Download Cervical cancer

Cervical cancer
Epidemiology
• Cervical cancer is the 5th most common cancer in women worldwide
• In some parts of Africa, South America and South Eastern Asia is the
second most common cancer after breast cancer
• Cervical cancer is the most common cancer for women in Central America
and Southern Africa.
Risk factors
I. Environmental
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HPV=main risk factor
Smoking
AIDS
Diabetes (high glucose levels)
Daughters of women who had used DES
(diethylstilbestrol) to prevent miscarriages (~19501970) (although it doesn’t decrease the risk of
miscarriage)
II. Genetic
-there is sometimes familial aggregation of the disease
Human Papilloma Virus
• =“human wart virus”
Classification
• More than 150 subtypes of HPV
1. High risk: 16, 18, 31, 33, 35, 39, 45, 51, 52,
56, 58, 59, 68, 73, 82
-16 and 18 present in ~70% of cervical cancers
2. Probably high risk: 26, 53, 66
3. Low risk: 6, 11, 40, 42, 43, 44, 54, 61, 70, 72,
81
Vulvar cancer
Anal canal
cancer
Oral cavity, oropharyngeal,
nasopharyngeal and esophageal
cancer
Discovery
• 2008 Nobel-prize in medicine: Harald zur
Hausen: HPV causes cervical cancer (1977).
Incidence of infection
• 80% of women will be infected with at least one
subtype of HPV during their life, but the immune
system eliminates the infection in most of the cases
• In some cases the infection will be chronic and leads
to dysplasia (a premalignant condition) and later to
cancer
• The time from infection to cancer is usually long (1015 years), but it can be shorter, especially in younger
women
• Plus younger women eliminate the infection less
frequently
Histology
• Squamous cell carcinoma (80-90%)
• Adenocarcinoma of the cervix-more rare and
not related to HPV infection
Routes of spread
• Local extension: vagina, parametria, rectum,
bladder, uterine corpus
Lymphatic
spread
Metastases
• Para-aortic lymph nodes-potentially curable
• Other non-regional lymph nodes:
supraclavicular, neck
• Lung
• Rarely: bone, liver
Symptoms
• Vaginal hemorrhage
-postcoital
-intermenstrual (metrorrhagia)
- heavy and prolonged menstrual bleeding
(menorrhagia)
-in menopause (metrorrhagia)
• Leucorrhea
• Pelvic pain
• Urinary symptoms: hematuria
• Rectal symptoms: rectorrhagia, obstruction
• Lumbar pain: para-aortic metastases or
hydronephrosis
Diagnosis
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Pelvic examination
Biopsy
Pelvi-abdominal CT/MRI/PET-CT
Rectal symptoms=> rectoscopy
Hematuria=> cystoscopy
Chest radiography
General work-up
Laparoscopic lymphatic staging-if available
Treatment
• Stage IA=tumor not
seen by the naked eye
and diagnosed only
microscopically
a)Total hysterectomy
b)Younger patients:
conization for fertility
preservation
c)Brachytherapy
Treatment
• Stage IB-IIA-tumor seen
by the naked eye, but
not extending to the
parametria
a) Total hysterectomy and
bilateral salpingooophorectomy
(TH+BSO) plus pelvic
lymphadenectomy
+ adjuvant RT
b) Exclusive radiochemotherapy
Treatment
• Stage IIB-IVA-tumors
extending at least to
the parametria or the
lower third of the
vagina
a) Exclusive radiochemotherapy
b) Radio-chemotherapy
followed by surgery
Radiotherapy
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a)
b)
External beam radiotherapy
Brachytherapy
Intracavitary
Interstitial
Vaccines
• Cervarix: 16, 18
• Silgard = Gardasil: 6, 11, 16, 18
• When is ideal to vaccinate?
Before the first sexual contact. (Furthermore girls
age 10-14 develop the strongest immunity.)
But can vaccinate at any age, because of the low
probability to have been infected with all subtypes
(6, 11, 16, 18).
• How many people have been vaccinated to date?
Over 30 000 000.
• How many adult women have been vaccinated in
Romania?
Over 35 000.
• How many girls were vaccinated in RO during the
2008-2009 school campaign?
Over 10 000.
• No serious side effects. (Medical events after
vaccination couldn’t be linked with the
vaccination.)
=> Vaccine appears to be safe.
Screening for cervical cancer
• Cervical cytology = Pap smear
-cells from the cervix are
removed with a swab
• Starting at 3 yrs from first vaginal intercourse
• Yearly
• Women aged 70 may discontinue screening if during the last 10
years did not have abnormal cytology
Questions
• What are the risk factors for cervical cancer?
• What are the symptoms of cervical cancer?
• What are the treatment options for cervical
cancer?
• How should be cervical cancer screened for?