Pre-invasive and Invasive Lesions of the Cervix

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Pre-invasive and Invasive Lesions of the Cervix

Pre-invasive and Invasive Lesions of the Cervix

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  • 1. Pre-invasive & Invasive Lesions of the Cervix http://crisbertcualteros.page.tl
  • 2. Normal Cervix Cancer Cervical Intraepithelial Neoplasia (CIN) Carcinogenic Factors CIN I CIN II CIN III Carcinogenesis
  • 3.  
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8. Carcinogenesis Normal Cervix Cancer Cervical Intraepithelial Neoplasia (CIN) Carcinogenic Factors CIN I CIN II CIN III
  • 9. Human Papilloma Virus
  • 10. Predisposing Factors
    • Human Papilloma Virus Infection
    • High Grade ( invasive cancer)
    • HPV type 16, 18 , 45, 56
    • Intermediate Grade (CIN II / III)
    • HPV type 31, 33, 35, 51, 52
    • Low Grade (Condyloma a. / CIN I)
    • HPV type 6, 11, 40, 41, 42
  • 11. HPV E3 E1 E2 E4 E5 E6 E7 L1 L2 Human Genome p53 pRB Viral Genome Integration
  • 12. E6 p53 DNA Repair Programmed Cell Death (Apoptosis) Viral Oncoprotein – Host Regulatory Protein Complex
  • 13. E7 pRB Viral Oncoprotein – Host Regulatory Protein Complex S G2 M G1 G0 cell cycle
  • 14. Predisposing Factors
    • Sexual behavior
    • Early age of first coitus
            • Adolescent age group
            • Time interval from menarche
            • Active cellular proliferation of the transformation zone
  • 15. Predisposing Factors
    • Sexual behavior
    • Multiple sexual partners
            • Higher risk of HPV infection
            • Likely to have first coitus at an early age
            • Epidemiologic studies: rare in celibate women
  • 16. Normal CANCER INITIATOR PROMOTER Carcinogenesis
  • 17. Predisposing Factors
    • Oral Contraceptive Pills
            • Less likely to use barrier method
            • Screening bias: more likely to be seen by a physician regularly
            • Associated with Adenocarcinoma
  • 18. Predisposing Factors
    • Sexual behavior
    • Male factor
            • Multiple sexual partner
            • Uncircumcized
  • 19. Cervical Intraepithelial Neoplasia
  • 20. Cervical Intraepithelial Neoplasia
    • Pathology
    • Nuclear aneuploidy
    • Abnormal mitotic figures
    • Loss of maturation of the epithelium
    • *Dysplasia CONFINED to the epithelium
  • 21.  
  • 22. Cervical Intraepithelial Neoplasia
    • Subtypes
    • CIN I – 1/3 involved
    • CIN II – 1/3 – 2/3 involved
    • CIN III – 2/3 – whole epithelium
  • 23.  
  • 24. Cervical Intraepithelial Neoplasia
    • Screening Tools
    • Cytology ( Papanicolau smear)
    • Colposcopy
    • HPV DNA Typing
  • 25. Cervical Intraepithelial Neoplasia
    • Pap Smear
    • “ Normal tissue sheds normal cells, abnormal tissue sheds abnormal cells “
    • Samples from the ENDOCERVIX
    • and ECTOCERVIX
  • 26. Cervical Intraepithelial Neoplasia
    • Steps in Doing the Pap Smear
        • Insert the speculum lubricated with water only
        • Visualize the cervix and vagina
        • Sample the endocervix and ectocervix separately
        • Spread sample thinly on a labelled glass slide
        • Fix sample immediately with 95% ethanol
        • Send sample to cytopathologist
  • 27.  
  • 28.  
  • 29.  
  • 30.  
  • 31.  
  • 32.  
  • 33. Cervical Intraepithelial Neoplasia
    • Pap Smear
    • Recommendation:
    • Yearly pap smear for women who are sexually active. Then less frequent thereafter if with two successive normal results.
  • 34. Cervical Intraepithelial Neoplasia
    • Pap Smear
    • Instructions for the patients:
        • No sexual intercourse a day before the smear
        • Do not do vaginal douching or use any vaginal lubricant a day before the smear
        • No vaginal bleeding (menstruation, etc.)
