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Ca cervix evaluation and staging
- 1. CARCINOMA CERVIX INTRODUCTION ANDEVALUATION Student: Surg Lt Cdr Ankur Shah Moderator: Lt Col Tony Jose
- 2. ● References: – Berek's andNovak's Gynaecology, 15th ed – William's Gynaecology, 2nd ed – DiSaia, Creasman Clinical Gynaecologic Oncology, 7th ed – Berek and Hacker's Gynaecologic Oncology, 5th ed – WHO Weekly Epidemiological Record, No 15 dated 10 April 2009
- 3. Introduction ● Latin - “neck”,entry to womb ● Anatomy – 2-4 cm in length – Cervical canal – antomical external os to internal os – Histologic internal os – transition from endocervical to endometrial glands ● Histology – Exocervix – stratified squamous epithelium ● Basal, parabasal, intermediate and superficial layers – Endocervix – cylindrical epithelium, arranged in branching folds
- 6. ● Squamocolumnar junction – Embryogenesis– upward migration of squamous epi from vaginal plate replacing mullerian epi. – Low vaginal pH stimulates squamous metaplasia – Location of SCJ varies with age & hormonal status ● Everts outwards during adolescence, pregnancy & OCP use ● Regresses into endocervix with menopause, low estrogen states
- 8. ● Transformation zone – Adjacentto SCJ – Most active zone of squamous metaplasia – prone to carcinogenic effects ● Risk factor for Cervical cancer – Metaplasia, most active during adolescence and pregnancy
- 10. Pre-invasive Lesions ● Squamous epilesions, considered to be precursors, but lack features of invasive Ca ● Cervical cytology – major tool to detect CIN lesions early before onset of invasive Ca ● Pap Smear
- 11. ● Pap smear – Conventionalsmear ● Smear made directly on glass slide at time of sampling – Liquid based Cytology ● Cells collected in liquid transport medium, further processed to produce a monoloayer of cells on slide ● Advantage of LBC – Most of the collected material available for sampling – Abnormal cells, which are few, obscured, clustered on conventional Pap are easily visible
- 13. ● Before a PapSmear, ensure: – Avoid menstruation – Abstain from intercourse, douching, use of vaginal tampons, or contraceptive creams for min of 24-48 hrs – Avoid touching the cervix before Pap smear – Discharge from cervix may be removed with a swab without touching the cervix
- 14. PAP Smear Classification ● TheClass System (I to IV) ● The CIN System – Based on degree of cellular abnormalities ● The Bethesda System
- 15. ● Bethesda (2001) reportingof Pap Smear: – Specimen type – conventional, LBC – Specimen adequacy – satisfactory, unsatisfactory – General Categorisation: ● Negative for intra-epithelial lesion ● Epithelial cell abnormality ● Other findings that may indicate increased risk – Interpretation of results
- 18. Epidemiology & RiskFactors ● 'Preventable' disease ● Third most frequently diagnosed carcinoma in women ● 370,000 cases diagnosed annually – 78% in developing countries – Lack of screening
- 19. ● Risk factors – HPVInfection – Cigarette smoking – Parity – Oral Contraceptive use – Early sexual activity, Multiple partners – STDs – Chronic Immunosuppression
- 20. ● HPV Infection – Theinitiating event in cervical dysplasia and carcinogenesis – DNA virus – More than 100 subtypes ● Low risk – 6, 11 – cause genital warts, rarely asso with cancer ● High risk – 16, 18, 45, 31 – asso with 95% of cervical cancers ● HPV 16 predominant subtype – 40-70% of invasive cervical cancer – Spread through sexual contact ● Gains access to the basal layer of the cervical epithelium, which becomes the viral reservoir
- 22. HPV and CaCervix
- 23. ● Vaccination against HPV –Recombinant vaccine ● Prepared from purified structural proteins – Two types of vaccine ● Quadravalent – against HPV 6, 11, 16, 18 ● Bivalent – against HPV 16, 18 – Recommended age ● Before initiation of sexual intercourse ● Age between 9 – 26 yrs ● Routine vaccination for girls aged 10-14 yrs ● Catch-up vaccination for adolescent girls and older women
- 24. ● Dosage schedule – Quadravalentvaccine – 3 doses 0, 2, 6 months – Bivalent vaccine – 3 doses 0, 1, 6 months ● Quadravalent vaccine approved for use in males for prevention of anogenital warts ● Duration of protection: – Quadravalent – 5 yrs – Bivalent – 6.4 yrs
- 25. Clinical Picture ● Asymptomatic ● Vaginal Bleeding –Post coital – Intermenstrual spotting – Irregular or Postmenopausal bleeding ● Discharge P/V ● Pain referred to flanks ● Dysuria, hematuria, rectal bleeding ● Massive Haemorrhage, uraemia
- 26. Evaluation ● Clinical Examination – Perspeculum – Per rectal examination – Presence of lymph nodes – Colposcopy – Cervical Biopsy
- 27. ● Colposcopy – Examination ofcervical, vaginal or vulval epithelia for identification and evaluation of suspected malignant or pre-malignant changes – Biopsy an integral part of the procedure – Indications ● In response to abnormal Pap Smear ● Clinically suspicious cervical lesion ● Abnormal/unexplained bleeding P/V ● Persistent vaginal discharge
