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1、CERVICAL CANCER.,Diagnosis Treatment,CERVICAL CANCER.,The most common malignancy in gynecological oncologyIncidence:7.8/100,000Mortality:2.7/100,000Diagnosis:biopsyMain modality of treatment:surgery and radiationGoal of treatment:cure,except stage 4b,Special Case,38 yrs,G3/P1,nurseC/O:postcoital ble
2、eding for 2 monthsMenstruation regular with 30 days cycle and 5 days duration.Abnormal discharge with bad smell.LMP:12 days agoPap smear:squamous cell cancer PV:Vulva:Normal,Vaginal:yellowish discharge with bloody stained,Cervix:growth with ulceration and contact bleeding.Uterus:N/S,mobile.Parametri
3、um:thickening not to pelvic sidewall on both side,CERVICAL CANCER.,How can we make a diagnosis?How can we evaluate the patient?How can we manage the patient?How should we explain to the patient?Can we prevent cervical cancer?,How can we make a diagnosis?,SYMPTOMSAbnormal vaginal bleeding postcoital
4、bleeding*contact bleeding Abnormal vaginal dischargeAsymptomatic,just abnormal pap smear,SYMPTOMS,The classic symptom is intermittent,painless metrorragia or spotting only postcoitally or after douching.Probably the first symptom of early cancer of the cervix is a thin,watery,blood-tinged vaginal di
5、scharge that frequently goes unrecognized by the patients.As the maligancy enlarges,the bleeding episodes become heavier and more frequent,and they last longer.,SYMPTOMS,Late symptom or indicators of more advanced disease include the development of pain referred to the flank or leg.Many patients c/o
6、 dysuria,hematuria or rectal bleeding or obstipation resulting from bladder or rectal invasion.Distant metastasis and persistent edema of one or both lower extremities as a result of lymphatic and venous blockage by extensive pelvic wall disease are late manifestation of primary disease and frequent
7、 manifestations of recurrent disease.,How can we make a diagnosis?,SIGNSVagina:mucous,fornixCervix:erosion growth ulceration barrel-shapedUterus:size,mobilityParamet:thickening,Gross appearence,Three categories of gross lesions have traditionally been described.The most common is the exophytic lesio
8、n,which usually arises on the ectocervix and ofter grows to form a large,friable,polypoid mass,arises on the endocervical canal,creating barrel-shaped lesion.Little visible ulceration or exophytic mass like a stone-hard cervix that regresses slowly with radiation therapy.Ulcerative tumor,usually ero
9、des a portion of the cervix or replacing the cervix,erodes a portion of the upper vaginal vault with a large crate.,How can we make a diagnosis?,CLINICAL TESTS:Pap smearColposcopy and target biopsyEndocervical curettage(ECC)Cone biopsyBiopsy,Pap smear,Pap smear is the most common and effective scree
10、ning method.Exfoliated cervical cells are scraped from the cervix by spatula.The entire T zone must be sampled.Incomplete sampling could produce a false-negative smear.The endocervical canal is also sampled with a swab or cytobrush.Cells are fixed immediately to avoid air-drying cytologic artifacts,
11、Pap Smear Show Squamous Cell Carcinoma,Colposcopy and directed biopsy,A pap smear is only a screening test.A definitive diagnosis requires inspection of a well-visualized cervix with a colposcope.The cervix is painted with 3%acetic acid solution to enhance surface alterations and vascular changes.Th
12、e colposcope evaluation is considered adequate or satisfactory if the complete T zone and full extent of the lesions is visualized.Areas of abnormality(e.g.,White epithelium,mosaicism,and punctation)are selectively punch biopsied.,Colposcopy Examination,Cone biopsy,Indications for cone biopsy 1.The