  • 35. Cervical Intraepithelial Neoplasia
    • Pap Smear
    • Bethesda System (cytopathology report)
    • Normal
    • Benign cellular changes
    • Infection
    • Atypical cells of Undetermined significance (ASCUS)
  • 36. Cervical Intraepithelial Neoplasia
    • Pap Smear (Bethesda System)
    • Low Grade Squamous Intraepithelial Lesion (LSIL)
            • HPV infection
            • CIN I
        • High Grade Squamous Intraepithelial Lesion (HSIL)
            • CIN II
            • CIN III
        • Glandular Cell Abnormalities
  • 37. Cervical Intraepithelial Neoplasia
    • Pap Smear
    • Pitfalls:
        • Sampling error (bloody, inadequate cells, etc.)
        • Poor fixation of sample (dry smear)
        • Skill of cytopathologist
  • 38. Colposcopy
  • 39. Cervical Intraepithelial Neoplasia
    • Colposcopy
    • Clinical evaluation of the biochemical and metabolic changes in the cervix as reflected by changes in the:
          • Topography of the epithelial surfaces
          • Vascular architecture
  • 40. Colposcopy of the Cervix
  • 41.  
  • 42. Cervical Intraepithelial Neoplasia
    • Colposcopy
    • Indications:
        • Abnormal cervical cytology
        • Clinically suspicious cervix
        • Women with high risk factors for cervical abnormalities
        • Women with genital warts or HPV infection
        • Women exposed to carcinogens (DES, etc.)
  • 43. Cervical Intraepithelial Neoplasia
    • HPV DNA Typing
    • PCR – most sensitive test
    • Prevalence of HPV is dependent on:
    • age
    • sexual activity
    • laboratory technique
    • frequency of testing
  • 44. Cervical Intraepithelial Neoplasia
    • Management
    • Cryotherapy
    • Ablative procedures
    • LEEP / Conization
    • Hysterectomy
  • 45.  
  • 46.  
  • 47. Cervical Carcinoma
  • 48. Cervical Carcinoma
    • PUBLIC HEALTH CONCERN
    • Most common gynecologic cancer
    • Top 5 - Most common cancer in women
    • Top 5 - Most common cause of cancer death in women
    • Majority present at advanced stage
  • 49.  
  • 50. Cervical Carcinoma
    • Pathology
    • Epithelial Tumors
    • Squamous Cell Carcinoma
    • Large cell, non keratinizing
    • Large cell, keratinizing
    • Verrucous Carcinoma
    • Adenosquamous Carcinoma
    • Glassy Cell Carcinoma
    • Adenoid Cystic Carcinoma
    • Adenoid Basal Epithelioma
  • 51. Cervical Carcinoma
    • Pathology
    • Epithelial Tumors (Adenocarcinoma)
    • Mucinous
    • Mesonephric
    • Endometrioid
    • Clear Cell
    • Villoglandular
    • Papillary Serous
    • Minimal deviation
  • 52. Cervical Carcinoma
    • Pathology
    • Neuroendocrine Tumors
    • Small Cell Carcinoma
    • Large Cell Carcinoma
    • Carcinoid Tumors
    • Typical
    • Atypical
  • 53. Cervical Carcinoma
    • Symptoms & Pattern of Spread
    • Symptoms
    • Vaginal bleeding
    • Foul smelling vaginal discharge
    • Pelvic pain
    • Leg edema
  • 54. Cervical Carcinoma
    • Symptoms & Pattern of Spread
    • Pattern of Spread
    • Direct invasion of adjacent structures
    • Lymphatic invasion
    • Hematogenous
  • 55. Cervical Carcinoma
    • Diagnosis & Staging
    • Pelvic examination & Cervical Biopsy
    • Chest x-ray
    • Colposcopy
    • Cystoscopy
    • Proctosigmoidoscopy
    • Intravenous pyelogram
    • Barium enema
  • 56. Cervical Carcinoma
    • Diagnosis & Staging
    • Other tes ts
    • CT Scan
    • MRI
    • PET Scan
    • Laparoscopy / hysteroscopy
    • Lymphography
  • 57.  
