Cervical Tumor 宫颈肿瘤 Xin LU

Obstetrics and Gynecology Hospital Fudan University

Contents CIN CIN

HPVHPVHistologyHistologyPathologyPathologyDiagnosisDiagnosisTreatmentTreatment

Cervical Cancer Cervical Cancer General informationGeneral information PathologyPathology Spread pattern Spread pattern FIGO staging FIGO staging Clinical signsClinical signs Diagnosis and Diagnosis and

differential diagnosis differential diagnosis Principle for treatmentPrinciple for treatment PreventionPrevention

Key words

Human Papillomavirus (HPV)Human Papillomavirus (HPV) Radical Hysterectomy (RHRadical Hysterectomy (RH)) Radiotherapy (RT)Radiotherapy (RT) Chemotherapy (CT)Chemotherapy (CT) Neoadjuvant chemotherapyNeoadjuvant chemotherapy

(NACT) (NACT) Concurrent chemo-radiotherapy Concurrent chemo-radiotherapy

(CCCR)(CCCR) Radical TrachelectomyRadical Trachelectomy

人乳头瘤状病毒人乳头瘤状病毒广泛全子宫切除术广泛全子宫切除术放射治疗放射治疗化学治疗化学治疗新辅助化疗新辅助化疗

同步放化疗同步放化疗

宫颈根治术宫颈根治术

Female Reproductive Anatomy

Transformation Zone

Cervical Cancer 子宫颈癌 World report: World report:

Account forAccount for 1/3 1/3 female malignancies female malignanciesNew cases: New cases: 529 800529 800Death: Death: 275 100275 10085% developing country

The The 4th4th most common cause of death most common cause of death from malignancy in women.from malignancy in women.

流行病学

新发病例数死亡病例数

Cervical cancer progression

HPV infectionHPV infection

CINs CINs 10-15yrs10-15yrs

Carcinoma in situCarcinoma in situ

Cervical cancerCervical cancer

Cervical tumorigenesis ProgressionProgression

Host immunityHost immunity Environmental factorsEnvironmental factors Genetics: Genetics:

oncogene E6, E7oncogene E6, E7

tumor suppresor gnen p53, Rbtumor suppresor gnen p53, Rb RegressionRegression

High Risk Factors

HR-HPVHR-HPV Use of oral contraceptivesUse of oral contraceptives Smoking Smoking Multiple sexual partnersMultiple sexual partners History of herpes infection History of herpes infection History of STDHistory of STD

Human Papillomavirus , HPV 人乳头瘤状病毒 1972 ： Harald zur Hausen

1995 ： High-risk HPV by International Agency for Research on Cancer ， IARC

90% cervical cancer with HPV infection

HPV

High risk HPV （ HR-HPV ） oncogenic HPV HPV 16,18,31,33,35,39,45,51,52,56,58,59,68,73,82 HSIL, Cervical cancer

Low risk HPV （ LR-HPV ） non-carcinogenic HPV HPV 6,11,42,43,44,54,61,70,72,81 LSIL

Precursors

CIN: CIN: 宫颈上皮内瘤样病变宫颈上皮内瘤样病变 CIN ICIN I ：： mild dysplasiamild dysplasia ，， 1/31/3 CIN IICIN II ：： moderate moderate dysplasiadysplasia ，， 1/3-2/3 1/3-2/3

CIN IIICIN III ：： severe dysplasia severe dysplasia

CIS(carcinoma in situ) CIS(carcinoma in situ) 原位癌原位癌

CIN

Histological Types

Squamous carcinoma 80-85%Squamous carcinoma 80-85%Adenocaricinoma 15-20%Adenocaricinoma 15-20%Endometrial carcinomaEndometrial carcinomaClear cell carcinomaClear cell carcinomaAdenosquamous 3-5%Adenosquamous 3-5%Undifferentiated carcinomaUndifferentiated carcinoma

FromFrom ：： 20032003 年年 WHOWHO 女性生殖器官肿瘤女性生殖器官肿瘤

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Spread pattern

Local tumor extension Local tumor extension most commonmost common

Lymphatic Lymphatic pelvic and para-aortic pelvic and para-aortic

Hematogenous disseminationHematogenous dissemination uncommonuncommon

FIGOFIGOstagstagee

Symptoms

AsymptomaticAsymptomatic Abnormal pap smearAbnormal pap smear Watery, blood-tinged vaginal dischargeWatery, blood-tinged vaginal discharge Post-coital bleedingPost-coital bleeding Pelvic painPelvic pain

