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Gynecology 5th year, 10th lecture (Dr. Hanaa)

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The lecture has been given on Apr. 11th, 2011 by Dr. Hanaa.

The lecture has been given on Apr. 11th, 2011 by Dr. Hanaa.

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  • 1.  
  • 2.
    • Incidence
    • The most common form of carcinoma in women in developing countries.& the second most common form of carcinoma in the world
    • Up to 450000 new cases of invasive carcinoma of the cervix occur per year in developing countries
    • The benefits of screening are only now becoming apparent
    • A decrease in mortality rate about 5% due to widespread coverage of screening
  • 3. What is cervical cancer? Cervical cancer is the rapid, uncontrolled growth of severely abnormal cells on the cervix , the lower part of the uterus that opens into the vagina. Fortunately, when detected at an early stage, cervical cancer is highly curable. Pap test screening, when done regularly, is the single most important tool for preventing cervical cancer because it can detect abnormal cervical cell changes before they become cancerous, when treatment is most effective.
  • 4.
    • There are 2 main types of cervical cancers:
    • 1- squamous cell carcinoma
    • 2-adenocarcinoma.
    • About 80% to 90% of cervical cancers are squamous cell carcinomas, which are composed of cells that resemble the flat, thin cells called squamous cells that cover the surface of the endocervix. Squamous cell carcinomas most often begin where the ectocervix joins the endocervix.
    • The remaining 10% to 20% of cervical cancers are adenocarcinomas. Adenocarcinomas are becoming more common in women born in the last 20 to 30 years. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix. Less commonly , cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.
  • 5.
    • What causes cervical cancer?
    • The cervix is made up of two kinds of cells: columnar cells and squamous cells. Columnar cells constantly change into squamous cells in an area of the cervix called the transformation zone. As a result of this natural process of change, some cervical cells can become abnormal. Infection can also cause abnormal cervical cell changes. When abnormal cell changes persist over time (years) and become severe, these cells may develop into cervical cancer
  • 6.
    • Aetiology
    • The cause of Ca cervix is unknown
    • *HPV type ( 16, 18)
    • 80-90% of sexually active women acquire HPV infection of genital tract at some stage of their life.
    • *this association has led to the development of vaccine both to prevent & to treat this disorder,
    • . *high parity
    • *increasing number of sex partners
    • *young at 1 st intercourse
    • *low socioeconomic status
    • *positive smoking history
  • 7. What screening tests are available?
    • The current hallmark of cervical cancer screening is the Pap test. Pap is short for Papanicolaou, the inventor of the test,
    • . A Pap test is easily performed in doctor's office. During a pelvic examination, the doctor uses a wooden spatula and/or a brush to get samples of cervical cells. These cells are placed on a slide, fixed, and sent to a laboratory where an expert in examining cells under a microscope can look for cancerous changes.
  • 8.
    • Women should begin having yearly Pap tests done at the onset of sexual activity, or the age 18 - whichever comes first. Most women should continue to have Pap tests done on a yearly basis
    • Women in low risk groups who have had three normal Pap tests may want to discuss the option of getting the tests done every two or three years.
    • Women who have had a "subtotal or supracervical" hysterectomy still have a cervix, and need to continue Pap testing annually. Women who have had a total hysterectomy need to have the tissue in their vaginas examined by a Pap test every 3 to 5 years. Women who are post-menopausal still need Pap exams, but the frequency will depend on their physician's understanding of their particular health needs.
  • 9.
    • A new screening modality for cervical cancer that may become important in the future is HPV testing . With modern DNA analysis, we have the ability to tell which subtype, or strain, of HPV a person is infected with
    • What are the signs of cervical cancer?
    • Unfortunately, the early stages of cervical cancer usually do not have any symptoms. This is why it is important to have screening Pap tests. As a tumor grows in size, it can produce a variety of symptoms including:
    • abnormal bleeding (including bleeding after sexual intercourse, in between periods, heavier/longer lasting menstrual bleeding, or bleeding after menopause)
    • abnormal vaginal discharge (may be foul smelling)
    • pelvic or back pain
    • pain on urination
    • blood in the stool or urine
  • 10.
    • How is cervical cancer diagnosed and staged? Having symptoms (bleeding/discharge) from a cervical cancer, then it can probably be visualized during a pelvic exam. Any time the doctor can see a cervical tumor on pelvic exam, it will be immediately biopsied.
    • There are a few different ways to do a biopsy.
    • A punch biopsy, removes a small section of the cervix.
    • A LEEP (loop electrosurgical excision procedure) is another method to do a biopsy where a thin slice of the cervix is removed.
    • Finally, sometimes a conization or cone biopsy is performed. A cone biopsy removes a thicker section of the cervix, and allows the pathologist to see if malignant cells have invaded underneath the surface.
  • 11.
    • *Another important test is called intravenous pyelography (IVP)
    • *Tests like CAT scans (3-D x-rays) or MRIs (like a CAT scans but done with magnets) can examine the cervix and localized lymph nodes. X-rays may be taken of bones and/or chest.