  • 58. Cervical Carcinoma
    • Staging
    • Stage I – Carcinoma confined to the cervix
    • I A – Microinvasive carcinoma
    • IA 1 – Stromal invasion < / = 3.0 mm in depth and < / =7.0 mm in horizontal dimension
    • IA 2 – Stromal invasion > 3.0 mm in depth and > 7.0 mm in horizontal dimension
  • 59.  
  • 60. Cervical Carcinoma
    • Staging
    • Stage I – Carcinoma confined to the cervix
    • I B – Clinically visible lesion
    • IB 1 – lesion < / = 4 cms.
    • IB 2 - lesion > 4 cms.
  • 61. Cervical Carcinoma
    • Staging
    • Stage II – Carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower vagina.
    • II A – No parametrial involvement
    • II B – With parametrial involvement
  • 62. Cervical Carcinoma
    • Staging
    • Stage III – Carcinoma extends to the pelvic wall and / or involves the lower third of the vagina or causes hydronephrosis or nonfunctioning kidney.
    • III A – Involves lower third of vagina with no extension to the pelvic wall III B – With extension to the pelvic wall and / or hydronephrosis or nonfunctioning kidney
  • 63. Cervical Carcinoma
    • Staging
    • Stage IV – Carcinoma extends beyond the true pelvis or has involved the mucosa of the bladder or rectum (biopsy proven)
    • IV A – Spread to adjacent organs
    • IV B – Spread to distant organs
  • 64.  
  • 65. Stage III A Stage III B Extension to the LOWER 3rd of Vagina Extension to the PELVIC WALL
  • 66. Surgical Management
  • 67. Cervical Carcinoma
    • Surgical Management
    • Stage IA 1 – Extrafascial Hysterectomy
    • Stage IA 2 to IB 1 and II A
    • Radical Hysterectomy with
    • pelvic lymphadenectomy
  • 68.  
  • 69. Cervical Carcinoma
    • Surgical Management
    • Advantages
        • Extent of metastasis evaluated
        • Ovaries preserved in young patients
        • Treatment duration is short
        • Psychological benefit
        • Sexual function not impaired
  • 70. Cervical Carcinoma
    • Surgical Management
    • Complications
        • Hemorrhage
        • Injury to the ureter and adjacent organs
        • Infection
        • Fistula and lymphocyst formation
  • 71. Multimodality Treatment
  • 72. MultiModality Treatment
    • Combination Platinum based chemotherapy AND Radiotherapy
    • Chemotherapy:
    • - Cisplatin
    • - given weekly or every three weeks
    • Radiotherapy:
    • - External Radiation ( Cobalt, Lin-Acc)
    • - Brachytherapy
  • 73.  
  • 74.  
  • 75.  
  • 76.  
  • 77.  
  • 78.  
  • 79. Cervical Carcinoma
    • Cervical Carcinoma in Pregnancy
        • The response to treatment and prognosis of the cancer is not affected by the pregnancy and vice-versa
        • Management dependent on the age of gestation of the pregnancy and stage of the cervical cancer
  • 80. Cervical Carcinoma in Pregnancy
    • Management
    ChemoRT Stage IB2, IIB, III & IV RHBLND Stage IA2, IB1 & IIA < 20 weeks Management Stage of Cancer Age of Gestation
  • 81. Cervical Carcinoma in Pregnancy
    • Management
    * Once with fetal lung maturity CS* + ChemoRT postpartum Stage IB2, IIB, III & IV CS* + RHBLND Stage IA2, 1B1 & IIA >20 weeks Management Stage of Cancer Age of Gestation
  • 82. Follow-Up
  • 83. Cervical Carcinoma
    • Follow-up
        • Monthly follow-up for the first year and bi-monthly on the second year
        • Pap smear every 3 – 6 months
        • Chest X-ray every year
        • Other imaging studies – dependent on clinical suspicion of recurrence
  • 84.  
  • 85.
    • Please visit:
    • http://crisbertcualteros.page.tl