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CA Cervix +.ppt
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- 4. Early stage cervicalcancer
- 5. Incidence Commonest cancerin women in India High incidence in developing countries In US – accounts for 2 % of cancer related deaths In Mexico accounts for 25 % of cancer related deaths Incidence and mortality declining in developed countries with screening
- 6. Causation RISK FACTORS Sexworkers First coitus at early age Multiple sex partners Promiscuous male STDs Cigarette smoking Immunodeficiency Vit A & D deficiency
- 7. Natural History CIN I CINII CIN III CIS INVASIVE CANCER 5 yrs 3 yrs 1 yrs 10 yrs
- 8. Types Squamous cellcarcinoma Adenocarcinoma Small cell carcinoma
- 9. Spread Direct spreadto cervical stroma, LUS, vagina or paracervical tissues; bladder or rectum Lymphatic spread to internal & external iliac, obturator, common iliac, prescaral and aortic nodes Distant spread to lung, extrapelvic nodes, lung & bone
- 10. INCIDENCE OF PELVIC/PARAAORTICNODES IN CA CX I B II A II B III Pelvic Para- aortic Pelvic Para- aortic Pelvic Para- aortic Pelvic Para- aortic 12- 25% <5% 20- 35% 10- 15% 30- 45% 15- 20% 40- 50% 25- 35%
- 11. PATHOLOGY A. EPITHELIAL TUMORS 1.Squamous Tumors (a) CIN I, II, III (b) Sq Cell Ca 2. Glandular Tumors (a) CGIN (b) Adenocarcinoma 3. Others (a) Adenosquamous (b) Small cell ca B. MESENCHYMAL TUMORS 1. Leiomyosarcoma 2. Stromal sarcoma 3. Sarcoma botryoides C. MIXED TUMORS 1. Adenosarcoma 2. Carcinosarcoma D. MISCELLANEOUS TUMORS
- 12. Clinical Features SYMPTOMS Asymptomaticin pre- invasive and early stage Abnormal vaginal bleeding Abnormal vaginal discharge Pelvic pain Flank pain Hematuria/ incontinence
- 13. Clinical Features SIGNS (To beelicited on inspection & palpation by bimanual & recto-vaginal exam) Cachexia and pallor Lymphadenopathy Cervical growth Bleeds on touch May extend to vagina &/or parametrium Exclude involvement of rectal mucosa & pyometra
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- 15. Investigative Work-up Toconfirm diagnosis To assess the extent of disease Pre-treatment investigations
- 16. Investigative Work-up Cervicalbiopsy (and rarely by colposcopy) Chest X-ray for all patients USG/IVP to evaluate renal status Cystoscopy/ proctoscopy if indicated by patient’s symptoms Role of CT/MRI/PET for nodal status evaluation doubtful Std lab tests including CBC, LFT & RFT
- 17. FIGO Staging Stage 0Carcinoma in situ Stage I Ca confined to cervix IA Invasive ca limited to a depth of 5mm and width of 7mm IA1 Invasion not > 3mm IA2 Invasion > 3mm but < 5mm IB Clinical lesions confined to cx or preclinical lesions > IA IB1 Lesions not > 4cm IB2 Lesions > 4cm
- 18. FIGO Staging contd… StageII Ca extends beyond cx but not upto LPW or lower 1/3 vagina IIA No obvious para involvement IIB Obvious para involvement Stage III Ca extends upto LPW or lower 1/3 vagina or hydronephrosis IIIA No extn to LPW but lower 1/3 vagina IIIB Extn to LPW or hydronephrosis Stage IV Extn beyond true pelvis or to bladder/rectal mucosa
- 19. Treatment FACTORS INFLUENCING TREATMENT Tumor stage Tumor size Evidence of nodal involvement Risk factors for surgery or radiotherapy Patient preference Physician preference
- 20. Treatment options Surgery Radiotherapy Concurrent chemoradiation
- 21. Options for surgery Conisation of cervix Simple hysterectomy Modified radical hysterectomy (Class II) Radical hysterectomy (Class III) Exenteration operations
- 22. Treatment Role of surgery Pre-invasive lesions Superficial ablation For IA1 Conisation or extrafascial hysterectomy For IA2 Class II Wertheim’s with BPLND For IB & IIA Class III Wertheim’s with BPLND In central recurrence Exenterative surgery
