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Cervical Cancer Xin LU OB/GYN Hospital Fudan University. Contents. General information CINs Spread pattern FIGO staging Clinical signs Diagnosis and differential diagnosis Principle for treatment Prevention Surveillance. Key words. Cervical cancer (Cxca) - PowerPoint PPT Presentation
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Cervical Cancer
Xin LU
OB/GYN Hospital Fudan University
ContentsGeneral informationCINs Spread pattern FIGO staging Clinical signsDiagnosis and differential diagnosis Principle for treatmentPreventionSurveillance
Key wordsCervical cancer (Cxca)Human Papillomavirus (HPV)Radical Hysterectomy (RH)Radiotherapy (RT)Chemotherapy (CT)Neoadjuvant chemotherapy (NACT) Concurrent chemo-radiotherapy (CCCR)Radical Trachelectomy
Female Reproductive Anatomy
Cervical Cancer World report: Account for 1/3 female malignanciesNew cases: 529 800Death: 275 10085% developing country
The 4th most common cause of death from malignancy in women.
Cxca Progression
HPV infection CINs Carcinoma in situ 10-15yr Cervical cancer
EtiologyHigh-risk factorsHR-HPVUse of oral contraceptivesSmoking Multiple sexual partnersHistory of herpes infection History of STD
Human Papillomavirus , HPV
1972Harald zur Hausen Zur Hausen
1995High-risk HPV by International Agency for Research on CancerIARC
90% cervical cancer with HPV infection
HPVHigh risk HPVHR-HPVoncogenic HPVHPV 16,18,31,33,35,39,45, 51,52,56,58,59,68,73,82HSIL, Cxca
Low risk HPVLR-HPVnon-carcinogenic HPV HPV 6,11,42,43,44,54,61,70,72,81LSIL
PrecursorsCIN: Cervical Intraepithielial NeoplasmCIN Imild dysplasia1/3CIN IImoderate dysplasia1/3-2/3 CIN IIIsevere dysplasia , 3/3
CIS : carcinoma in situ
Precursors ---CINs
Cervical cancer Histological TypesSquamous carcinoma 80-85%Adenocaricinoma 15-20%Endometrial carcinomaClear cell carcinomaAdenosquamous 3-5%Undifferentiated carcinoma
Minimal deviation adenocarcinoma (MDA)Neuroendocrine tumor (small cell)
Spread patternTranscelomic most common
Lymphatic retroperitoneal ( pelvic and paraaortic ) LN spreading is common in advanced- stage
Hematogenous uncommon
FIGOstage
FIGO StagingI The carcinoma is strictly confined to the cervix (extension to the uterine corpus should be disregarded).IA Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5mmb and no wider than 7mm. (All gross lesions even with superficial invasion are Stage IB cancers.) IA1: Measured invasion of stroma 3mm in depth and 7mm width. IA2 : Measured invasion of stroma >3mm and 4cm in size.
II The carcinoma extends beyond the uterus, but has not extended onto the pelvic wall or to the lower third of vagina.IIA Involvement of up to the upper 2/3 of the vagina. No obvious parametrial involvement. IIA1: Clinically visible lesion 4cm IIA2: Clinically visible lesion >4cmIIB Obvious parametrial involvement but not onto the pelvic sidewall.
III The carcinoma has extended onto the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumor and pelvic sidewall. The tumor involves the lower third of the vagina. All cases of hydronephrosis or non-functioning kidney should be included unless they are known to be due to other causes.IIIA Involvement of the lower vagina but no extension onto pelvic sidewall.IIIB Extension onto the pelvic sidewall, or hydronephrosis/non-functioning kidney.
IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.IVA Spread to adjacent pelvic organs.IVB Spread to distant organs.
Platform of diagnosis for cervical diseasesPap smear TBS classificationTCTHPVColposcopy--biopsyLEEP
Cervical cancerSymptoms
No symptomsAbnormal pap smearLeukorrheaPostcoital bleedingPelvic pain
HistoryPhysical examinationCytology (pap smear, TCT)Biopsy (colposcopy)ConizationImagingCervical cancerDiagnosis
Principle for treat cervical cancerEvidence based medicineFIGO ( International Federation of Gynecology and Obstetrics) NCCN (National Comprehensive Cancer Network)
Individualized therapy
Cervical Cancer TreatmentPrecursor- CINsMicro-invasive cancerInvasive cancer
Treatment for CINsCIN I: follow up 36monthsCIN II: local therapy conizationCIN III: conization hysterectomy
Ia1: hysterectomyIa2: modified hysterectomyIa with positive margin (Ia or CIS): radical hysterectomy
Treatment for micro-invasive cervical cancer
Surgical threatment Ib-IIaRadiotherapyChemotherapy Combined therapy
Treatment for invasive cervical cancer
Cervical cancerb1/a1)
1. RH+PLND+/- PALND Radical hysterectomy+ pelvic lymph node dissection para-aortic lymph node dissection;
2. RT Pelvic RT+ Brachytherapy concurrent cisplatin-containing chemotherapy
Cervical cancerb2/a2)
1. RT Pelvic RT+concurrent cisplatin-containing chemotherapy + Brachytherapy
2. RH+PLND+/- PALND Radical hysterectomy+ pelvic lymph node dissection para-aortic lymph node dissection;
3. RT+ Hysterectomy Pelvic RT+concurrent cisplatin-containing chemotherapy + Brachytherapy +adjuvant hysterectomy
Flow-chat for management IB, IIA cervical cancer) IB1, IIA14cm
RH+PLND+/-PALNDRTCCRTRH+PLND+PALNDNACT+RH+PLND +PALNDRT+CTLN positivepositive margin
RT+/- CTpoor differentiateddeep myometrial invasionLVSIAdjuvant Therapy(according to high-risk factors)
Complications of RHVesicovaginal fistulaUreterovaginal fistulaSevere bladder atomyBowel obstructionLymphocystThrombophlebtisPulmonary embolus
Post-surgical treatment(high risk factors)
poor differentiateddeep myometrial invasionLVSILN positivepositive margin (Vaginal, parametrium)
Advanced stageb)
Radiotherapy (RT)NACT + RadiotherapyConcurrent chemo-radiotherapyCombined RT and CT
Prognosis 5yr survival rate recurrent rate patients with RT (RH)Stage I: 91.5% (86.3%) 1.5%Stage IIa: 83.5% (75%)Stage IIb: 66.5% (58.9%) 5%Stage IIIa: 45% (43%) 7.5%Stage IIIb: 36% 17%Stage IV: 14%
Data from MD Anderson Hospital
Pregnant with cervical cancer20w, evaluation, Ia-Ib1 observation;>24w, 32-34w CS+RH;
Primary prevention1. Health care2. Sexual behavior 3. Dual protection4. HPV vaccines4. Cancer screening5. Treat precursors
PreventionSecondary prevention1.Early screening2. Early treatment
SurveillanceInterval H & PEvery 3-6months for 2yr;Every 6-12months fro 3-5yrCytology/yrImaging : PET, PET-CT, MRI, CTLab oratory assessmentPatient education
Take home message HPV (HR)CINsFIGO stageSurgery: Radical hysterectomy and PLNDPost-operation treatment: high risk factorsRT and CTFertility sparing trachelectomyHPV Vaccine
OB/GYN Hospital of Fudan University THANKS
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