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fpsms
ob-gyn
Malignant Diseases of the Cervix :
Microinvasive and Invasive Carcinoma:
Diagnosis and Management
2. Ectocervix
extends from the squamo columnar junction to
the vaginal fornices
covered by non keratinising stratified squamous
epithelium
3. Squamocolumnar
Junction (SCJ)
located at the point
where the columnar
epithelium and the
squamous epithelium
meet
basal zone
single layer of cylindrical cells 12 m diameter
main function is epithelial regeneration
superficial layer
composed of several layers of loosely attached
cells that are broader and thinner than those of
the mid zone
They have small nuclei 2-3 m diameter
18 - 20 layers of large
squamous cells containing
keratin precursors which
protects the cervix from the
vaginal environment to
which it is exposed
cells in the surface layers
are 50m diameter and
have abundant cytoplasm
and nuclei 2m diameter
It is thinner and
stratification and
glycogenation is lost
infection is common Because the epithelium is
so thin
process of metaplasia
- It starts initially in the crypts and at the tips of the
endocervical villae which gradually fuse
Incidence
cervical cancer - second most common and
the fifth most deadly cancer in women
Risk Factors
HPV Infection HPV 16 and 18
The presence of HPV-DNA in cervical neoplasia is
the first necessary cause of a human CA identified
High Grade ( invasive cancer)
HPV type 16, 18, 45, 56
Parity of 7 4x increase
High parity may increase the risk of cervical CA
because it maintains the transformation zone on
the ectocervix for many years facilitating the
direct exposure to HPV
Hormonal changes induced by pregnancy may also
modulate the immune response
HISTOLOGIC TYPES
CERVICAL CARCINOMA
Gross lesions may
be
Fungating or
exophytic
Ulcerating
Infiltrative or
endophytic
Types
Adenosquamous
Glassy cell/clear cell
Small cell
Mucoepidermoid
Adenoid cystic
Carcinoid like
Undiferentiated
KERATIN PEARL
VERRUCOUS CARCINOMA
ADENOCARCINOMA 15-20 %
Tall columnar glandular cells with basally oriented nuclei
and apical cytoplasmic mucin
Resembles endocervical mucinous glandular epithelium
4X
10X
MUCINOUS CARCINOMA
10X
QUIT
ENDOMETRIOID ADENOCARCINOMA
(ADENOCARCINOMA WITH SQUAMOUS DIFFERENTIATION)
10X
SEROUS ADENOCARCINOMA
ADENOSQUAMOUS
Mixture of squamous and
glandular components
Squamous component is
malignant (squamous cell
carcinoma)
consisting of large cells containing
cytoplasm with a ground-glass
appearance.
Glassy cell carcinomas tend to
metastasize early to lymph nodes
as well as to distant sites and
usually have a fatal outcome
CLEAR CELL
Similar to clear cell
carcinoma of the ovary
Vagina or cervix may be
involved
Adenocarcinoma variant
with clear cytoplasms and
hobnailing of the nuclei
Related to maternal DES
exposure
SMALL CELL
< 5%
Cells are small hyperchromatic
with scant cytoplasm
cells are small anaplastic cells
with scan cytoplasm
they behave very aggressively
and frequently associated with
widespread metastasis to
multiple sites, including bone,
liver, skin, and brain
4X
20X
Adenoma malignum
consist of well-differentiated mucinous glands that
vary in size and shape and infiltrate the stroma
tend to be deeply invasive and metastasize early
MICROINVASIVE CARCINOMA OF
THE CERVIX
tiny lesions that have begun to invade the
cervical stroma
designated as stage IA
vaginal discharge
vaginal mass
FIGO Staging
Stage I the CA is strictly confined to the
cervix
IA invasive CA that can be diagnosed only
microscopically with deepest invasion of 5mm
and largest extension of 7 mm
IA1 measured stromal invaion of 3 mm depth
and extension of 7 mm
1A2 - measured stromal invaion of 3 mm depth
and extension of 7 mm
Endophytic assymptomatic
- early stage of development
- tend to be deeply invasive when diagnosed
- usually starts in the endocervical location
and often fill the cervix and lower uterine
segment, resulting in a barrel shaped cervix
Prognostic Factors
FIGO stage
most important determinant of prognosis for
carcinoma of the cervix
tumor characteristics
tumor size
patient characteristics
MANAGEMENT
Pretherapy Evaluation
conducted to determine the extent of disease,
to arrive at an accurate clinical staging, and to
plan the program of therapy
thorough history and physical examination,
routine blood studies, an intravenous pyelogram
or a CT scan, and chest radiograph
extrafascial hysterectomy
class II operation
modified radical hysterectomy
removes more paracervical tissue than class I, but
the ureters are retracted laterally yet are not
dissected from their attachments distal to the
uterine artery, and the uterosacral ligaments are
ligated approximately halfway between the uterus
and rectum.
