Carcinoma cervix


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Carcinoma cervix

  2. 2. AETIOLOGY• Human Papilloma Virus(HPV)• High risk- types 16, 18, 31, 33• Low risk- types 6 and 11• HPV viral proteins interact with the tumoursuppressor gene p53
  3. 3. RISK FACTORS• Young age at first intercourse• Multiple sexual partners• Cigarette smoking (both active and passive)• Increasing parity• Low socioeconomic status• Sexually transmitted diseases• Immunosuppression- HIV, autoimmune diseasesetc.• Oral contraceptive use
  4. 4. PREVENTION• Safe sexual practices• Regular Pap smears- early detection• HPV vaccine
  5. 5. DOWNSTAGING• Detection of cancer cervix at an earlierstage by nurses and other health workersusing simple speculum and visualinspection of the cervix
  6. 6. HISTOLOGIC TYPES• Squamous cell carcinomaLarge cell keratinizing tumoursLarge cell non- keratinizing tumoursSmall cell tumours• AdenocarcinomaAdenoma malignumVilloglandular papillary adenocarcinomaClear cell carcinoma• Adenosquamous carcinoma• Neuroendocrine tumours• Sarcomas• Malignant melanoma
  7. 7. PATTERNS OF SPREAD• Direct invasion- cervical stroma,parametrium, body of uterus, vagina,anteriorly to the bladder and posteriorly tothe rectum and bowel• Lymphatic spread- pelvic nodes andparaaortic nodes• Haematogenous spread- lungs, bones andliver
  8. 8. SYMPTOMS• Vaginal bleeding• Vaginal discharge• Pain• Asymptomatic• Advanced cases- weight loss, obstructiveuropathy
  9. 9. SIGNS• General examinationLymphadenopathy (supraclavicular andinguinal)Cachexia and anaemia in advanced casesOedema of legs• Abdominal examinationHepatomegalyAscites
  10. 10. • Speculum examinationCauliflower like growthBarrel- shaped cervixUlcerVaginal involvement• Bimanual examinationClassic signs of malignancy- friability, induration,bleeding on touch and fixity due to parametrial spreadEnlarged uterus due to tumour invasion or a pyometra• Rectovaginal or rectal examinationInduration laterally denoting parametrial spreadFixed mass indicates that the tumour has extended tothe pelvic side wallsThick rectovaginal septumRectal mucosal involvement
  11. 11. INVESTIGATIONS• ColposcopyAbnormal blood vesselsIrregular surface contourChange in colour tone• Examination under anaesthesia to assess parametrialspread• Barium enema, proctoscopy and sigmoidoscopy if rectalspread is suspected• Cystoscopy in locally advanced disease• Intravenous pyelogram• Chest X ray• Skeletal X rays if bone spread is suspected
  12. 12. MANGEMENTStage Management1a1 Cone biopsy or Type 1 simple hysterectomy1a2 Type 11 (modified radical) hysterectomy andpelvic lymphadenectomy1b1 Type 111 (radical) hysterectomy and pelviclymphadenectomy1b2 and 11a Primary chemoradiation or type 111 (radical)hysterectomy with pelvic and para- aorticlymphadenectomy (former preferred)11b onwards Primary chemoradiation (primaryexenteration in some 1V a)
  13. 13. RADICAL HYSTERECTOMYType 3 radical hysterectomy• Pelvic lymphadenectomy (common iliac, externaliliac, internal iliac and obturator nodes)• Removal of uterosacral and cardinal ligaments andthereby most of the parametrium• Removal of the uterus, cervix and upper one- thirdof vagina
  14. 14. Advantages over Radiotherapy• Ovaries can be conserved• Ovarian transposition can be done at surgery toprevent ovarian destruction by subsequentradiation• Vaginal shortening is less than followingradiotherapy• Avoidance of the chronic bowel and bladderproblems of radiotherapy• Surgical complications are easier to treat• Avoids the risk of radiation- induced malignancies
  15. 15. ComplicationsImmediate• Haemorrhage• Injury to ureter, blader orbowel• Pulmonary embolismDelayed• Bladder atony due todenervation of bladder• Small intestinalobstruction• Vesicovaginal fistulae(1%)• Ureterovaginal fistulaedue to avascular necrosisor ureteral injury (1-2%)• Lymphocyst formation
  16. 16. ADJUVANT THERAPYIntermediate riskfactors• Size of lesion morethan 2 cm• Cervical stromainvasion to middle ordeep third• Lymphovascular spaceinvasionHigh risk factors• Margins positive fortumour• Positive lymph nodes• Microscopicparametrialinvolvement
  17. 17. PRIMARY RADIOTHERAPY• Brachytherapy• External beam or teletherapy
  18. 18. ComplicationsImmediate• Perforation duringinsertion of uterinetube• Diarrhoea, abdominalcramps, nausea andfrequent urination• Rarely haematuria orbleeding per rectumDelayed• Small bowelobstruction and smallbowel fistulas• Vesicovaginal fistulas• Rectovaginal fistulas• Proctosigmoiditis andbleeding per rectum
  19. 19. Results of treatment• Stage 1- 85%• Stage 2- 60%• Stage 3- 45%• Stage 4- 18%
  20. 20. SURGERY RADIOTHERAPYSurvival 85% 85%Vaginal length andcoitusBetter Vaginal stenosismoreOvarian function Can be preserved Usually destroyedFistulas 1-2% 1-5% and lesstreatableSeriouscomplicationsLess More, especiallybowel and bladderBest candidates Young and in goodhealthAny patient
  21. 21. THANK YOU