Management of Cervical Cancers

1
Management of Cervical Cancers

• Dr. H. Osore
• Shesor Clinic
• Gaborone

2
Cervical Cancer

• Causative Agents (old teaching)
• Smoking, hormones,infections
• Cervical cancer is rare in virgins but more
  common in sexually active women
• Cervical cancer more common in women who become
  sexually active at early age
• Highly sexually active women with multiple sexual
  partners or those in contact with partner who has
  multiple sexual partners

3
Cancer Cervix

• Cancer Cervix is an infectious disease
• Therefore Preventable disease

4
(No Transcript)
5
Cancer Cervix

• Magnitude of Problem
• 500,000 new cases diagnosed yearly
• 80 of new cases occur in developing countries
• More than 200,000 deaths each year
• Second most cancer amongst women world wide
• Botswana- Cancer cervix second commonest
  nationally

6

• Magnitude of the Problem Contd
• Therefore high risk increase in developing
  intraepithelial neoplasia and more likely rapid
  progression to invasive cervical cancer
• HIV increases the risk of pre-invasive disease (2
  to 12 times higher cytological abnormalities rate
  in HIV positive women)

7
Cervical Cancer

• Magnitude of problem contd
• Women with HIV have a higher prevalence of HPV
  infection and are more likely to develop
  persitent infection
• Treatment outcomes for patients with cervical
  cancer are poorer for positive HIV than for HIV
  negative women

8
Cervical Cancer

• Types of Cervical Cancers
• (histopathologically)
• Epithelial tumours-(Squamous Cancer) -80-90
• Mesenchymal tissue tumours-( Adenocarcinoma,
  sarcoma, embryonal)-10-20

9
Cancer Cervix

• Symptoms -
• Asymptomatic in early stages/preclinical stage
• Haemorrhage-Metrorrhagia /Postcoital
• Bleeding is usually severe in cauliflower-like
  exophytic (growth) lesions
• Discharge- watery, offensive, blood stained

10
Cancer Cervix

• Clinical features- Cachexia( wasting) and pain in
  advanced lesions
• Signs-
• -Obvious lesion or growth may or may not be
  present
• -when obvious lesion growth present, it may be
  exophytic cauliflower-like or endophytic,
  ulcerative and scirrhous
• -

11
Cancer Cervix

• Signs-
• Cervix usually indurated, hard, friable, easily
  bleeds on contact and its mobility may be
  restricted or lost
• Endocervical growth- cervix is expanded, firm and
  feels barrel shaped

12
Cervical Cancer

• Diagnosis
• Pap Smear examination
• Colposcopy
• Biopsy-
• -Excisional biopsy preferred to Punch biopsy
• Schillers Test/Acetic Acid helps in selecting
  the biopsy site where growth may not be obvious
• Cone biopsy-in early cases
• Endocervical curettage

13
Cancer Cervix

• Investigations
• Complete Physical Exam, Pelvic Exam, Rectal Exam-
  EUA to be done
• Abdominal/Pelvic Ultrasound
• Chest X-ray
• IVP
• Cystoscopy
• Proctosigmoidoscopy

14
Cancer Cervix

• Treatment Quandary
• Surgery Or Radiotherapy?

15
Cervical Cancer

• Staging-(Clinical for treatment Planning) (FIGO)
• O Carcinoma-in-situ
• 1a Micro-invasive lt3mmD,lt7mmW (Ia1,Ia2)
• 1b Invasive (gt5mm FIGO, gt3mm SGO)
• IIa Upper 2/3 of vagina
• IIb Parametrial Involvement ( but Pelvic wall)
• IIIa Lower 1/3 vagina
• IIIb Pelvic wall involvement or
  hydronephrosis/non-funtional kidney
• IVa Bladder or rectal mucosa involvement
• IVb Distant metastases

16
(No Transcript)
17
Cervical Cervix

• Treatment Options
• Stage 1a-1 (lt1mm)
• -Conisation
• -Simple hysterectomy-abdominal/vaginal approach
• Stage 1a-2 (1-3mm, lymph node -1)
• -Modified radical hysterectomy-removal of
  medial ½ of uterosacral and cardinal ligaments
  with smaller vagina margin

