and <5mm in depth and ≤7mm width.
IB Clinical lesions confined to the cervix, or preclinical lesions greater than stage IA.
IB1: Clinical lesions no greater than 4cm in size.
IB2: Clinical lesions >4cm in size.
II The carcinoma extends beyond the uterus, but has not extended onto the pelvic wall or to the lower third of
vagina.
IIA Involvement of up to the upper 2/3 of the vagina. No obvious parametrial involvement.
IIA1: Clinically visible lesion ≤4cm
IIA2: Clinically visible lesion >4cm
IIB Obvious parametrial involvement but not onto the pelvic sidewall.
III The carcinoma has extended onto the pelvic sidewall. On rectal examination, there is no cancer-free space
between the tumor and pelvic sidewall. The tumor involves the lower third of the vagina. All cases of
hydronephrosis or non-functioning kidney should be included unless they are known to be due to other
causes.
IIIA Involvement of the lower vagina but no extension onto pelvic sidewall.
IIIB Extension onto the pelvic sidewall, or hydronephrosis/non-functioning kidney.
IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder
and/or rectum.
IVA Spread to adjacent pelvic organs.
IVB Spread to distant organs.
Platform of diagnosis for
cervical diseases
 Pap
smear
TBS classification
 TCT
 HPV
 Colposcopy--biopsy
 LEEP
Cervical cancer
Symptoms
No symptoms
 Abnormal pap smear
 Leukorrhea
 Postcoital bleeding
 Pelvic pain

Cervical cancer
Diagnosis
History
 Physical examination
 Cytology (pap smear, TCT)
 Biopsy (colposcopy)
 Conization
 Imaging

Principle for treat
cervical cancer

Evidence based medicine
 FIGO ( International Federation of Gynecology and Obstetrics)
 NCCN (National Comprehensive Cancer Network)

Individualized therapy；
Cervical Cancer Treatment
Precursor- CINs
 Micro-invasive cancer
 Invasive cancer

Treatment for CINs
CIN I: follow up 3—6months
 CIN II:
 local therapy
 conization
 CIN III:
 conization
 hysterectomy

Treatment for micro-invasive
cervical cancer
Ia1: hysterectomy
 Ia2: modified hysterectomy
 Ia with positive margin (Ia or CIS):
radical hysterectomy

Treatment for invasive
cervical cancer
Surgical threatment Ib-IIa
 Radiotherapy
 Chemotherapy
 Combined therapy

Cervical cancer（Ⅰb1/Ⅱa1)
1. RH+PLND+/- PALND
Radical hysterectomy+ pelvic lymph
node dissection ±para-aortic lymph
node dissection;
2. RT
Pelvic RT+ Brachytherapy
±concurrent cisplatin-containing
chemotherapy
Cervical cancer（Ⅰb2/Ⅱa2)
1. RT
Pelvic RT+concurrent cisplatin-containing chemotherapy +
Brachytherapy
2. RH+PLND+/- PALND
Radical hysterectomy+ pelvic lymph node dissection ±paraaortic lymph node dissection;
3. RT+ Hysterectomy
Pelvic RT+concurrent cisplatin-containing chemotherapy +
Brachytherapy +adjuvant hysterectomy
Flow-chat for management
（ IB, IIA cervical cancer)
IB2, IIA2
>4cm
IB1, IIA1
<4cm
CCRT
RH+PLND+PALND
NACT+RH+PLND +PALND
RH+PLND+/-PALND
RT
Adjuvant Therapy
(according to high-risk factors)
RT+CT
LN positive
positive margin
RT+/- CT
poor differentiated
deep myometrial invasion
LVSI
Complications of RH
Vesicovaginal fistula
 Ureterovaginal fistula
 Severe bladder atomy
 Bowel obstruction
 Lymphocyst
 Thrombophlebtis
 Pulmonary embolus

Post-surgical treatment
(high risk factors)
poor differentiated
deep myometrial invasion
LVSI
LN positive
positive margin (Vaginal, parametrium)
Advanced stage（Ⅱb，Ⅲ，Ⅳ)
Radiotherapy (RT)
 NACT + Radiotherapy
 Concurrent chemo-radiotherapy；
 Combined RT and CT

Radical Trachelectomy






Fertility sparing
Ib <4cm
Evaluation of infertility factor
Procedure of trachelectomy
 Vaginal
 Laparoscopic
 Abdominal
Complications
Outcome
Prognosis






5yr survival rate
patients with RT (RH)
Stage I: 91.5% (86.3%)
Stage IIa: 83.5% (75%)
Stage IIb: 66.5% (58.9%)
Stage IIIa: 45% (43%)
Stage IIIb: 36%
Stage IV: 14%
recurrent rate
Data from MD Anderson Hospital
1.5%
5%
7.5%
17%
Pregnant with cervical cancer
<20w, operation;
 >20w, evaluation, Ia-Ib1 observation;
 >24w, 32-34w CS+RH;

Prevention
Primary prevention
1. Health care
2. Sexual behavior
3. Dual protection
4. HPV vaccines
4. Cancer screening
5. Treat precursors
Secondary prevention
1.Early screening
2. Early treatment
Surveillance
Interval H & P
 Every 3-6months for 2yr;
 Every 6-12months fro 3-5yr
 Cytology/yr
 Imaging : PET, PET-CT, MRI, CT
 Lab oratory assessment
 Patient education

Take home message








HPV (HR)
CINs
FIGO stage
Surgery: Radical hysterectomy and PLND
Post-operation treatment: high risk factors
RT and CT
Fertility sparing trachelectomy
HPV Vaccine
THANKS
OB/GYN Hospital of Fudan University