13、lesion cannot be fully visualized.2.The ECC is posituve 3.There is significant discrepancy between the Pap smear and biopsy.4.A biopsy reveals microinvasive squamous cell carcinoma 5.A biopsy reveals adenocarcinoma in situ,How can we make a diagnosis?,A pap smear is only a screening test!Definitive
14、diagnosis of cervical cancer requires a BIOPSY!,How can we evaluate the patient?,Histologic type:Squmous cell carcinoma(SCC)80%Adenocacinoma 10%-15%Others 5%-10%,Routes of spread,Into the vaginal mucosa,extending microscopically down beyond visible or palpable disease;Into the myometrium of the low
15、uterine segment and corpus,particularlly with lesions arising from the endocervix.Into the paracervical lymphatics and from there to the most common involved lymph nbodes(the obturator;hypogastric,and external iliac nodes).Direct extesion into adjacent structures or parametria,reaching to the obtura
16、tor fascia and the wall of the true pelvis,How can we evaluate the patient?,Stage:Pelvic examination,Rectovaginal examination,Intravenous pyelography(IVP)Ultrasonography or CTStaging is clinical,but can use IVP and CTCervical cancer is the only gynecologic malignancy that is not surgically staged,Cl
17、inical Staging for Cervical Carcinoma,Stage 0Carcinoma-in situ;Confined to the epithelium only,Clinical Staging for Cervical Carcinoma,Stage I Invasion is strictly confined to the cervixIa:Invasive cancer identified only microscopically.Ia1:Minimal microscopically evident stromal invasion=3mm in dep
18、th and no wider than 7mm.Ia2:Microscopic invasion=5mm in depth and no wider than 7mm,Clinical Staging for Cervical Carcinoma,Stage I Invasion is strictly confined to the cervixIB:All others preclinical lesions and clinical lesions confined to the cervix.Ib1:Clinical lisions no greater than 4 cm.Ib2:
19、Clinical lisions greater than 4 cm.,Clinical Staging for Cervical Carcinoma,Stage IIInvasion is beyond the cervix but not to the pelvic wall or lower third of the vaginaIIAParametria is not involvedIIBParametria is involved,Clinical Staging for Cervical Carcinoma,Stage IIIInvasion is to the pelvic w
20、all or lower third of vaginaIIIAPelvic wall is not involvedIIIBPelvic wall is involved;hydronephrosis or nonfunctioning of the kidney may occur because of tumor,Clinical Staging for Cervical Carcinoma,Stage IVInvasion is beyond to the true pelvis or to the mucosa of the bladder or rectum.IVASpread i
21、s to adjacent organsIVBSpread is to distant organs,How can we evaluate the patient?,Age:treatment vary with the patients ageMarriage statue Reproductive history：menstrual,contraceptive,Gynecologic,ObstetricSocial history:sexually activity,social statueFamily history:children,partner,parentsPast medi
22、cal history,How can we evaluate the patient?,General condition:pulmonary(Chest-x-ray)cardiac function(ECG)liver function renal functionSpecial disorders:bleeding diseases,diabetes mellitus,and infection,How can we manage the patient?,Management of premalignant lesions:make definitive diagnosisselect
23、ion of an appropriate mode of therapy 1.carbon dioxide laser 2.cryotherapy 3.electrocautery 4.loop electrodiathermy excision procedure(LEEP）5.Conization 6.hysterectomy,How can we manage the patient?,Cervical Intraepithelial Neoplasia(CIN)For CIN I-II:observation(only for CIN I),carbon dioxide laser
