CERVICAL CANCER.ppt
- 1. PREMALIGNANT LESION OF THE CERVIX AND CERVICAL CANCER: PRESENTATION, PREVENTION AND MANAGEMENT DR ADULOJU OLUSOLA PETER DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, EKITI STATE UNIVERSITY, ADO-EKITI
- 2. PREMALIGNANT LESIONS OF THE CERVIX Premalignant lesion of the cervix is also known as cervical intra-epithelial neoplasia (CIN) They are precursor lesions which have a significant potential to become an invasive malignant lesion Most of these lesions are usually asymptomatic and are of clinical importance because they may progress to invasive malignancies
- 3. DEFINITION OF TERMS Squamo-columnar junction (SCJ): This is the point of intersection between the columnar and the squamous epithelium. An important landmark for neoplastic changes. Transformation zone (TFZ): Part of the columnar epithelium of the cervix undergoes squamous metaplasia. The metaplastic area and
- 4. and columnar epithelium form the TFZ. Over 95% of all the CIN lesions arise from this zone
- 5. SCJ &TFZ
- 6. PREMALIGNANT LESIONS AND HUMAN PAPILLOMA VIRUS (HPV) HPV has been implicated in the pathogenesis of premalignant lesions of the female genital tract HPV are double stranded DNA viruses The viral genome has 3 regions The upstream regulatory region involved in viral replication and control of transcription The early genes responsible for DNA replication,
- 7. transcriptional regulation and transformation (E1, E2, E3, E4, E5, E6, E7). E6 and E7 encode for major transforming proteins capable of inducing cell proliferation and immortalization by binding to tumor suppressor gene products p53and pRB The late genes (L1, L2) control formation of capsid (virus) coat HPV infection is a sexually transmitted infection and occurs in between the sexes
- 8. Over 100 types of HPV have been identified and classified into: Low risk 6 & 11 cause papilloma of the upper airways and external genital condyloma Intermediate risk 31, 33, 35, 51 & 52 are associated with dysplasia High risk 16 & 18 associated with high and low grade squamous lesions respectively
- 9. EPIDEMIOLOGY OF CIN Multiple sexual partners Early coitarche Early marriage Male partner with previous multiple female sexual partners Low socio-economic status Oral contraceptive pills Cigarette smoking
- 10. GRADING OF CIN Histologic grading based on the proportion of the epithelium occupied by dysplastic cells Cytologic grading based on the severity of dysplasia in the epithelium Both grading use a three tier system CIN I (Mild dysplasia): Dysplastic cells occupy the lower third of the epithelium CIN II (Moderate dysplasia): Dysplastic cells occupy the lower two-thirds of the epithelium
- 11. CIN III (Severe dysplasia, carcinoma in situ): Dysplastic cells extend into the upper third and may occupy the full thickness of the epithelium The Bethesda system: Uses a two tier system Low grade squamous intra-epithelial lesion (LGSIL) HPV changes on smears and CIN I High grade squamous intra-epithelial lesion (HGSIL) CIN II and CIN III/ Ca in situ
- 12. NATURAL HISTORY OF CIN LESIONS LESION REGRESS PERSIST PROGRESS TO CIN III PROGRESS TO INVASIVE CANCER CIN 1 60% 30% 5-8% 1% CIN II 43% 35% 8-10% 12% progress to CIS or invasive Ca CIN III 32% 54% - 14%
- 13. SCREENING FOR CIN Cervical cancer is the only gynecologic cancer that’s amenable to extensive screening and this has reduced its death rate to about 70% Cervix is easily accessible and exfoliative cells can easily be obtained The disease has a well defined pre-clinical stage The screening methods are simple and cheap Treatments are available for the pre-clinical stage
- 14. SCREENING METHODS PAP smear test: Cervical specimen are taken by wooden or plastic spatula or cytobrush (traditionally). The specimen is smeared on a glass slide and fixed in alcohol Liquid based method has improved the sensitivity of the test. The brush is broken, the part with the specimen is dropped in a bottle containing preservative and sent to the laboratory
- 15. Visual inspection of the cervix unaided: Also referred to as clinical downstaging and aim is to detect abnormal/ suspicious looking cervix. Abnormality includes: Hypertrophy, irregular surface, distortion or erosion of the cervix Visual inspection of the cervix with Acetic acid: The cervix is swabbed with 3-5% Acetic Acid prior to visualization Abnormal cells turn white (aceto-white) due to
