cervical cancer Flashcards
common sites of distant spread
para- aortic nodes
supraclav or mediastinal nodes
bone
lungs
liver
epidemiology
-85% found in developing countries
-Mortality high there too due to little assess of screening and treatment
-incidence of cancer is higher in some ethic groups-hispanic, black and asian women
Aetiology
cervical cancer can be caused by
pt1
-persisant infection with HPV virus
it can be passed by skin to skin contact from oral,vaginal. or anal sex.
cervical cancer can be caused by pt 2
-immunosupression such as HIV which can 5x the risk
-history of sexual transmitted disease
cervical cancer can be caused by pt 3
-high parity (3 or more babies)
-early age for first born (doubles the risk)
-early age of onset of coitus
-multiple sexual partners
-oral contraceptive(combined oestrogen-progestogen-5years)
-tobacco smoking
Grading Systems- pre cancerous
-Cervical Intraepithelial Neoplasia (CIN)
-Bethesda System
-Cervical Intraepithelial Neoplasia (CIN)
different degrees of dysplasia
Bethesda Grading System:
low grade squamos intraepithelial cells=low risk HPV subtypes with a low risk of progessiing into a invasive cancer
high grade squamos intraepithelial cells=high risk PHV with a high risk of progressing into a invasive cancer
Grading System- CIN
what does the CIN refer to
categorised by
stages
-a lesion that could progress into a invasive cancer
-depth of involvement
-CIN1-CIN3
CIN1-
caused by
treatment
-caused by low risk HPV
-no tx unless persisent
-regular monitoring / smears
CIN 2&3
caused by
treatment
-considered pre true cancer
-tx required
-excision
-follow up
Signs and Symptoms
pt1
post coital spotting
intermenstrual bleeding
prominent menstrual bleeding
post menopausal bleeding- result in anemia and fatigue
Vaginal discharge with offensive smell
Signs and Symptoms
pt2
-pelvic pain or dragging sensation
-pain during sex
-blood in urine
-rectal bleeding
DIAGNOSTIC WORK-UP AND STAGING:
staging system
International Federation of Gynecology and Obstetrics (FIGO)
Staging- Investigative procedures pt1
-pelvic examination
-biopsy
a)punch biopsy
b)small loop biopsy or cone biopsy
c)Endo cervical curettage
-Colposcopy
-FBC
-liver and renal function test
Endo cervical curettage
scrapping of cells from endocervical canal to test for any abnormal cells
Staging- Investigative procedures (imaging modalities)
pt1
MRI Pelvis (pelvic and abdominal)
-best method of radiological assessment of primary tumours greater thab 10mm
ultrasound
-good diagnostic accuracy
Staging- Investigative procedures (imaging modalities)
pt2
-CT (abdo/pelvis)
◦ Thoracic-metastasis assessment
-PET/CT
◦accurate
◦can detect nodal mestastese less than 10mm
-Chest xray
Clinical Staging- Investigative procedures:
-Hysteroscopy
-cystoscopy
-proctoscopy
-intravenous urography/pyelography
Hysteroscopy
visual examination of the cervix canal and the interior part of the uterus using a thin and flexible tube
cystoscopy
examines urinary bladder and urethra
proctoscopy
investigates anal cavity, rectum and sigmoid colon
Intravenous urography/pyelography
examine kidneys , bladder , urethra and ureter
Histological Types
-70- 80% Squamous cell (epidermoid) carcinoma
-20-25% adenocarcinoma including adenosquamous
adenocarcinoma including adenosquamous
-increasing particular in young women
-exposure to oestrogen, obesity and conttraceptives
-not always detected on screening
Grading
Does not modify stage groups
GX: Grade cannot be assessed
G1: Well differentiated
G2: Moderatley differentiated
G3:Poorly or undifferentiated.
Treatment Options Available
surgery
chemo
radiation
brachy
Surgery
-primary tx of early stage cancer( stage - 1A,1B1,1B2 )
-allows lymph nodes to be assessed accurately
-ovarian function remains = no early menopause
Sentinel Lymph Node Mapping
-what is it
-when is it used
- Recommended for
-benefits
-dyes and radioactive substances to identify lymph nodes that may contain tumor cells.
-stage 1cervical
-T1b1/T2a1
-decreases the need in pelvic lymphadectonomy
Strategic Plan for T1b1/T2a1
aim to avoid combining treatments-
surgery and RT = highest morbidity after. tx
Fertility Sparing procedures
-only offered to highly selected patients
-Not recommended for patients with neuroendocrine tumours or adenoma malignum(lack of data)
Criteria for Adjuvant treatments
-if pathological risk factors are discovered after radical hysterectomy (removal of womb)
-observation is needed if patient has sedlis criteria
sedlis criteria
risk factors for recurrence warranting post-hysterectomy radiation for early-stage cervical cancer
Criteria for Adjuvant treatments:
-Post-op RT is recommended for
high risk disease (positive pelvic nodes & positive surgical margin).
Neo- adjuvant chemotherapy
no recommended outside a clinical trial
Awaiting result of new key trial
◦ INTERLACE
aim of interlace
investigate whether a short course of chemo given out weekly immediately before the standard chemoradiation
improves OS for locally advanced cervical cancer
Chemoradiation
-Primary treatment of Stage IIB-IVA
-suitable for early stages if patient not suitable for surgery
-results in ovarian failure for pre-menopausal women
-ovarian transportation may be considered in women less 45
Concurrent Chemotherapy
-Patients with FIGO IB2- proven effectiveness of chemoradiation to radiation alone
-Standard treatment:cisplatin 40mg/m2 IV
weekly
Criteria for Adjuvant treatments:
Pelvic EBRT is recommended
w or w/o concurrent platinum based chemotherapy for patients with all
-stage IA2, IB, or IIA1 disease
-negative lymph nodes after sx
-large primary tumors, deep stromal invasion