- 28. ● ASCCP Guidelines forcolposcopy – Negative for intraepithelial abnormality – routine cytological screening – ASC-H, LSIL, HSIL – colposcopy and biopsy – ASC-US – Repeat cytology, Reflex testing for HPV. If still abnormal – colposcopy – AGC – colposcopy, endocervical and endometrial evaluation – AIS – excision biopsy
- 29. ● Solutions: – Normal saline –Acetic acid, 3 – 5% – Lugol's iodine (Schiller's solution) ● Colposcopic Grading – Reid's Colposcopic Index – Peripheral margin – Color – Vascular patterns – Lugol's staining
- 31. ● Colposcopic Findings ofInvasion – Abnormal blood vessels – Irregular surface contour – Color
- 32. ● Confirmation by CervicalBiopsy – Punch biopsy – LEEP ● Outpatient procedure ● Diagnosis and therapy at same time ● Main side effect – secondary haemorrhage ● Endocervical location and incomplete excision predictors for treatment failure (40% recurrence rate)
- 33. ● Conization – Cold knife –Laser – Curative procedure, with low recurrence rate (0.6%) – If cut margins free from cancer, then almost 100% disease free follow-up – Post-conization, surgical margins show disease ● No further treatment necessary, only regular follow up
- 36. ● Histologic Subtypes – SquamousCell – Adenocarcinoma ● Adenoma malignum ● Villoglandular – Adenosquamous Carcinoma ● Glassy cell ● Adenoid basal cell ● Adenoid cystic ● Sarcoma ● Malignant Melanoma ● Neuroendocrine carcinoma
- 37. ● Tumour Spread: – DirectInvasion ● Vaginal mucosa – microinvasive spread ● Myometrium of lower uterine segment ● Adjacent structures and parametrium, lateral pelvic wall
- 38. ● Lymphatic Spread – PrimaryGroup ● Parametrial nodes ● Paracervical/ureteral nodes ● Obturator nodes ● Hypogastric nodes ● External iliac nodes ● Sacral nodes – Secondary Group ● Common Iliac nodes ● Inguinal nodes (deep and superficial) ● Periaortic nodes
- 39. Staging Investigations ● Physical Examination –Lymphnode examination – Per Vaginum – Bimanual rectovaginal examination ● Radiology – IVP – Barium Enema – X Ray Chest – Skeletal X Ray
- 40. ● Procedures – Biopsy, Conization –Hysteroscopy – Endocervical Curettage – Cystoscopy, Proctoscopy ● Optional Investigations – CT Scan – MRI – USG – Laparoscopy – Radionuclide Scanning
- 41. Non-invasive diagnostic testing ● CTScan- – Evaluation of lymphnodes, liver, urinary tract and bony structures – Can detect only changes in size of nodes, < 1cm considered as positive ● MRI- – Valuable modality to determine tumour size, degree of stromal invasion, vaginal/corpus extension, parametrial involvement, lymph node status – LN evaluation was comparable to CT Scan
- 42. ● PET Scan – Useof radionuclides, which decay with emission of positrons – Most commonly used is Fluoro-deoxy-glucose – Tumour cells actively use glucose, detected on scanning as area of increased glycolysis – Delineates extent of disease more accurately, esp nodes which are not enlarged and distant sites not picked up by conventional radiology
- 43. Pre-Operative Evaluation ● NICE guidelinesfor pre-op testing ● Patients categorised based on – Age – Surgical grade (minor, intermediate, major, major+) – ASA grade ● Recommended investigations – Blood counts – Renal/Liver function tests – Blood sugar levels – Xray Chest –
- 44. Staging ● Clinically staged disease ● Incase of doubt, earlier stage should be allotted ● Stage must not be changed because of subsequent findings on extended clinical findings or surgical findings
- 45. FIGO Staging (2009) ● StageI – carcinoma confined to cervix – IA: invasive carcinoma diagnosed microscopically. Stromal invasion depth upto 5 mm and width less than 7 mm ● IA1 – stromal invasion <3mm depth and <7mm width ● IA2 – stromal invasion 3-5 mm and <7mm width – IB: clinically visible lesion confined to the cervix ● IB1 – lesion <4 cm or less ● IB2 – lesion >4 cm
- 47. ● Stage II –carcinoma invading beyond uterus but not to pelvic wall or lower 1/3 of vagina – IIA – Tumour without parametrial invasion ● IIA1 – lesion < 4 cm ● IIA2 – lesion > 4 cm – IIB – Tumour with parametrial invasion
- 49. ● Stage III –tumour extending to lateral pelvic wall/lower third of vagina/causing hydronephrosis or non-functioning kidney – IIIA – Tumour involves lower 1/3 of vagina, no extension to pelvic wall – IIIB – Tumour extends to pelvic wall or causing hydronephrosis/non-functioning kidney
- 51. ● Stage IV – IVA– Tumour invades mucosa of bladder or rectum or extends beyond true pelvis – IVB – Distant metastasis
- 53. ● All macroscopically visiblelesions, even with superficial invasion – allot stage Ib ● Diagnosis of Ia1 and Ia2 should be based on microscopic examination of tissue, preferably, cone ● Vascular space involvement does not alter the stage of disease ● Extension of disease to corpus uteri should be disregarded since it cannot be assessed clinically ● Growth fixed to pelvic wall by short and
- 54.