18.Cervical Cancer
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Transcript of 18.Cervical Cancer
Cervical Dysplasia and Cervical Cancer
Qu [email protected] First Central Hospital
New Cases of Cervical Cancer per Year
459400Total
1570044000472003130036900131500716009700
703001200
105100354300
North AmericaLatin America
EuropeSoviet Union
AfricaChinaIndeaJapan
Asia( Other Areas)Australia/New Zealand
Advanced AreasDeveloping Aeras
New CasesArea
(Parkin D.M,et al Bulletin of the WHO.1984,62:163-183)
Etiology and Epidemiology
HPV infection High risk factors Young age at first coitus(<20yr) Multiple sexual partners Sexual partner with multiple sexual partners Young age at first pregnancy High parity Lower socioeconomic status Smoking
•DS DNA
•No growth cell culture
LCR E6E7
E1
E2
E4E5L2
L1
HPV
HPV infection via HPV infection via wounds in epitheliumwounds in epithelium
Infection From Time of First Sexual Intercourse
From Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol. 2003;157:218–226. Reprinted with the permission of Oxford University Press.
0 4 8 12 16 20 24 28 32 36 40 44 48 52 560
0.2
0.4
0.6
0.8
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Months Since First Intercourse
Cu
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V In
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1
2
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CIN Invasive Cervical Cancer
Re
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sti
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* ≥ 23 or Never18–22
≤ 17
*Mantle-Haenszel estimates adjusted for age only1. La Vecchia C, Franceschi S, DeCarli A, et al. Cancer. 1986;58:935–941.
Age at First Intercourse (Years)
(n=206) (n=327)
Cervical Intraepithelial Neoplasia
9,710 new cases of cervical cancer1
330,000 new cases of high-grade cervical dysplasia (CIN 2/3)2
1.4 million new cases of low-grade cervical dysplasia (CIN 1)2
1 million new cases of genital warts3
Incidence of HPV infection, CIN and Incidence of HPV infection, CIN and Cervical Cancer in USACervical Cancer in USA
Several Conceptions Cervical intraepithelial neoplasia(CIN) the condition
that different degree of abnormal epithelial proliferation and maturation above the basement membrane.
Transformation zone the area of metaplastic squamous epithelial located between the original squamocolumnar junction and new squamocolumnar junction.
Original squamocolumnar junction The junction between the embryologic squamous and columnar epithelia at or near the external cervical os is called the original squamocolumnar junction.
Before puberty
After puberty and reproductive period
child-bearing period
Peri-menopausal period
menopausal period
Classification of an abnormal papanicolaou smear(According to the standard of the 2001 Bethesda classification of cytologic abnormalities )
squamous epithelial cell abnormalities glandular epithelial cell abnormalities
Atypical squamous cells of undetermined significance (ASCUS) cannot exclude HSIL(ASC-H)
Low-grade squamous intraepithelial lesion(LSIL) encompassing:human papillomavirus/mild
High-grade squamous intraepithelial lesion(HSIL) encompassing:moderate and server dysplasia, carcinoma in situ; CIN2 and CIN3
Squamous cell carcinoma
Atypical glandular cells(AGC)(specify endocervical, endometrial, or not otherwise specified)
Atypical glandular cells, favor neoplastic (specify endocervical, or not otherwise specified)
Endocervical adenocarcinoma in situ(AIS)
Adenocarcinoma
Normal ASCUS LSIL HSIL
Conventional Pap Smear
Decrease
Sensitivity
Liquid-based Cytology
HPV infection and endocrine change
The Liquid-based Cytology
CIN 1 CIN2 CIN3
LSIL HSIL
Normal or benign disease Carcinoma in situ
Early invasive carcinoma
CIN
Pathology
Cytology
Colposcopy
At colposcopy, the original or native squamous epithelium appears gray and homogeneous. The columnar epithelium appears red and grapelike. The transformation zone can be identified by the presence of gland openings that are not covered by the squamous metaplasia and by the paler color of the metaplastic epithelium compared with the original squamous epithelium.Normal blood vessels branch like a tree.
Squamous epithelial Columnar epithelial
Squamous epithelial Columnar epithelial
(iodine test)
Biopsy and endocervical Curettage
A diagnostic cone biopsy of the cervix is indicated if : Colposcopic examination is unsatisfactory Endocervical curettings show a high-grade lesion Papanicolaou smear shows a high-grade lesion that is n
ot confirmed on punch biopsy Papanicolaou smear indicates adenocarcioma in situ Microinvasive is present on the punch biopsy
Pathology of CIN
CIN I CIN 2 CIN 3 carcinoma in situ
Treatment of intraepithelial neoplasia
Loop excision of the transformation LEEP,loop electrodiathermy excision procedure
Laser Cryosurgery Electrocoagulation Cervical conization Hysterectomy
Cervical carcinoma
Incidence of Cervical Cancer in China
New Cases 130,000/year
Died from CC 20,000~30,000/year
Incidence of CC has increased
tends to occur in younger
Incidence: 138.75/100,000 (8 million samIncidence: 138.75/100,000 (8 million samples, 25 provinces) ples, 25 provinces)
High incidence of Age: High incidence of Age: ≤ 35 4.8% (80’s) ≤ 35 4.8% (80’s) 34.1% (2000) 34.1% (2000)
Mortality: 10.28/100,000 (70’s)Mortality: 10.28/100,000 (70’s) 3.25/100,000 (90’s) 3.25/100,000 (90’s) 69% dropped 69% dropped
The presence of The presence of HPVHPV in virtually all in virtually all cercervical cancervical cancer implies the highest worldw implies the highest worldwide attributabe fraction so far reported foide attributabe fraction so far reported for a specific cause of any major human r a specific cause of any major human cancercancer
Pre-Invasive Cancer Invasive Cancer
Normal Pre-Invasive Cancer Invasive Cancer
Natural History of Cerical Carcinogenesis
Signs and Symptoms
Abnormal vaginal bleeding presents with postcoital, intermenstrual, or postmenopausal
vaginal bleeding. Abnormal vaginal discharge Advanced symptomes such as, pelvic
pain, leg swelling, and urinary frequency.
