carcinoma cervix
TRANSCRIPT
CERVICAL CARCINOMA
ANATOMYParts of Uterus1.Body/Corpus2.Isthmus3.cervix-a)supra-vaginal part b)vaginal part
Ligaments1.Broad ligament2.Round ligament3.Uterosacral ligament
LYMPHATICSLYMPH NODES AROUND UTERINE CERVIX1.Uppermost-Hypogastric LN2.Obturator LN & External illiac LN3.Inferior & superior gluteal, Common illiac,Presacral and Subaortic LN4.Anterior branch-Internal illiac LN5.Posterior branch-superificial rectal LN
COMMON ROUTES OF LYMPHATIC SPREADObturator LN or Hypogastric LN or External illiac LN
Common illiac LN or para-aortic LN
ANATOMIC SITES OF FIRST METASTASIS
HISTOLOGY
• Squamocolumner junction
• Transformation zone
RISK FACTORSEarly coitusMultiple sexual partnersEarly childbirthMulti-parity with poor birth spacingPartner with penile cancer
Poor personal hygeinePoor socioeconomic status
Smoking,alcohol,drugs
Immunosuppression(eg.transplant recipients)Infections-STDs,HIV,HSV2,CondylomataHPV(16,18,31,33,45…)Pre-invasive lesions
HPV-an essential criteria for CA Cervix
HPV infection & proliferation
Molecular biology of HPV infection
HPV vaccination•GARDASIL-Quadrivalent(VLPs for HPV 6,11,16,18)•CERVERIX-Bivalent(VLPs for HPV16,18)Efficacy 100% for seronegative or seropositive but with negative HPV DNA
•ACS GUIDELINESReccomended for girls @ 11 to 12 years(9-18years)Cervical Screening programme to remain unaffected
PRE-INVASIVE LESIONS of CERVIX
COMPARISON B/W VARIOUS CLASSIFICATION SYSTEMS
Pre-invasive to invasive% of CIN REACH INVASIVE STAGE IN YEAR
4% 1 Y
11% 3 Y
22% 5 Y
30% 10 Y
screening ACS NCCN ACOG
Start Within 3 years of 1st sexual activity, no later than 21 year
Age 21 year
Upto 30 Y
Conventional Pap-annuallyLiquid Pap-2yearly
Every 2 years
>30Y Every 2-3 years after 3 consecutive normal pap smears
Every 2-3 years after 3 consecutive normal pap smearsOr every 3 years when cytology + HPV Test
Every 3 years after 3 consecutive normal pap smears
Stop Age 70 years after 3 consecutive normal Paps & no abnormal results within 10 years
Age 70 years after 3 consecutive normal Paps & no abnormal results within 10 years
Age 65-70 years after 3 consecutive normal Paps & no abnormal results within 10 years
Post hystere ctomy
none none None.except H/O CIN2-CIN3
HPV DNA
>30 years,every 3 years with cytology
DIAGNOSIS• Clinical features Mostly asymptomatic Post coital bleeding Post menopausal bleeding On Inspection- cervicitis/erosion - bleeds on touch
• investigations Pap smear test Liquid based cytology DNA study Colposcopy Cone biopsy
CONVENTIONAL PAP GIVING WAY TO LIQUID PAP
HYBRID CAPTURE TEST FOR HPV DNA
COLPOSCOPY & BIOPSY
29
Conization• Removes a cone-
shaped piece of tissue
• Often allows for diagnosis and treatment
• Performed with local anesthesia in the office or under general anesthesia in the operating room
CONE BIOPSY
TREATMENT
LOCAL DESTRUCTION LOCAL EXCISION RADICAL TREATMENT
CeauterisationCryo-surgeryLaser ablation
ConisationLLETZLEEPNETZ
TrachelectomyHysterectomy with removal of vaginal cuff
Local excision methods
RADICAL SURGICAL TREATMENT
INVASIVE CERVICLE CANCER
PATHOLOGY•Invasive squamous carcinomaSmall cellLarge cellKeratinisingNon-keratinising
Rare varientsPapillaryVerrucoussarcomatoid
Adenocarcinoma •Adenocarcinoma in situ•Invasive adenocarcinomaMucinousMinimal deviation adenocarcinomaGlassy cell adenocarcinomaAdenoid basal adenocarcinomaAdenoid cystic adenocarcinoma
Serous
Other types
• Neuroendocrine tumors-Anaplastic small cell tumors
• Rare neoplasms Metastasis-from colon , breast Sarcomas - Embryonal Rhabdomyosarcoma,
Leiomyosarcoma,Adenosarcoma Lymphoma melanoma
38
CLINICAL FEATURES 1. BLEEDING --- postmenopausal, metrorrhagia, menorrhagia, post coital bleeding.
2. PAIN in the pelvis or hypogastrium
3. URINARY Symptoms
4. RECTAL Symptoms
5. DISTANT SITE SPECIFIC METASTATIC MANIFESTATIONSa. LYMPHATIC SPREAD --- to supraclavicular LN, para-aortic lymphadenopathy (non
specific abdominal symptoms)b. HEMATOGENOUS SPREAD---- to lungs (cough, respiratory distress, in 21% of patients
in metastatic setting) ---- bone pain
INTERNAL EXAMINATION (EXAMINATION UNDER ANAESTHESIA – ADVISED)1. INSPECTION --- Cauliflower like growth --- exophytic nature Bleeding from the growth Serosanguineous vaginal discharge2. PALPATION ----1) uterus ---- size, shape, position2) cervix ---- bulky3) growth might obliterate the vaginal fornices 4) friable growth, ulcerated , which bleeds to touch ---- blood
present on finger tips5) parametrium – nodular thickening extending upto the
lateral pelvic wall (by per –rectal examination)
39
CLINICAL FEATURES -EXAMINATION - DIAGNOSIS
40
41
STAGING --- FIGO STAGING
1) FIGO staging was based on anatomical compartmental spread of cervical cancer.
2) No inclusion of lymph nodal status
3) LVI not included because pathologists do not agree on status on presence of LVI
4) MRI, CT and PET Scan – not included in formal staging.
FIGO STAGING OF CA CERVIX
Staging & survival
IMAGING STUDIES
CT scan Detects para-aortic metastasis(Sp-100%)
MRI scan Assessment of extracervical tumor extension Assessment of local tumor control Early prediction of tumor regression Can differentiate reccurant tumors from fibrosis
FDG PET scan detects para-aortic metastasis(Sn-72% & Sp-92%) Detects metabolically active recurrence or residual