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Pre-invasive and Invasive Lesions of the Cervix
 

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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    Pre-invasive and Invasive Lesions of the Cervix Pre-invasive and Invasive Lesions of the Cervix Presentation Transcript

    • Pre-invasive & Invasive Lesions of the Cervix http://crisbertcualteros.page.tl
    • Normal Cervix Cancer Cervical Intraepithelial Neoplasia (CIN) Carcinogenic Factors CIN I CIN II CIN III Carcinogenesis
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    • Carcinogenesis Normal Cervix Cancer Cervical Intraepithelial Neoplasia (CIN) Carcinogenic Factors CIN I CIN II CIN III
    • Human Papilloma Virus
    • 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
    • HPV E3 E1 E2 E4 E5 E6 E7 L1 L2 Human Genome p53 pRB Viral Genome Integration
    • E6 p53 DNA Repair Programmed Cell Death (Apoptosis) Viral Oncoprotein – Host Regulatory Protein Complex
    • E7 pRB Viral Oncoprotein – Host Regulatory Protein Complex S G2 M G1 G0 cell cycle
    • Predisposing Factors
      • Sexual behavior
      • Early age of first coitus
              • Adolescent age group
              • Time interval from menarche
              • Active cellular proliferation of the transformation zone
    • 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
    • Normal CANCER INITIATOR PROMOTER Carcinogenesis
    • 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
    • Predisposing Factors
      • Sexual behavior
      • Male factor
              • Multiple sexual partner
              • Uncircumcized
    • Cervical Intraepithelial Neoplasia
    • Cervical Intraepithelial Neoplasia
      • Pathology
      • Nuclear aneuploidy
      • Abnormal mitotic figures
      • Loss of maturation of the epithelium
      • *Dysplasia CONFINED to the epithelium
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    • Cervical Intraepithelial Neoplasia
      • Subtypes
      • CIN I – 1/3 involved
      • CIN II – 1/3 – 2/3 involved
      • CIN III – 2/3 – whole epithelium
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    • Cervical Intraepithelial Neoplasia
      • Screening Tools
      • Cytology ( Papanicolau smear)
      • Colposcopy
      • HPV DNA Typing
    • Cervical Intraepithelial Neoplasia
      • Pap Smear
      • “ Normal tissue sheds normal cells, abnormal tissue sheds abnormal cells “
      • Samples from the ENDOCERVIX
      • and ECTOCERVIX
    • 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
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    • 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.
    • 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.)
    • Cervical Intraepithelial Neoplasia
      • Pap Smear
      • Bethesda System (cytopathology report)
      • Normal
      • Benign cellular changes
      • Infection
      • Atypical cells of Undetermined significance (ASCUS)
    • 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
    • Cervical Intraepithelial Neoplasia
      • Pap Smear
      • Pitfalls:
          • Sampling error (bloody, inadequate cells, etc.)
          • Poor fixation of sample (dry smear)
          • Skill of cytopathologist
    • Colposcopy
    • 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
    • Colposcopy of the Cervix
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    • 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.)
    • Cervical Intraepithelial Neoplasia
      • HPV DNA Typing
      • PCR – most sensitive test
      • Prevalence of HPV is dependent on:
      • age
      • sexual activity
      • laboratory technique
      • frequency of testing
    • Cervical Intraepithelial Neoplasia
      • Management
      • Cryotherapy
      • Ablative procedures
      • LEEP / Conization
      • Hysterectomy
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    • Cervical Carcinoma
    • 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
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    • 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
    • Cervical Carcinoma
      • Pathology
      • Epithelial Tumors (Adenocarcinoma)
      • Mucinous
      • Mesonephric
      • Endometrioid
      • Clear Cell
      • Villoglandular
      • Papillary Serous
      • Minimal deviation
    • Cervical Carcinoma
      • Pathology
      • Neuroendocrine Tumors
      • Small Cell Carcinoma
      • Large Cell Carcinoma
      • Carcinoid Tumors
      • Typical
      • Atypical
    • Cervical Carcinoma
      • Symptoms & Pattern of Spread
      • Symptoms
      • Vaginal bleeding
      • Foul smelling vaginal discharge
      • Pelvic pain
      • Leg edema
    • Cervical Carcinoma
      • Symptoms & Pattern of Spread
      • Pattern of Spread
      • Direct invasion of adjacent structures
      • Lymphatic invasion
      • Hematogenous
    • Cervical Carcinoma
      • Diagnosis & Staging
      • Pelvic examination & Cervical Biopsy
      • Chest x-ray
      • Colposcopy
      • Cystoscopy
      • Proctosigmoidoscopy
      • Intravenous pyelogram
      • Barium enema
    • Cervical Carcinoma
      • Diagnosis & Staging
      • Other tes ts
      • CT Scan
      • MRI
      • PET Scan
      • Laparoscopy / hysteroscopy
      • Lymphography
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    • 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
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    • 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.
    • 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
    • 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
    • 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
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    • Stage III A Stage III B Extension to the LOWER 3rd of Vagina Extension to the PELVIC WALL
    • Surgical Management
    • Cervical Carcinoma
      • Surgical Management
      • Stage IA 1 – Extrafascial Hysterectomy
      • Stage IA 2 to IB 1 and II A
      • Radical Hysterectomy with
      • pelvic lymphadenectomy
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    • Cervical Carcinoma
      • Surgical Management
      • Advantages
          • Extent of metastasis evaluated
          • Ovaries preserved in young patients
          • Treatment duration is short
          • Psychological benefit
          • Sexual function not impaired
    • Cervical Carcinoma
      • Surgical Management
      • Complications
          • Hemorrhage
          • Injury to the ureter and adjacent organs
          • Infection
          • Fistula and lymphocyst formation
    • Multimodality Treatment
    • MultiModality Treatment
      • Combination Platinum based chemotherapy AND Radiotherapy
      • Chemotherapy:
      • - Cisplatin
      • - given weekly or every three weeks
      • Radiotherapy:
      • - External Radiation ( Cobalt, Lin-Acc)
      • - Brachytherapy
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    • 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
    • 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
    • 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
    • Follow-Up
    • 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
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      • Please visit:
      • http://crisbertcualteros.page.tl