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Carcinoma of the CervixJacqui Morgan
March 4, 2020
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Case 1⚫25yo, G2P1
⚫Here for WWE, no problems, healthy, needs refill on OCPs.
⚫Pap- Abnormal Glandular Cells-NOS
⚫Now What??
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Case 1⚫Colposcopy
⚫What findings?
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Case 1⚫ECC
⚫Cervical Biopsy
⚫HPV testing if not already done
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Case 1⚫Bx and ECC- negative for abnormal glandular
pathology
⚫Now What?
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Case 1⚫Review cytology
⚫If AGC- NOS
⚫Cotest in 12 and 24 months
⚫If AGC favour neoplasia or AIS
⚫Conisation
⚫Endometrial sampling, Pelvic U/S
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Case 2⚫37yo, G3P2
⚫Here for WWE, Fluffy, “Pre-diabetic”
⚫Regular periods, every 4 months
⚫Pap- Abnormal Glandular Cells
⚫Now What??
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Case 2⚫ECC
⚫Cervical Biopsy
⚫EMBx
⚫HPV testing
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Case 2⚫ECC- Adenocarcinoma in situ
⚫Cervix biopsy CIN I-II
⚫EMBx- Proliferative endometrium
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Case 2⚫Diagnostic Excisional Procedure
⚫“Why can’t I just have a partial hysterectomy”
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Case 2⚫Cannot diagnose ACIS from ECC alone
⚫“Skip lesions”
⚫Margins
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ACIS⚫1/3 of patients with ACIS on cytology, will have an
invasive carcinoma found on excisional procedure.
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Case 2⚫Hysterectomy- Residual ACIS
⚫6-25% of hysterectomy specimens performed for ACIS with negative margins will have residual ACIS
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Case 3⚫29 yo seen in outside ER for fatigue, back pain.
⚫Hb 6.2
⚫Cr 7.0
⚫Non contrast CT- Poor image quality due to habitus and lack of contrast. Uterine mass, possible fibroid, recommend pelvic U/S. Bilateral hydronephrosis.
⚫Transferred to local facility with ICU.
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Case 3⚫Transfused 3 U PRBC
⚫Dialysis catheter inserted
⚫Started on dialysis.
⚫Renal sono- hydonephrosis/hydroureters bilaterally
⚫Seen by medicine, nephrology, surgery
⚫Urology consulted for ureteric stent placement, they recommended ……
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Case 3⚫Gyn consult, Day 4 in ICU
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Case 3⚫History
⚫Postcoital bleeding for 3 months
⚫Heavy bleeding last 2 weeks to point that boss threatened to fire her for amount of time spent in bathroom/off work
⚫Last pelvic/pap, cant remember
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Case 3⚫Exam
⚫9cm friable mass replacing entire cervix. Extending to both sidewalls.
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Case 3⚫Biopsy⚫Poorly differentiated SCC
⚫Ureteric stents placed
⚫Stage?
⚫Treatment?
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Case 3⚫What stage?
⚫What treatment?
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Case 3⚫What can be done if Urology were unable to insert
stents?
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Case 3⚫Related pt- What happens when you live in a tent by the river
with bilateral nephrostomy tubes?
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Case 4⚫30yo G4P2
⚫Pap HGSIL
⚫Colpo & Biopsy CIN II-III
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Case 4⚫LEEP- CIN III and Invasive adenocarcinoma 2.5mm
depth, 3mm lateral spread
⚫Stage?
⚫Treatment?
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Case 5⚫47yo G 3 P3 referred from Family Physician
⚫HGSIL Pap
⚫Colposcopy- Acetowhite changes and mosaicism
⚫Biopsy CIN III
⚫What next?
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Case 5⚫Exam- 1x1cm lesion on anterior cervix
⚫Plan?
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Case 5⚫Excisional procedure
⚫Pathology- Squamous cell carcinoma. Depth of invasion 1.5mm. Lesion 5mm width. Margins negative for invasive disease. CIN III extending to ecto-cervical margin.
⚫Stage?
⚫Treatment plan?
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Cervical Cancer⚫Approx 14,000 cases annually in US
⚫4,500 deaths
⚫Mean age 51
⚫Internationally much higher incidence.
⚫Second most common cancer and leading cause of cancer death in women in developing world
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Presentation⚫Asymptomatic, pap only abnormality
⚫Abnormal bleeding
⚫Postcoital bleeding
⚫Vaginal discharge
⚫Pelvic pain
⚫Renal failure
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Cervical Cancer⚫Squamous
⚫Adenocarcinoma
⚫Adenosquamous
⚫Melanoma
⚫Clear cell
⚫Small cell
⚫Sarcoma
⚫Lymphoma etc…
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Staging⚫Clinical, not surgical.
⚫Why?
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Clinical staging⚫Most disease is not treated surgically
⚫Limitations on imaging/testing to be applicable to areas with higher disease burden.
