Management of Cervical Cancers Dr. H. Osore Shesor Clinic Gaborone

Management of Cervical Management of Cervical CancersCancers

Dr. H. OsoreDr. H. Osore

Shesor Clinic Shesor Clinic

GaboroneGaborone

Cervical CancerCervical CancerCausative Agents Causative Agents (old teaching)(old teaching)• Smoking, hormones,infectionsSmoking, hormones,infections• Cervical cancer is rare in virgins but Cervical cancer is rare in virgins but

more common in sexually active womenmore common in sexually active women• Cervical cancer more common in Cervical cancer more common in

women who become sexually active at women who become sexually active at early ageearly age

• Highly sexually active women with Highly sexually active women with multiple sexual partners or those in multiple sexual partners or those in contact with partner who has multiple contact with partner who has multiple sexual partnerssexual partners

Cancer CervixCancer Cervix

•Cancer Cervix is an Cancer Cervix is an infectious diseaseinfectious disease

•Therefore Preventable Therefore Preventable diseasedisease

Classification of HPV types by Classification of HPV types by Oncogenic RiskOncogenic Risk

HPV subtypesHPV subtypes Risk categoryRisk category

16,18,45,5616,18,45,56 HighHigh

30,31,33,35,3930,31,33,35,39,,

51,52, 58,6651,52, 58,66

IntermediateIntermediate

6,11,42,43,44,6,11,42,43,44,53,54,5553,54,55

LowLow


Magnitude of ProblemMagnitude of Problem• 500,000 new cases diagnosed yearly500,000 new cases diagnosed yearly• 80% of new cases occur in 80% of new cases occur in

developing countriesdeveloping countries• More than 200,000 deaths each yearMore than 200,000 deaths each year• Second most cancer amongst Second most cancer amongst

women world widewomen world wide• Botswana- Cancer cervix second Botswana- Cancer cervix second

commonest nationallycommonest nationally

Magnitude of the Problem Magnitude of the Problem Cont’dCont’d

•Therefore high risk increase in Therefore high risk increase in developing intraepithelial developing intraepithelial neoplasia and more likely rapid neoplasia and more likely rapid progression to invasive cervical progression to invasive cervical cancer cancer

•HIV increases the risk of pre-HIV increases the risk of pre-invasive disease (2 to 12 times invasive disease (2 to 12 times higher cytological abnormalities higher cytological abnormalities rate in HIV positive women)rate in HIV positive women)

Cervical CancerCervical Cancer

Magnitude of problem cont’dMagnitude of problem cont’d

• Women with HIV have a higher Women with HIV have a higher prevalence of HPV infection and are prevalence of HPV infection and are more likely to develop persitent more likely to develop persitent infectioninfection

• Treatment outcomes for patients Treatment outcomes for patients with cervical cancer are poorer for with cervical cancer are poorer for positive HIV than for HIV negative positive HIV than for HIV negative women women


Types of Cervical CancersTypes of Cervical Cancers

(histopathologically) (histopathologically) • Epithelial tumours-(Squamous Epithelial tumours-(Squamous

Cancer) -80-90%Cancer) -80-90%• Mesenchymal tissue tumours-Mesenchymal tissue tumours-

( Adenocarcinoma, sarcoma, ( Adenocarcinoma, sarcoma, embryonal)-10-20%embryonal)-10-20%


SymptomsSymptoms:: - -• Asymptomatic in early stages/preclinical Asymptomatic in early stages/preclinical

stagestage• Haemorrhage-Metrorrhagia /PostcoitalHaemorrhage-Metrorrhagia /Postcoital• Bleeding is usually severe in cauliflower-Bleeding is usually severe in cauliflower-

like exophytic (growth) lesionslike exophytic (growth) lesions• Discharge- watery, offensive, blood Discharge- watery, offensive, blood

stainedstained


Clinical features- Cachexia( wasting) and pain in advanced lesions

• Signs:- -Obvious lesion or growth may or may

not be present -when obvious lesion growth present, it

may be exophytic cauliflower-like or endophytic, ulcerative and scirrhous

-

Cancer Cervix

Signs:-Signs:-•Cervix usually indurated, hard, Cervix usually indurated, hard,

friable, easily bleeds on contact friable, easily bleeds on contact and its mobility may be and its mobility may be restricted or lostrestricted or lost

•Endocervical growth- cervix is Endocervical growth- cervix is expanded, firm and feels barrel expanded, firm and feels barrel shapedshaped


DiagnosisDiagnosis• Pap Smear examinationPap Smear examination• ColposcopyColposcopy• Biopsy:-Biopsy:- -Excisional biopsy preferred to Punch biopsy-Excisional biopsy preferred to Punch biopsy Schiller’s Test/Acetic Acid helps in selecting Schiller’s Test/Acetic Acid helps in selecting

the biopsy site where growth may not be the biopsy site where growth may not be obviousobvious

Cone biopsy-in early cases Cone biopsy-in early cases • Endocervical curettageEndocervical curettage


InvestigationsInvestigations• Complete Physical Exam, Pelvic Complete Physical Exam, Pelvic

Exam, Rectal Exam- EUA to be done Exam, Rectal Exam- EUA to be done • Abdominal/Pelvic Ultrasound Abdominal/Pelvic Ultrasound • Chest X-rayChest X-ray• IVPIVP• CystoscopyCystoscopy• ProctosigmoidoscopyProctosigmoidoscopy


Treatment QuandaryTreatment Quandary

Surgery Or Radiotherapy?Surgery Or Radiotherapy?