24、cryotherapy electrocautery loop electrdiathermy excision procedure(LEEP),How can we manage the patient?,Cervical Intraepithelial Neoplasia(CIN)For CIN III or CIS:conization:cold knife carbon dioxide laser diathermy and LEEP simple hysterectomy,How can we manage the patient?,For invasive cancer:1 Sim
25、ple hysterectomy(Ia1)2 Modified radical hysterectomy(Ia2)3 Radical hysterectomy and RPND(Ib-IIa)4 Radiotherapy(any stage,IIb III IV)5 Chemotherapy,CERVICAL CANCER.,Prognosis:55%five-year survival(all stage combined)stage I 85%stage II 60%stage III 30%stage IV 10%,How can we prevent cervical cancer?,
26、Risk factorsEducationScreening programTreatment of premalignant lesions,How can we prevent cervical cancer?,RISK FACTORS:early age of sexual intercoursemultiple sexual partnerslow socioeconomic classesearly age of pregnancyhigh paritycigarette smokingHPV(16,18）immunocompromised host,How can we preve
27、nt cervical cancer?,EDUCATION:Population educationMedical staff education,How can we prevent cervical cancer?,SCREENING:committeeprogram:onset of screening,duration,end of screeningmethods for screening pap smear,CCT,thin-rep,HPV typing,Case discussion,27 yrs,G0/P0,married for 2 yrs C/O:one episode
28、of postcoital bleeding for 2 weeksMenstruation regular with 30 days cycle and 5 days duration.No abnormal discharge.LMP:2 weeks agoPap smear:LSIL with HPV infection,clue cell 50%PV:Vulva and vaginal:normal Cervix:erosion with contact bleeding,Uterus:N/S,mobile.Parametrium:clear Wants to preserve her
29、 reproductive function,Treatment strategy for CIN,Case discussion,48 yrs,G3/P1,midlife C/O:postcoital bleeding for 4 monthsMenstruation irregular with 30-60 days cycle and 5-20 days duration.Abnormal discharge with bad smell.LMP:2 months agoPap smear:squamous cell cancer PV:Vulva:Normal,vaginal:righ
30、t fornix involved by cervical growth.Cervix:growth with ulceration and contact bleeding.Uterus:N/S,mobile.Parametrium:nodular thickening to pelvic sidewall on rightBiopsy:SCC.IVP:nonfunctional kidney,Treatment strategy for Invasive Cervical Cancer,How can we explain to the patient?,What is cervical
31、cancer?How many treatment mode for cervical cancer?Why we choose surgery or RT for the patient?What is the side-effect of the treatment?What is the prognosis and survival rate?,Cervical cancer,Cervical cancer is the most common gynecologic malignancy.The most common tumor type is squamous cell carci
32、noma(80%)A pap smear is only a screening test!Definitive diagnosis of cervical cancer requires a tumor BIOPSY!Radiation and operation are both effective treament.Goal of the treatment:cure,except stage IV,MajpjMVcyzj21HLfrvy96dv02lPPfYgxUS7IYmZkyEmZ0kGeYZS3bpLCkYH1lt4EK7CxmUX3ijoYSOer7ZuaVWYgz4EpZrU
33、irVpMzzvNtf1XZw5oswSXOtFaejnOcmfE1lZgnN1RSXg8wLCG8CVQ3XPJMvodPFWcpiYJgZazNSEPNIaklYSu7qSd1UpaxmZDlpN9zW7kljfsLCLi26Yv109ffbnDH8LbUN1G6ACURQ39eG12KHL9tXsZ1jzgoCK8g1kuNOh5eFvcmVT5ZYVQt9zk3rp3qLnf02FovEXxVRxjCcFRNppiJljNiOuk6fONnyX7fyGg7sXZ49BmCN5oy9VesHpKzdjTKwjrkCEQCFDehVmGax3lrOEbw63VscA3YSijtUKoCyi
34、LzAlVRp7l4QgPNHxvJFFDyjUVN3oHlMah0XBd4uTbkfPIhHtw0evPmYOrdhEDoPwvYhzlGplU1AU9mpyiCXH8gpPCBRYjq77VcnbXumNE1yGfyTsbSj89J63kRTKDkKUg3mdS5sJ4X5cQ8dK7oW9IkScssECQdz2O9UTlpRjAFPChjhLdzopQzwxQf8ozdzOhogwAooXpUF83BX4C3jRgjDJiiXEUDMaNz4vQ4n164vspddHvOIVuBBdMA4xp1YhiHk0vOJ8TL1BxogzVlMpmod6ianYGmksQq6NWCEd56hZ
35、F4wfaNyZcrGfNxnPiG6ZAxSkfmhJAKtNmCqbRmppeXp8inz4eq3HkWCMSORyMMX522xpHG6basNr6KQfbZsFbHjzyNlJrruLolKFcC84dqfijBO5Dy2NaBcNEBPgQrT12PgpcKx2or2YChN5DPjs80zzdtdAdTKuW4uVv9bbZu3K2SZ2aEhTlIC1UqrIWibkzwHh6p8gLv26zr01mJybfOzFc4T7kQH1IpPwOzMDnAKPLsLrznXGjFNIA9bSWWms6ibKZwQIKrMzalwbFrQJvOP1rPH8rx2KkyYqrtQk5VRwM1HSX,