18
Cervical Cancer

• Treatment Options
• Recurrent disease- as per previous treatment
• -DXT gt Exenteration
• -Surgery- DXT
• Stage III and IV-Radiation/!!Exenteration
• Radiation, as primary treatment is an option in
  all stages
• Chemotherapy- as adjunct to DXT or for palliation

19
Cancer Cervix

• Options
• Stage Ib IIa -Type III hysterectomy (radical
  hysterectomy with removal of most uterosacral and
  cardinal ligament, upper 1/3 of vagina, pelvic
  lymphadenectomy
• -Postop DXT
• Bulky lesions and stage IIb
• -Full irradiation followed 3-4 weeks later by
  type II hysterectomy

20
Cancer Cervix

• Radical hysterectomy
• Removes corpus, Cervix, parametria, upper 1/3 of
  vagina
• Uterine arteries divided at origin
• Ureters dissected through tunnel
• Uterosacral ligament divided near rectum
• Lymphadenectomy
• Oophorectomy not mandatory

21
Cervical CancerTreatment Complications

• Acute-
• Fever
• Perforation
• Diarrhoea
• Bladder spasms

• Chronic-
• Proctitis
• Radiation Cystitis
• Fistula
• Enteritis
• Femoral head necrosis
• Rectal stricture

22
Cancer Cervix

• Follow-up
• At 2-3 months interval for 2 years
• At 3-4 months interval next 2-4 years
• At 6 months interval- Rest of the life
• Tumour markers- CEA

23
Cervical Cancer
Five-Year Survival -
Grigsby, P.W., et.al Radiother Oncol 12289, 1988
24
Cervical Cancer

• Special Cases Difficulty to deal with
• Invasive cancer on cone biopsy
• Cervical stump carcinoma
• Invasive carcinoma found after simple
  hysterectomy
• Cervical carcinoma in pregnancy
• Large barrel shaped lesion

25
Cancer Cervix

• Adenocarcinorma
• Has poorer prognosis stage by stage relative to
  squamous cancer
• Tends to grow endophytically thus more often
  undetected until large tumour volume is present

26
Cancer Cervix

• Summary
• Prevention is the best cure
• Must carry out evaluation and Proper staging
  prior to treatment
• Surgery and radiotherapy are complimentary-(Surgeo
  n and Radiotherapist together)
• Mortality still high stage for stage
• Overall mortality is decreasing as cancers are
  diagnosed early

27
Cervical Cancer

• Vaccines Cervical Cancer
• Gardasil manufactured by Merck Co. in USA
• the first vaccine developed to prevent genital
  lesions and genital warts due to human
  papillomavirus (HPV) types 6, 11 (warts), 16 and
  18 (cervical cancer).
• Vaccine is approved for use in females 9-26
  years of age
• HPV types 16 and 18, cause approximately 70
  percent of cervical cancers and against HPV types
  6 and 11, cause approximately 90 percent of
  genital warts. 

28
Cervical Cancer

• HPV Vaccine contd..
• Gardasil is a recombinant vaccine (contains no
  live virus)
• Given as three injections over a (6/12)six-month
  period
• Females are not protected if they have been
  infected with that HPV type(s) prior to
  vaccination
• Immunization before potential exposure to the
  virus

29
Cervical Cancer

• Gardasil does not protect against less common HPV
  types not included in the vaccine, therefore
  routine and regular Pap screening remain
  critically important to detect precancerous
  changes in the cervix to allow treatment before
  cervical cancer develops.

30
Cervical Cancer

• Cervarix- second vaccine being researched
• Studies suggest that the vaccine may prevent
  infection against HPV-31 and HPV-45 in addition
  to HPV strains 16 and 18.
• Vaccine has not yet been approved for use in the
  general population in the United States.

31
Thank You
Shesor Clinic Caring for women