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Tissue Diagnosis⚫Biopsy required⚫Cytology not sufficient from Pap
⚫Tischler biopsy⚫LEEP⚫Glove
⚫Monsel’s⚫Pressure⚫Cautery⚫Packing if needed
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Imaging⚫PET/CT or CT alone
⚫Used as substitute for cystoscopy, barium enema and IVP
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FIGO 2009⚫ Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would ⚫ be disregarded)⚫ IA Invasive carcinoma which can be diagnosed only by microscopy, with deepest⚫ invasion <5 mm and the largest extension >7 mm⚫ IA1 Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mm⚫ IA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of ⚫ not >7.0 mm⚫ IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers ⚫ greater than stage IA⚫ IB1 Clinically visible lesion <4.0 cm in greatest dimension⚫ IB2 Clinically visible lesion >4.0 cm in greatest dimension
⚫ Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower⚫ third of the vagina⚫ IIA Without parametrial invasion⚫ IIA1 Clinically visible lesion <4.0 cm in greatest dimension⚫ IIA2 Clinically visible lesion >4.0 cm in greatest dimension⚫ IIB With obvious parametrial invasion
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FIGO 2009⚫Stage III The tumour extends to the pelvic wall and/or
involves lower third of the vagina and/orcauses hydronephrosis or non-functioning kidney
IIIA Tumour involves lower third of the vagina, with no extension to the pelvic wallIIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the
mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to
be allotted to Stage IVIVA Spread of the growth to adjacent organsIVB Spread to distant organs
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Early Stage Disease⚫Surgical Mx over Primary chemoradiation if a
suitable surgical candiate
⚫Lymph node dissection if above
stage IA1
⚫Ovaries
⚫Squamous vs adenocarcinoma
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Stage IA1⚫<3mm depth, 7mm width.
⚫Negative margins on excisional specimen
⚫Cervical conisation if fertility desired
⚫Extrafascial hysterectomy
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Stage IA 2⚫3-5mm depth, 7mm width
⚫No visible lesion
⚫Modified Radical hysterectomy and pelvic lymph node assessment
⚫If fertility desired- Radical trachelectomy and LNs
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Stage IB1⚫Confined to cervix, 4cm or less tumor
⚫Radical hysterectomy and pelvic LNs
⚫Equivalent survival with chemoradiation, but different long term toxicities.
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Radical Hysterectomy⚫Incorporation of parametrial tissues, cardinal
ligaments, uterosacral ligaments and upper vagina
⚫Initially assess lymph nodes, any suspicious nodes assessed intraoperatively.
⚫If nodal disease, abort procedure.
⚫Assess parametrial tissue for disease
⚫What spaces are developed?
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Radical Hysterectomy⚫3 separate studies have identified decreased PFS with
robotic approach in cervical cancer
⚫Uterine cancer showed no such difference in surgical approach
⚫Open approach standard of care
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Paravescial space⚫Obliterated umbilical artery
⚫Obturator internus
⚫Cardinal ligament
⚫Pubic symphysis
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Pararectal space⚫Rectum
⚫Hypogastric artery
⚫Cardinal ligament
⚫Sacrum
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Radical Hysterectomy
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Radical Hysterectomy
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Stage IB2 and aboveOr Not a surgical candidate⚫Pelvic radiation
⚫Concurrent cisplatin chemotherapy
⚫+/- paraaortic radiation
⚫Radiation will rapidly control bleeding
⚫ Initial fractions given at higher dose, then more detailed planning can be performed.
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Pelvic Radiation⚫5-6 weeks external beam treatments
⚫28-30 Fractions
⚫3-5 internal brachytherapy treatments
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Radiation toxicity⚫GI- diarrhea, urgency, nausea, colitis, fistula
⚫GU- Frequency, pain, dysuria, fistula
⚫Sexual function- Ovarian ablation, atrophy, vaginal stenosis
⚫General- fatigue
⚫Bone- sacral insufficiency fractures
⚫Heam- bone marrow suppression
⚫Lymph- lymphedema
⚫Secondary malignancies
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Concurrent Cisplatin Chemotherapy⚫IV weekly treatment during radiation
⚫Toxicity
⚫Renal impairment
⚫Substitute carboplatin if elevated Cr.
⚫Nausea
⚫Myelosuppresion
⚫Neurotoxicity
⚫Hypokalemia, Hypomagnesemia
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Distant metastatic Disease⚫Systemic chemotherapy
⚫Carboplatin/Paclitaxel/Bevacizumab
⚫PD1, Keytruda
⚫Palliative radiation
⚫Potential benefit of treating pelvic disease with radiation
⚫Palliative only care
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Cervical cancer⚫Most advanced disease presents in unscreened or
inadequately screened population
⚫No matter how frequent pap screening is performed, some rapid developing disease will arise between tests.
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