Cervical LesionsMaria Julieta V. Germar, FPOGS, FSGOP Section of Gynecologic OncologyUP College of Medicine-Philippine General HospitalThe Medical City
Ateneo School of Medicine and Public Health 16 November 2011
Normal Cervix Cervical Cancer
How do we diagnose cervical cancer ?
Squamous Cell CarcinomaHPV 16, 18
Cervical AdenocarcinomaHPV 16,18, 45
How is it staged ?
IIIB
CLINICAL STAGING
Bimanual examination of the pelvis, which includes palpation of the uterus and ovaries.
Rectovaginal Exam- to assess the parametria
parametriaparametria
Rectovaginal Exam- to assess the parametria
October 2009 Update:New Cervical Cancer Staging
1988 FIGO 1988 FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E 0E 0 Carcinoma in situCarcinoma in situ
cervical intraepithelial neoplasia cervical intraepithelial neoplasia grade IIIgrade III
STAGSTAGE IE I
The carcinoma is strictly The carcinoma is strictly confined to the cervixconfined to the cervix
IAIA invasive carcinoma that can be invasive carcinoma that can be diagnosed only microscopically, with diagnosed only microscopically, with deepest invasion of <5mm and largest deepest invasion of <5mm and largest extension of >7mmextension of >7mm
IA1IA1 Measured stromal invasion of Measured stromal invasion of <3mm in depth and extension of <7mm<3mm in depth and extension of <7mm
1A21A2 Measured stromal invasion of Measured stromal invasion of <3mm and not >5mm with an <3mm and not >5mm with an extension of >7mmn depth and extension of >7mmn depth and extension of <7mmextension of <7mm
2009 FIGO 2009 FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E 0E 0 deleteddeleted
STAGSTAGE IE I
The carcinoma is strictly The carcinoma is strictly confined to the cervixconfined to the cervix
IAIA invasive carcinoma that can be invasive carcinoma that can be diagnosed only microscopically, with diagnosed only microscopically, with deepest invasion of <5mm and largest deepest invasion of <5mm and largest extension of >7mmextension of >7mm
IA1IA1 Measured stromal invasion of Measured stromal invasion of <3mm in depth and extension of <7mm<3mm in depth and extension of <7mm
1A21A2 Measured stromal invasion of Measured stromal invasion of <3mm and not >5mm with an <3mm and not >5mm with an extension of >7mmn depth and extension of >7mmn depth and extension of <7mmextension of <7mm
STAGING Revised October 2009
1988 FIGO 1988 FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E IBE IB Clinically visible lesions limited to Clinically visible lesions limited to
the cervix uteri or subclinical cancers the cervix uteri or subclinical cancers greater than stage IAgreater than stage IA
IB1IB1 clinically visible lesions not large clinically visible lesions not large than 4 cmthan 4 cm
IB2IB2 clinically visible lesions larger clinically visible lesions larger than 4 cmthan 4 cm
2009 FIGO 2009 FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E IBE IB Clinically visible lesions limited to Clinically visible lesions limited to
the cervix uteri or subclinical cancers the cervix uteri or subclinical cancers greater than stage IAgreater than stage IA
IB1IB1 clinically visible lesions not large clinically visible lesions not large than 4 cmthan 4 cm
IB2IB2 clinically visible lesions larger clinically visible lesions larger than 4 cmthan 4 cm
STAGING Revised October 2009
1988 FIGO 1988 FIGO STAGING STAGING
STAGSTAGE IIE II
The carcinoma extends beyond The carcinoma extends beyond the cervix but has not extended to the the cervix but has not extended to the pelvic wall. The carcinoma involves the pelvic wall. The carcinoma involves the vagina but not as far as the lower thirdvagina but not as far as the lower third
IIAIIA no obvious parametria no obvious parametria involvementinvolvement
IIBIIB with obvious parametria with obvious parametria involvementinvolvement
2009 FIGO 2009 FIGO STAGING STAGING
STAGSTAGE IIE II
The carcinoma extends beyong The carcinoma extends beyong the uterus but has not extended to the the uterus but has not extended to the pelvic wall or to the lower third of the pelvic wall or to the lower third of the vaginavagina