Physical finding General physical examination such as weight loss, enlar
ged inguinal lymph nodes, edema of the legs, ascites, pleural effusion, or hepatomegaly.
Pelvic examination In early cervical cancer may reveal a cervix that appears normal, especially if the lesion is endocervical. Visible disease may take several forms: ulcerative, exophytic, granular, or necrotic. The lesion may involve the upper potion of the vagina. The cervix may be distorted or completely replaced by tumor.
Rectovaginal examination Essential to determine the extent of involvement. The degree of cervical expansion and spread to the parametria are much more easily deteced with a finger in the rectum, as is extension into the uterosacral ligaments.
Laboratory test
Cervical squmous carcinoma
Cervical squmous carcinoma
Cervical squmous carcinoma
Three Steps Diagnosis for Cervical Carcinoma
Cytologic test Colposcopic test Cervical biopsy and Endocervical Curett
age
Pathologic features
Squamous carcinoma Adenocarcinoma Adenosquamous carcinomas Melanomas Sarcomas
Cervical squmous carcinoma
Cervical squmous carcinoma
Cervical adenocarcinoma
Cervical adenocarcinoma
Patterns of spread
Direct invasion cervical stroma, vagina, and parametrium.
Lymphatic spread pelvic and then paraaortic lymph nodes
Hematogenous spread such as lungs, liver, and bone
The International Federation of Gynecology and Obstetrics(FIGO) staging of cervical carcinoma
Stage Range
0 Carcinoma in situ, intraepithelial carcinoma
I The carcinoma is strictly confined to the cervix
Ia Invasive cancer is identified only microscopically. All grossslesions even with superficial invasion are Ib cancer. Invasion is limited to a measured stromal invasion, with a maximal depth 5 mm and a horizontal extension of not more than 7 mm
Ia1 Measured invasion of stroma not greater than 3 mm in depth and 7 mm in width
Ia2 Measured invasion of stroma greater than 3 mm and not greater than 5 mm and width not greater than 7 mm
Ib Clinical lesions confined to the cervix or preclinical lesions greater than stage Ia
Ib1 Clinical lesions not greater than 4 cm in size
Ib2 Clinical lesions greater than 4 cm in size
II The carcinoma extends beyond the cervix but has not extended to the pelvic wall or to the lower third of the vagina.
IIa No obvious parametrial involvement.
IIb Obvious parametrial involvement.
III The carcinoma has extended to the pelvic wall. On rectal examination there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina. All cases with hydroeprosis or nonfunctioning kidney should be included, unless they are known to be due to another cause.
IIIa Tumor involves lower third of the vagina with no extension to the pelvic wall.
IIIb Extension onto the pelvic wall and /or hydronephrosis or nonfunctioning kidney.
IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV
IVa Spread of the growth to adjacent organs.
IVb Spread to distant organs.
Preoperative investigations
Biopsies, cystoscopy, sigmoidoscopy, chest and skeletal radiographs, and liver function tests.
For patients with advanced disease, an abdominal and pelvic computed tomographic scan is helpful in planning management, but the results do not influence the FIGO stage.
Treatment of cervical cancer
Stage Ia (microinvasive cervical carcinoma) Operation radical hysterectomy and bilateral pelvi
c lymphadenectomy Radiation therapy intracavitary and external rad
iation. chemoradiation, using weekly cisplatin as the radiation sensitizer improve survival
Treatment of cervical cancerStage II Stage IIa radical surgery or chemoradiation therapy Stage IIb No operation. Combination of external beam chemo
radiation and intracavitary therapy. Stage III Stage IIIa and IIIb Chemoradiation therapy, usually externa
l beam followed by intracavity brachytherapy.Stage IV Stage IVa Pelvic chemoradiation therapy. Stage IVb Some pelvic radiation therapy to control bleeding
from the vagina, and chemotherapy is for distant metastases.
Prognosis for cervical cancer
Clinical stage Pathologocal type Adenocarcinoma and
adenosquamous carcinoma have a somewhat lower 5-year survival rate than squamous carcinoma, stage for stage.
Key points
Main cause for cervical carcinoma What is CIN, transformation zone How to differentiate CIN I, CIN II, CIN III? Diagnosis? Pathologic type? Patterns of spread in cervical carcinoma.
Questions 1
Which examination is the first step in cervical lesion
A. Cervical conizationB. Endocervical curettageC. Cervical pap smearD. ColposcopyE. Biopsy
Questions 2
Which patient should be treated by operation?
A. Stage IIIaB. Stage IVaC. Stage IIaD. Stage IIbE. Stage IIIb