- 16. high nuclear content Visual inspection with Lugol’s Iodine: Also known as Schiller’s test. The cervix is swabbed Iodine and the abnormal areas turns yellow due to lack of glycogen
- 17. Visual inspection of the cervix unaided Normal looking cervix Abnormal looking cervix
- 18. Visual inspection of the cervix aided Aided with 3-5% Acetic acid Aided with Lugol’s Iodine
- 19. MANAGEMENT OF ABNORMAL PAP SMEAR This could be mild, moderate or severe dysplasia on cytology (cell diagnosis) Refer for colposcopy with acetic acid and Lugol’s iodine to identify the abnormal area Colposcopically directed biopsy of abnormal looking spot for histology (tissue diagnosis)
- 20. Histology may be HPV changes, CIN I, CIN II or CIN III Treatment options available include: CIN I (LGSIL): Follow up with frequent cytology screening (4- 6 months) Refer for colposcopy if dysplasia persists or worsens and then treat Revert to routine screening if test becomes
- 21. normal CIN II and CIN III (HGSIL): Offer Local ablative treatment- cryotherapy, CO2 laser therapy, electrocautery and thermal ablation Tissue destruction is to a depth of 8mm The ablative therapy does not yield any tissue for histological diagnosis Side effect are cramping, pain, watery discharge
- 22. Excisional treatment- conisation, loop electrosurgical excision procedure (LEEP) or large loop excision of transformation zone (LLETZ) and hysterectomy Provides tissue for histological diagnosis Complications include bleeding, cervical stenosis, incompetence and dystocia in labour Follow up is done with Pap smears and colposcopy after therapy
- 23. INTRODUCTION Cervical cancer constitutes a major public health threat to women in many low and middle income countries including sub-Saharan Africa 2nd most common cancer among women worldwide and commonest cause of cancer related morbidity and mortality Commonest female genital tract cancer and it
- 24. accounts for over 70% of gynaecological cancers Over 500,000 new cases and 250,000 deaths each year, 80% of which occur in the low income countries The incidence and mortality of cervical cancer have fallen in the high income countries due to a well established screening programs Cervical cancer is a detectable and preventable disease
- 25. Has a pre-existing lesion called cervical intraepithelial neoplasia (CIN) Association between cervical cancer and human papilloma virus has been established Cervical cancer cases are directly linked to previous infections with one or more oncogenic strains of HPV (especially HPV 16 & 18) Cervical cancer is now considered as one of the AIDS defining lesions
- 26. EPIDEMIOLOGICAL RISK FACTORS High risk behavior associated Early coitarche Early marriage Multiple child birth High risk husband- husband that is promiscuous. Has cancer of the penis or has consorts with cervical cancer Immunosuppression- It enhances viral
- 27. persistence in host cervical cells Epidemiological factors Familial predisposition Cigarette smoking Use of combined oral pills Age- Mean age is 51.4years but has two peak incidences (30-39years and 60-69years) Race – commoner among the black race Low socio-economic status
- 28. HISTOLOGICAL TYPES Squamous cell carcinoma (85-90%) Adenocarcinoma (10-15%) Mixed- adeno-squamous, glassy cell Others- lymphoma, melanoma, sarcoma
- 29. Types of growth Endophytic or ulcerative growth Exophytic or cauliflower growth Spread Direct extension- local spread to the uterine body, upper vagina, bladder, rectum, broad ligament and uterosacral ligament Lymphatic spread Haematogenous spread- rarely
- 30. COMPLICATIONS OF CA CERVIX Pyometra due to endocervical obstruction Vesico-vaginal fistula due to bladder invasion Recto-vaginal fistula due to rectal invasion Ureteric obstruction with hydroureter, hydropelvis, hydronephrosis and pyonephrosis Uraemia Haemorrhage Cachexia
- 31. CLINICAL PRESENTATION Asymptomatic- discovered during screening (CIS Symptomatic Bleeding- irregular, recurrent, post-coital Vaginal discharge- purulent and malodorous In advanced cases Cachexia Micturition symptoms- dysuria, frequency Rectal symptoms such as pains