IIAIIA Without parametrial invasionWithout parametrial invasion
IIA1IIA1 clinically visible lesion less than clinically visible lesion less than or equal to 4cm in greatest dimensionor equal to 4cm in greatest dimension
IIA2IIA2 Clinically visible lesion >4 cm in Clinically visible lesion >4 cm in greatest dimensiongreatest dimension
IIBIIB With obvious parametrial With obvious parametrial involvementinvolvement
STAGING Revised October 2009
1995 FIGO STAGING FOR CERVICAL CANCERSTAGE IIA The carcinoma extends beyond the uterus but has The carcinoma extends beyond the uterus but has not extended to the pelvic wall or to the lower third of the vagina with not extended to the pelvic wall or to the lower third of the vagina with NO parametrial involvementNO parametrial involvement
1995 FIGO STAGING FOR CERVICAL CANCERSTAGE IIB The carcinoma extends beyond the uterus but has not The carcinoma extends beyond the uterus but has not extended to the pelvic wall or to the lower third of the vagina With extended to the pelvic wall or to the lower third of the vagina With obvious parametrial involvementobvious parametrial involvement
1988 FIGO 1988 FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E IIIE III The carcinoma extends beyond The carcinoma extends beyond
the cervix but has not extended to the the cervix but has not extended to the pelvic wall. The carcinoma involves the pelvic wall. The carcinoma involves the vagina but not as far as the lower third. vagina but not as far as the lower third. The carcinoma has extended to the The carcinoma has extended to the pelvic wall. On rectal examination, pelvic wall. On rectal examination, there is no cancer free space between there is no cancer free space between the tumor and the pelvic wall. The the tumor and the pelvic wall. The tumor involves the lower third of the tumor involves the lower third of the vagina. All cases of hydronephrosis or vagina. All cases of hydronephrosis or nonfunctioning kidney are included, nonfunctioning kidney are included, unless they are known to be due to unless they are known to be due to other causesother causes
IIIAIIIA no extension to the pelvic wallno extension to the pelvic wall
IIIBIIIB extension to the pelvic wall extension to the pelvic wall and/or hydronephrosis or non and/or hydronephrosis or non functioning kidneysfunctioning kidneys
2009FIGO 2009FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E IIIE III The carcinoma extends beyond The carcinoma extends beyond
the cervix but has not extended to the the cervix but has not extended to the pelvic wall. The carcinoma involves the pelvic wall. The carcinoma involves the vagina but not as far as the lower third. vagina but not as far as the lower third. The carcinoma has extended to the The carcinoma has extended to the pelvic wall. On rectal examination, pelvic wall. On rectal examination, there is no cancer free space between there is no cancer free space between the tumor and the pelvic wall. The the tumor and the pelvic wall. The tumor involves the lower third of the tumor involves the lower third of the vagina. All cases of hydronephrosis or vagina. All cases of hydronephrosis or nonfunctioning kidney are included, nonfunctioning kidney are included, unless they are known to be due to unless they are known to be due to other causesother causes
IIIAIIIA no extension to the pelvic wallno extension to the pelvic wall
IIIBIIIB extension to the pelvic wall extension to the pelvic wall and/or hydronephrosis or non and/or hydronephrosis or non functioning kidneysfunctioning kidneys
STAGING Revised October 2009
1995 FIGO STAGING FOR CERVICAL CANCERStage III The cancer extends to the pelvic wall. The tumor involves the lower third of the vagina. All cases of hydronephrosis or non-functioning kidneys are included.
IIIA Without extension to the pelvic wall
IIIB With extension to the pelvic wall and/or hydronephrosis or non-functioning kidney.