HistoryHistory Physical examinationPhysical examination Cytology (pap smear, TCT, HPV)Cytology (pap smear, TCT, HPV) Biopsy (colposcopy)Biopsy (colposcopy) ConizationConization ImagingImaging

Diagnosis

Platform of diagnosis for cervical diseases

Pap smear TBS Pap smear TBS classificationclassification

TCTTCT HPVHPV Colposcopy--biopsyColposcopy--biopsy LEEPLEEP

Colposcopy 阴道镜

Conization 宫颈锥切

CervicitisCervicitis Cervical polypsCervical polyps Benign cervical tumor:myomaBenign cervical tumor:myoma

Differential Diagnosis

宫颈糜烂分度

轻 度轻 度 中 度中 度 重 度重 度

宫颈糜烂分型

• 单纯型• 颗粒型• 乳突型

Cervical polyps 宫颈息肉

Principle for cervical cancer treatment

Evidence based medicineEvidence based medicine FIGO FIGO ( ( International Federation of Gynecology and International Federation of Gynecology and

Obstetrics) Obstetrics)

NCCN NCCN ((National Comprehensive Cancer Network)National Comprehensive Cancer Network)

Individualized therapyIndividualized therapy ；；

TREATMENT

Precursor- Precursor- CINsCINs Micro-invasive cancerMicro-invasive cancer Invasive cancerInvasive cancer

CINs

CIN I: follow up 3CIN I: follow up 3——6months6months CIN II: CIN II:

local therapy local therapy conizationconization

CIN III: CIN III: conization conization hysterectomyhysterectomy

Stage Ia1: hysterectomyStage Ia1: hysterectomy Stage Ia2: modified Stage Ia2: modified hysterectomyhysterectomy

Stage Ia with positive margin Stage Ia with positive margin (Ia or CIS): radical (Ia or CIS): radical hysterectomyhysterectomy

Micro-invasive cervical Micro-invasive cervical cancercancer

Surgical treatment Ib-IIaSurgical treatment Ib-IIa RadiotherapyRadiotherapy Chemotherapy Chemotherapy Combined therapyCombined therapy

Treatment for invasive Treatment for invasive cervical cancercervical cancer

Cervical cacner（Ⅰ b-Ⅱa)RH+PLND+/- PAD

1. 1. 标准的手术方式：广泛全子宫切除标准的手术方式：广泛全子宫切除 ++ 盆腔淋巴清扫盆腔淋巴清扫术术 ;;

2.2. 盆腔淋巴结清扫术盆腔淋巴结清扫术 腹股沟深淋巴结腹股沟深淋巴结 髂淋巴结髂淋巴结 闭孔淋巴结闭孔淋巴结

3.3. 腹主动脉旁淋巴结取样的指征：腹主动脉旁淋巴结取样的指征： 可疑的腹主动脉旁及髂总淋巴结可疑的腹主动脉旁及髂总淋巴结 大块附件病灶及增大的盆腔淋巴结大块附件病灶及增大的盆腔淋巴结 浸润肌层全层的低分化肿瘤浸润肌层全层的低分化肿瘤

Post-surgical treatment(high risk factors)

poor differentiatedpoor differentiated

deep myometrial invasiondeep myometrial invasion

LVSILVSI

LN positiveLN positive

positive marginpositive margin

Advanced stage（Ⅱ b ，Ⅲ，Ⅳ )

Radiotherapy (RT)Radiotherapy (RT) NACT + RadiotherapyNACT + Radiotherapy Concurrent chemo-radiotherapyConcurrent chemo-radiotherapy ；； Combined RT and CTCombined RT and CT

Trachelectomy

Fertility sparing Fertility sparing Ib <4cmIb <4cm Evaluation of infertility Evaluation of infertility factorfactor

Procedure of trachelectomyProcedure of trachelectomy Complications Complications Outcome Outcome

Primary prevention1. Health care2. Sexual behavior 3. Dual protection4. HPV vaccines4. Cancer screening5. Treat precursors

Prevention

Secondary prevention1.Early screening2. Early treatment

Take home message

HPV (HR)HPV (HR) CINsCINs FIGO stageFIGO stage Surgery: Radical hysterectomy and PLNDSurgery: Radical hysterectomy and PLND Post-operation treatment: high risk factorsPost-operation treatment: high risk factors RT and CTRT and CT Fertility sparing trachelectomyFertility sparing trachelectomy HPV VaccineHPV Vaccine

OB/GYN Hospital of Fudan University

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