    • *a cystoscopy, in which a lighted scope is inserted through the urethra into the bladder
    • a proctosigmoidoscopy, which uses a lighted scope to examine rectum and colon.
  • 12.
    • There are a few different staging systems, but the most popular one for cervical cancer is the FIGO system (International Federation of Gynecologists and Obstetricians). The FIGO system is a clinical staging system which means that the cancer is staged by a doctor's physical examination and the results of a biopsy. The FIGO staging system is for invasive cervical cancers, not pre-cancerous lesions. A simplified version of the FIGO staging system is:
    • Stage Ia - microscopic cancer confined to the cx
    • Stage Ib - cancer visible by the naked eye confined to the cx
    • Stage II - cervical cancer invading beyond the cx but not to the pelvic wall or lower 1/3 of the vagina
    • Stage III - cervical cancer invading to the pelvic wall and/or lower 1/3 of the vagina and/or causing a non-functioning kidney (hydronephrosis)
    • Stage IVa - cervical cancer that invades the bladder or rectum, or extends beyond the pelvis
    • Stage IVb - distant metastases
  • 13. the treatments for cervical cancer
    • Surgery
    • Surgery is generally only employed in early stage cervical cancers. The purpose of surgery is to remove as much disease as possible, but it usually isn't used unless all of the cancer can be removed at the time of surgery. Cancers that have a high chance of already being in the lymph nodes are not treated with surgery
  • 14.
    • There are a few different types of surgeries that can be performed.
    • The earliest stage Ia tumors can sometimes be treated with only a hysterectomy (removal of the uterus and cervix).
    • Bigger stage Ia, stage Ib, and occasionally stage IIa tumors can be treated with more extensive hysterectomies coupled with lymphadenectomies (procedures that remove lymph nodes in the pelvis). Depending on the amount of disease, surgeon may have to remove tissues around the uterus, as well as part of the vagina and the fallopian tubes. One of the benefits of surgery in young women is that sometimes their ovaries can be left, so that they do not go through menopause at an early age
  • 15.
    • Higher stage disease is usually treated with radiation and chemotherapy, but sometimes surgery is employed if cervical cancer comes back after it has already been treated. A pelvic exeneration is reserved for recurrent cervical cancers. A pelvic exeneration is a drastic surgery in which the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, rectum and part of the colon are removed. This surgery is not commonly employed, but is occasionally used for recurrent cancers.
  • 16.
    • Radiation therapy Radiation therapy is another option besides surgery for early stage cervical cancer; and when advanced stage cervical cancer needs to be treated, it is usually done with radiation therapy. Surgery and radiation have been shown to be equivalent treatments for early stage cervical cancers, and radiation helps avoid surgery in patients who are too ill to risk having anesthesia. Radiation has the benefit of being able to treat all of the disease in the radiation field; thus lymph nodes can be treated as well as the primary tumor in the course of the same treatment.
  • 17.
    • Radiation therapy for cervical cancer either comes from an external source (external beam radiation) or an internal source (brachytherapy). External beam radiation therapy requires patients to come in 5 days a week for up 6-8 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. With all cervical cancers above stage IB, the standard approach with radiotherapy is to use external beam radiation coupled with internal brachytherapy. Brachytherapy (also called intracavitary irradiation) allows radiation oncologist to "boost" the radiation dose to the tumor site.
  • 18.
    • Another use of radiation is for palliation - meaning that patients with very advanced cases of cervical cancer are treated with the intent of easing their pain or symptoms, rather than trying to cure their disease. Sometimes, women with early stage cancers get surgery, but after the results of the surgery, it becomes clear that they will need radiation as well. Finally, radiation is often combined with chemotherapy, and depending on the case
  • 19.
    • Chemotherapy
    • In order to decrease a patient's risk of a recurrence, they are often offered chemotherapy . Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. Practically all patients who are in good medical condition and receiving radiation for stage IIA or higher cervical cancer will be offered chemotherapy in addition to their radiation. It may even be offered for earlier stage patients depending on the particulars of their case. There have been many studies that demonstrate the usefulness of adding chemotherapy to radiation in terms of decreasing mortality from cervical cancer
  • 20.
    • The most commonly employed regimens use a drug called Cisplatin, but other drugs like 5-FU, Hydroxyurea, Ifosfamide, and Paclitaxel may also be employed
  • 21.
    • Cervical Cancer in Pregnancy
    • A small number of cervical cancers are found in pregnant women. If cancer is a very early cancer, such as stage IA, then most doctors believe that it is safe to continue the pregnancy to term. Several weeks after delivery, a hysterectomy or a cone biopsy is recommended (the cone biopsy is suggested only for substage Ia1).
    • If the cancer is stage Ib, the doctor must decide whether to continue the pregnancy. If not, treatment would be radical hysterectomy and/or radiation. Or the baby should be delivered by cesarean section as soon as it is able to survive outside the womb.
    • For more advanced cancers, immediate treatment is the safest option.
  • 22.  
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  • 26.