1988 FIGO 1988 FIGO STAGING OF STAGING OF
CERVICAL CANCERCERVICAL CANCERSTAGSTAG
E IVE IV The carcinoma has extended The carcinoma has extended
beyond the true pelvis or has clinically beyond the true pelvis or has clinically involved the mucosa of the bladder or involved the mucosa of the bladder or rectum. A bullous edema as such does rectum. A bullous edema as such does not permit a case allotted to be stage not permit a case allotted to be stage IVIV
IVAIVA spread of growth to the adjacent spread of growth to the adjacent organsorgans
IVBIVB spread to distant organsspread to distant organs
2009 FIGO 2009 FIGO STAGING OF STAGING OF
CERVICAL CANCER CERVICAL CANCER STAGSTAG
E IVE IV The carcinoma has extended The carcinoma has extended
beyond the true pelvis or has clinically beyond the true pelvis or has clinically involved the mucosa of the bladder or involved the mucosa of the bladder or rectum. A bullous edema as such does rectum. A bullous edema as such does not permit a case allotted to be stage not permit a case allotted to be stage IVIV
IVAIVA spread of growth to the adjacent spread of growth to the adjacent organsorgans
IVBIVB spread to distant organsspread to distant organs
STAGING Revised October 2009
1995 FIGO STAGING FOR CERVICAL CANCERStage IV The cancer extends beyond the true pelvis or involves the mucosa of the bladder or the rectum.
IVA Spread to adjacent organs
IVB Spread to distant organs
Cervical cancer
n = 532
VIV
I
IIIII
14%
38%41%
2%5%
Section of Gynecologic Oncology Annual Report 2008. UP-PGH Department of Obstetrics and Gynecology Staff Conference. 2009 (unpublished)
Majority of Filipina women we see ( 40-60 %) are in stage III disease
IIIB
SURGERYCHEMOTHERAPY
AND RADIOTHERAPY
Early Stage (Stage I-IIA)-SURGERYRADICAL HYSTERECTOMY
Late stage II-IV3-4 months txCHEMOTHERAPYevery week for 6 cycles
RADIATION THERAPYLinear accelerator25-28 days
Brachytherapy 4 sessions
Cervical cancer
n = 270
Lost to follow-up
Section of Gynecologic Oncology Annual Report 2008. UP-PGH Department of Obstetrics and Gynecology Staff Conference. 2009 (unpublished)
Why ?
Cancer of the CervixCancer of the CervixSUMMARYSUMMARY
Total Cost of Primary TreatmentTotal Cost of Primary Treatment
COST IN COST IN PESOSPESOS
COST IN USDCOST IN USD
Diagnosis and Diagnosis and Pre-treatment Pre-treatment EvaluationEvaluation
30,865 -91,130 700-2100700-2100
SurgerySurgery 98,560 - 376,635
2200-87002200-8700
ChemoradiationChemoradiation 111,201-398,236 2600-92002600-9200
Germar, JV, Manalo, A. The Cost of Being Sick with Gynecologic Cancer in the Philippines. Germar, JV, Manalo, A. The Cost of Being Sick with Gynecologic Cancer in the Philippines. SGOP Annual Convention 2007. (unpublished) REVISED 2011SGOP Annual Convention 2007. (unpublished) REVISED 2011
Minimum Wage : Php 404.00/day (USD 9.31)= USD 214 per monthMinimum Wage : Php 404.00/day (USD 9.31)= USD 214 per month
CERVICAL CANCER IS PREVENTABLE
Prevention of Cervical Cancer:
Primary Prevention: Monogamous sexual relationship between husband and wife
Delay in onset of sexual intercourse Use of barrier contraceptives Prompt and adequate treatment of STDs Prompt and adequate treatment of Pre-invasive disease (CIN)
HPV vaccination
Prevention of Cervical Cancer Secondary Prevention:
Cytologic Screening/Pap smear
The Pap Smear Begin at age 21 or at the onset of sexual
activity, if earlier, and continue every year
National Cancer Institute. Screening for cervical cancer. 2008.
The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1
The Pap Smear Begin at age 21 and continue every two years
National Cancer Institute. Screening for cervical cancer. 2008.
The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1
New 2010 New 2010 recommendationsrecommendations
The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1