- 23. What is radicalhysterectomy Also known as Wertheim’s hysterectomy or Meigs’ hysterectomy or Class III hysterectomy Involves removal of Uterus with cervix Cuff of vagina Total parametrium Bilateral pelvic lymph nodes Major complications Ureteric injury Vascular injury Bladder dysfunction Lymphocyst formation
- 24. What are Exenterationoperations Anterior exenteration Posterior exenteration Total exenteration
- 25. How do wegive radiotherapy Usually as concurrent chemoradiation Total dose to Pt A is 7000-8000 cGy & 5500 cGy to Pt B Initially external beam therapy Through two or four portals 180-200 cGy/25 #/4500-5000cGy Aim – to sterilize peripheral disease and reduce the size of the cervical growth Then brachytherapy Through uterine tandems and ovoids Fletcher-Suit afterloading technique LDR or HDR in 1-5 sittings Approx 3000 cGy to Pt A
- 26. Treatment Role of radiotherapy As primary therapy In IB & IIA disease - alternative to surgery In IIB, III & IVA - only choice for therapy In locoregional recurrence after surgery Adjuvant to surgery When nodal metastasis + Positive cut margins Parametrial involvement
- 27. Treatment Role of Chemotherapy Chemotherapy used concurrently with RT has been found to improve survival. Usually cis-platinum on a weekly basis till RT is completed. Chemotherapy is also used for palliation in recurrent or advanced cases beyond the scope of curative intent
- 28. Follow-up 3-monthly fortwo years; then, 6-monthly for next three years By symptoms such as vaginal bleeding, pelvic masses, renal lumps, chest symptoms Findings suggestive of recurrence Pap smear, colposcopy and imaging Annual X-rays
- 29. Possible questions LAQ Discuss the diagnosis and management of pre- invasive lesions of the cervix Discuss the management of Stage IIA cervical cancer How do we stage cervical cancer? Discuss the role of radiotherapy in the management of cervical cancer
- 30. Possible questions SAQs Colposcopy CIN III Pap Smear Staging of cervical cancer Diagnosis of cervical cancer Down-staging of cervical cancer LEEP
- 31. Possible questions MCQs Ca cervix involving upper 2/3 of the vagina is classed as IIA IIB IIIA IIIB For ca cervix IIIB, treatment of choice is Chemotherapy Surgery Surgery + radiotherapy Chemoradiation
- 32. Possible questions MCQs The commonest malignancy in women in India is Ca endometrium Oral ca Ca cervix Ca ovary Ca cervix commonly starts at Portio vaginalis Squamocolumnar junction Erosions of the cervix Endocervical canal
- 33. Possible questions MCQs Earliest symptom of cervical cancer is Pelvic pain Pelvic lump due to pyometra Post-coital bleeding Foul-smelling vaginal discharge Commonest cause of death in cervical cancer is Infection Uremia Cachexia Distant metastasis
- 34. Possible questions MCQs How will you evaluate an HSIL report on pap smear? Multiple punch biopsies Cold knife conisation Colposcopically directed biopsy Follow-up with Pap smears at 6-monthly intervals Which of the following is Schiller test positive? Erosion cervix Ectropion CIN III All of the above
- 35. Possible questions MCQs Staging of ca cervix is assigned by Physical examination Exploratory laparotomy Biopsy All of the above Treatment of choice for CIN III of cervix is Chemotherapy Radiotherapy Surgery Chemoradiation
- 36. Possible questions MCQs All of the following about ca cervix are correct EXCEPT Coital bleeding is an early sign HPV is a known causative factor Disease is fairly common in celibate nuns Screening programme is quite effective in prevention
- 37. Possible questions MCQs A patient with unilateral renal shutdown and hydronephrosis will be staged as: Stage IIA Stage IIIB Stage IVA Stage IVB
- 38. Possible questions MCQs The best method for diagnosis of an ulcero- proliferative lesion of the cervix suspected of ca cervix is Cervical smear Cervical punch biopsy Colposcopy CT scan or MRI
- 39. Possible questions MCQs In Stage 1A1 Ca cervix, invasion is limited to 1 mm 3 mm 5 mm 7 mm
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