- 32. Pains- low backache, deep pelvic ache, sciatica, ureteric colic Pedal edema Physical signs Cervical lesion- may be ulcerative or fungating Diagnosis Abnormal PAP smear- colposcopy and biopsy Endo- or exophytic lesions- Cervical biopsy done with Tischler biopsy forcep
- 33. EVALUATION Full blood count Renal function tests Chest radiograph Electro-cardiogram Intravenous urography (used in staging) Examination under anaesthesia, staging and cervical biopsy
- 34. FIGO STAGING OF CERVICAL CANCER Stage 1: Disease is limited to the cervix Stage 2: Involvement of the upper 2/3rd of the vaginal and parametrium Stage 3: Involvement of the lower 1/3rd of the vaginal, pelvic side wall and bilateral hydronephrosis /non functioning kidneys Stage 4: Distant metastasis (bladder, rectum…)
- 35. FIGO STAGING OF CERVICAL CANCER
- 36. TREATMENT Aims at treating both the primary tumor and the potential metastatic areas. Treatment modalities include: Surgery Radiotherapy Combination of both Adjuvant chemotherapy and radiotherapy (chemo-radiation)
- 37. Choice of treatment depend on The stage of the disease Available facilities and personnels including oncological surgeons Presence of other patients’ factors like advanced age, bleeding, prior surgery 1. CIN/carcinoma in situ: Ablative and excisional 2. Stage IA1: Hysterectomy 3. Stage IA2: Cone biopsy, simple hysterectomy
- 38. and pelvic lymphadenectomy 4. Stage IB1 & IIA: Extended abdominal hysterectomy with bilateral pelvic lymphadenectomy 5. Stage IB2, 2B-4B: Radiotherapy - Intracavitary irradiation (Brachytherapy) to lesion and external beam irradiation (Teletherapy) to the pelvic sidewall and para-aortic area
- 39. Combined chemotherapy and radiation (chemo- radiation) treatment may be offered. Cisplatin has been found most effective cytotoxic agent in the treatment of cervical cancer Causes of death in Cervical cancer Haemorrhage- painless Uraemia- becomes unconscious Cachexia- associated with recurrent haemorrhage
- 40. PREVENTION OF CERVICAL CANCER Primary prevention Education and awareness of disease Modify lifestyle and social habits (multiple sexual partners, smoking etc) Use of barrier method of contraception HPV testing and vaccination for young girls (9- 12yrs)-Bivalent and quadrivalent vaccines Establishment of cervical screening program
- 41. Secondary prevention Cervical screening with pap smear Colposcopy and directed biopsy Treatment of CIN Follow up after treatment of CIN Tertiary Management of cervical cancer and complications
- 42. GLOBAL STRATEGY AGAINST CERVICAL CANCER Cervical cancer remains a preventable disease It is curable if detected early and adequately treated However, it remains one of the most common cancers and causes of cancer-related death in women across the globe More than 85% of those affected are young, uneducated and live in low income countries Many are also mothers of young children whose survival is truncated by mother’s death
- 43. Proven and cost effective measures for eliminating cervical cancer exist Implementation is poor especially in regions of the world with highest disease burden There must be a strategic action towards eliminating cervical cancer as a public health problem The global strategy to eliminate cervical cancer was recently launched by WHO as a concerted effort to reduce the burden of cervical cancer all over the world
- 44. This strategy proposes: A vision of a world where cervical cancer is eliminated as a public health problem The following 90-70-90 targets that must be met by 2030 for countries to be on the path towards cervical cancer elimination: 90% of girls fully vaccinated by age 15 years 70% of women are screened with a high performance test by 35 years of age and again by 45 years of age 90% of women identified with cervical disease receive treatment (pre-cancer & invasive ca)
Editor's Notes
- #17: Normal squamous cell stained dark brown, abnormal areas- atypical/immature squamous cell
- #34: EUA: Assesses the involvement of parametria or uterosacrals. Vaginal and recto-vaginal examonations are helpful to determine the extent of the disease. Cystoscopy and proctoscopy with or without biopsy may be done to alloe visualisation of the vesical or rectal mucosa.
- #36: Stage 0: Carcinoma in situ (preinvasive carcinoma)