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Cervical cancer
Fuat Demirkıran, MDIstanbul University, CerrahpaşaSchool Of Medicine, OB&GYNDepartment, Gyn Oncology
Incidence of Cervical Cancer (GloboCan/IARC 2000) – in per 100 000
women
Cervical cancer is a preventable cancer because it has a long preinvasive state. The incidence of CC is decreasing and it is being diagnosed earlier during last 50 years ..... due to cervical cytology screening programsMean age for cervical cancer is 50 years and it
peaks at 35-40 years and 60-64 years.
Risk factors for development of CC
sexuel intercourse at an early agemultiple sexuel partners
young age at first pregnancycigarette smoking
HSV infection HPV infection
HPV and Cervical Cancer
International collection of cervical tumor specimens
showed that HPV DNA is present in 99.7% of cases.
Relative risks for the association between HPV and cervical
cancer are in 50-150 range.
The most important HPV types related to Cervical Preinvazive and invazive lesion
Schiffman, J Nat Cancer Inst, 85:958, 1993 and Liaw, J Nat Cancer Inst, 91:954, 1999
Transmision: genital skin to skin contact
Transient HPV infection
Persistent infectionwith oncogenic
HPV types
LSIL/CIN I HSIL/CIN II - III
Invasive cervical cancer
Cofactors
HormonalInfluances
Parity
Other STIs
Smoking
Nutritions
Host genetics
Viral genetics
from Franco and Harper 2005, Trottier H ,Franco EL, Vaccine 2006
HPV with the assistance of some cofactors can result in the development of CC. All of the invasive squamous CC develope at the end of progressive pathologic events. NNormal epithel CIN I CIN II CIN III Cancer
· Squamous carcinoma of the cervix arises at the active SCJ from pre-existing dysplastic lesion.
Briefly
CIN I
%57
%11
%0.3
Normal
CIN II - IIICancer
n: 4504 Ostor AG, 1993
CIN II CIN III
%43
Regress
%22
CIN III-Kanser
%14
Cancer
%30%
35%56
CIN II CIN III
Michell MF., 1996 Wright TC., 2002
Regress%31
CIN I
HHISTOLOGIC TYPES OF CC1. squamous cell carcinoma ....most common type 2. adenocarcinoma (AC) ....in recent years, an increasing number of AC affecting young women ....AC are populated by musinous endocervical cells, endometroid cells, clear cells ....10%-15 of CC ....considered that AC is poorly prognostic tumor compared with squamous cell carcinoma 3. minimal deviation adenocarcinoma(adenoma malignum) .....extremely well-diferentiated form of AC 4. villoglandular papillary adenocarcinoma5. adenosquamous carcinom6. glassy cell carcinoma
SYMPTOMS 1. 20% of patients are asymtomatic. . vaginal bleeding.......postcoital, irregular men, postmenopausal3 . vaginal discharge4.. pain
Asymptomatic abnormal cytology
Symptomatic biopsy
Diagnosis
Colposcopic examination
Biopsy
a. Conventional Pap test
b. Liquid-based cytology
Vaginal Cytology
Colposcopy
Punch biyopsy
Leep excision
Conization
Biopsy techniques for cervicalevaluation
LEEP Excision - Conization
Conizationend-point diagnostic work-up for cervical pathology
PATTERNS OF SPREADING 1. Direct invasion into the cervical stroma, vagina, uterine corpus and parametrium2. Lymphatic metastases3. Hematologic metastases4. Intraperitoneal metastases
Predominanat spread patterns : direct extension and lymphatic dissemination
Malignant cells spread by way of paracervival
lymphatic cannels into the obturator, internal iliac, external iliac, common iliac and para-aortic lymph
nodes group.
2009
Pathologic Prognostic Factors Related to Cervical Cancer
Pelvic lymphatic statusTumor size
Deep of invasionLVSI
Close surgical marginPositive surgical margin
The Relationship of Pelvic Lymph Node Metastasis and 5-year Survival
Monoghan 1990 392 92% 102 50%Delgado 1990 545 86% 100 83%Kamura 1992 281 91% 64 63%Lai 1999 610 87% 217 68%
n Survival n Survival
Node negative Node positive
The Main Prognostic Factors in Cervical Cancer
Tumor size (cm)< 2 58 %94 <0.000012-3.9 48 %79>4 10 % 47
Depth of invasion(mm)<10 75 %94 <0.0000111-15 27 %73 16-20 14 %57>20 9 %33
n 5-year survival p
Kristensen et al, Gynecol Oncol 1999
The Influence of LVSI on Pelvic Lymph Node Metastasis and Survival in Early Stage Cervical Carcinoma
Crissman 1985 94 97% 8% 30 64% 17%Delgado 1990 360 90% 8% 276 78% 25%Roman 1998 32 - 0% 73 - 32%
n survival pel nod + n survival pel nod +
LVSI negative LVSI positive
Molacular Prognostic Factors of Cervical Cancer
DNA cytometryCOX-2 expressionnm23 expressionTymidine kinase
Beta-cataninId-1 protein
Matrix metaloproteinasesand others
Treatment of Cervical Cancer
The principles of treatment for cervical cancer composed of..
Sites of spread
Primary tumor
SurgeryRadiotherapy
Surgery
Radiotherapy
Stage Ia-Ib1- II a
Stage Ib2-III-IV
The results of surgery and radiotherapy are almost equal
Treatment of cervical cancer depends on patients age, sexual
status, fertilty status
If the patient is young and sexualy active , surgery is the
best choise
Surgical TreatmentStage Ia1
Conization is adequate for women who desire fertility if there is no
lymphovascular space invasionor
Type I hysterectomy for women who not desire fertility
Surgical TreatmentStage Ia2
Type II or III hysterectomy with pelvic lymphadenectomy
Stage Ib1- Stage IIa- Type III hysterectomy with pelvic
lymphadenectomy
Radikal histerektomi and Lymphadenektomi
Radical Hysterectomy(Type II-III) for stage Ia2, Ib and IIa
immediate therapystaging and tailoring of therapy
conservation of the ovariesconservation of sexual function
The results of surgery and radiotherapy are almost equal
After surgery if surgical margin is positive or lymph node is
positive, postoperative RT is mandatory
Primer radio-chemotherapy is the best choise
For stage Ib2 and > IIb diseases
Results of Trachelectomy n:130
Ia1 17Ia2 36Ib1 74IIa 3Squamous 93Adeno ca 37< 2 cm 110> 2 cm 10
Intraop complication %9Postop “ %10Positive node %2.4Mean follow-up 27 ayTumor reccurrence %3.1Pregnancy 54
Dargent 2000, Plante 1999, Covens 1999, Shepherd 1998
Fertility sparing surgery for cervical cancer