The operation is usually performed with pelvic
lymphadenectomy
Class IV
complete dissection of the ureter from its bed and
sacrifice of the superior vesical artery
class V operation
involves resection of the distal ureter or bladder
or both with reimplantation of the ureter into the
bladder (ureteroneocystotomy)
Management
Concurrent chemotherapy and complete
radiotherapy standard treatment
For patients who are unable to receive
chemotherapy, radiation treatment alone may
be given
Adenocarcinoma have shown no significant
difference in clinical behavior from SCCA
Stage 1A1
a) Good surgical risk
Desirous of pregnancy, no LVSI
Negative margins, observe
Positive margins repeat cone biopsy
Stage 1A2
a) Good surgical risk
Desirous of pregnancy, no LVSI
Stage IB1, II A
a) Good surgical risk
RHBSO, LND
Concurrent chemotherapy, pelvic EBRT ,
brachytherapy
Radical vaginal hysterectomy +/- BSO and
extraperitoneal or laparoscopic pelvic
lymphadenectomy
Radical trachelectomy and extraperitoneal or
laparoscopic pelvic lymphadenectomy
Stage IIB IV
Concurrent chemo, pelvic EBRT + brachytherapy,
chemorad
Paraaortic lymphadenectomy + brachytherapy +
concurrent Cisplatin chemo
If with evidence of distant metastasis on imaging
or biopsy: systemic combination chemotherapy
and individualized RT
laparoscopy
associated with a reduction of surgical adhesions
Complications
small bowel obstruction
Fistulas from the urinary tract, particularly
ureterovaginal fistulas
postoperative bladder dysfunction
Radiation Treatment
External beam radiation
admin-istered in fractions, usually 180 cGy/day 5
days per week to destroy the tumor without
causing permanent damage to normal tissues
Outcomes
Radical radiation therapy achieves excellent
survival and pelvic disease control rates in
patients with stage IBIIA cervical cancer
CHEMORADIATION
use of chemotherapy to sensitize cells to
radiation therapy has been shown to improve
local regional control
Advisable to patients with these high-risk
factors after radical hysterectomy for stage
Ia2, Ib, and IIa disease
Studies
cisplatin-based concurrent chemoradiation was a
superior treatment when compared with
hydroxyurea and concurrent radiation
chemoradiation is the treatment of choice for
stage IIb to IVa disease and that those patients
with stage Ib2 and IIa disease may also benefit
from chemoradiation
Paraaortic Nodes
Patients with paraaortic lymph node
involvement can be treated effectively with
extended-field radiation
Patients are treated with a combination of
external beam radiation therapy and
brachytherapy
Radiation Complications
related to dose, volume treated, and
sensitivity of the various tissues receiving
radiation
diarrhea and nausea
Scarring of normal tissues can lead to severe
radiation fibrosis
hemorrhagic cystitis
Periureteral fibrosis
Proctosigmoiditis
POSTPARTUM EVALUATION
The likelihood of disease progression during
pregnancy is small
RECURRENCES
tumor recurrence
one third of patients
reappearance of tumor 6 months or more after
therapy.
Metastases can occur anywhere, but most are in
the pelvis (centrally in the vagina or cervix or
laterally near the pelvic walls) or less frequently
distally in the periaortic nodes, lung, liver, or
bone.
Symptoms
Vaginal discharge
abnormal bleeding
Malaise
loss of appetite
leg swelling
Low back pain
Examineation
every 3 months the first 2 years
Pelvic Recurrences
vaginal ultrasound
For patients who were initially treated by
surgery, radiation is usually prescribed for
pelvic recurrences
Pelvic Exenteration
central pelvic tumor recurrence
Total exenteration
combined anteroposterior exenteration to
remove all the pelvic contents
Nonpelvic Recurrences
treated with radiation, surgery, or
chemotherapy
Chemotherapy
Patients with advanced, recurrent, or persistent
cervical cancer
Sarcomas
Very rare
multiagent chemotherapy followed by
operation
better prognosis
Vaccination
Gardasil and Cervarix
Both vaccines can prevent most cases of cervical
cancer if given before a girl or woman is exposed
to the virus
both can prevent most vaginal and vulvar cancer
in women
Gardasil can prevent genital warts in women and
men
Prevention
Total sexual abstinence prevents HPV infection
Lifetime mutual monogamy prevents HPV infection
Consistent and correct use of barrier protection decreases cervical
CA incidence
Vaccination against HPV 16/18 is efficaceous against persistent HPV
infection and CIN 2
Thank you!!