Cervical Cancer

Staging-(Clinical for treatment PlanningStaging-(Clinical for treatment Planning) (FIGO)) (FIGO)• O: Carcinoma-in-situO: Carcinoma-in-situ• 1a: Micro-invasive <=3mmD,<=7mmW (Ia1,Ia2)1a: Micro-invasive <=3mmD,<=7mmW (Ia1,Ia2)• 1b: Invasive (>5mm FIGO, >3mm SGO)1b: Invasive (>5mm FIGO, >3mm SGO)• IIa: Upper 2/3 of vaginaIIa: Upper 2/3 of vagina• IIb: Parametrial Involvement ( but Pelvic wall)IIb: Parametrial Involvement ( but Pelvic wall)• IIIa: Lower 1/3 vaginaIIIa: Lower 1/3 vagina• IIIb: Pelvic wall involvement or IIIb: Pelvic wall involvement or

hydronephrosis/non-funtional kidneyhydronephrosis/non-funtional kidney• IVa: Bladder or rectal mucosa involvementIVa: Bladder or rectal mucosa involvement• IVb: Distant metastasesIVb: Distant metastases

Cervical CervixCervical Cervix Treatment OptionsTreatment Options• Stage 1a-1 (<1mm)Stage 1a-1 (<1mm)

-Conisation-Conisation

-Simple hysterectomy-abdominal/vaginal -Simple hysterectomy-abdominal/vaginal approachapproach

• Stage 1a-2 (1-3mm, lymph node -1%)Stage 1a-2 (1-3mm, lymph node -1%)

-Modified radical hysterectomy-removal -Modified radical hysterectomy-removal of medial ½ of uterosacral and cardinal of medial ½ of uterosacral and cardinal ligaments with smaller vagina marginligaments with smaller vagina margin


Treatment Treatment –Options:–Options:• Recurrent disease:- as per previous Recurrent disease:- as per previous

treatment treatment

-DXT > Exenteration-DXT > Exenteration

-Surgery- DXT-Surgery- DXT• Stage III and IV-Radiation/!!ExenterationStage III and IV-Radiation/!!Exenteration• Radiation, as primary treatment is an option Radiation, as primary treatment is an option

in all stagesin all stages

• Chemotherapy- as adjunct to DXT or Chemotherapy- as adjunct to DXT or for palliationfor palliation


Options:Options:• Stage Ib & IIa -Type III hysterectomy Stage Ib & IIa -Type III hysterectomy

(radical hysterectomy with removal of (radical hysterectomy with removal of most uterosacral and cardinal most uterosacral and cardinal ligament, upper 1/3 of vagina, pelvic ligament, upper 1/3 of vagina, pelvic lymphadenectomylymphadenectomy

-Postop DXT-Postop DXT • Bulky lesions and stage IIbBulky lesions and stage IIb -Full irradiation followed 3-4 weeks -Full irradiation followed 3-4 weeks

later by type II hysterectomy later by type II hysterectomy


RadicalRadical hysterectomy hysterectomy• Removes corpus, Cervix, parametria, Removes corpus, Cervix, parametria,

upper 1/3 of vaginaupper 1/3 of vagina• Uterine arteries divided at originUterine arteries divided at origin• Ureters dissected through tunnelUreters dissected through tunnel• Uterosacral ligament divided near Uterosacral ligament divided near

rectum rectum • LymphadenectomyLymphadenectomy• Oophorectomy not mandatoryOophorectomy not mandatory

Cervical CancerCervical CancerTreatment ComplicationsTreatment Complications

Acute:-Acute:-• FeverFever• PerforationPerforation• DiarrhoeaDiarrhoea• Bladder Bladder

spasmsspasms

Chronic:-Chronic:-• ProctitisProctitis• Radiation CystitisRadiation Cystitis• FistulaFistula• EnteritisEnteritis• Femoral head Femoral head

necrosisnecrosis• Rectal strictureRectal stricture


Follow-upFollow-up• At 2-3 months interval for 2 At 2-3 months interval for 2

yearsyears• At 3-4 months interval – next 2-4 At 3-4 months interval – next 2-4

yearsyears• At 6 months interval- Rest of the At 6 months interval- Rest of the

lifelife• Tumour markers- CEA


0

20

40

60

80

100

%

IA IB IIA IIB III

Stage

SCCAAdenoCA

Grigsby, P.W., et.al Radiother Oncol 12:289, 1988Grigsby, P.W., et.al Radiother Oncol 12:289, 1988

Five-Year Survival: -


Special CasesSpecial Cases –Difficulty to deal with –Difficulty to deal with• Invasive cancer on cone biopsyInvasive cancer on cone biopsy• Cervical stump carcinomaCervical stump carcinoma• Invasive carcinoma found after Invasive carcinoma found after

simple hysterectomysimple hysterectomy• Cervical carcinoma in pregnancyCervical carcinoma in pregnancy• Large barrel shaped lesionLarge barrel shaped lesion


AdenocarcinormaAdenocarcinorma• Has poorer prognosis stage by Has poorer prognosis stage by

stage relative to squamous stage relative to squamous cancercancer

• Tends to grow endophytically Tends to grow endophytically thus more often undetected until thus more often undetected until large tumour volume is presentlarge tumour volume is present

Cancer CervixCancer CervixSummarySummary• Prevention is the best curePrevention is the best cure• Must carry out evaluation and Proper Must carry out evaluation and Proper

staging prior to treatmentstaging prior to treatment• Surgery and radiotherapy are Surgery and radiotherapy are

complimentary-(Surgeon and complimentary-(Surgeon and Radiotherapist together)Radiotherapist together)

• Mortality still high stage for stageMortality still high stage for stage• Overall mortality is decreasing as Overall mortality is decreasing as

cancers are diagnosed earlycancers are diagnosed early


Vaccines & Cervical CancerVaccines & Cervical Cancer• GardasilGardasil – –manufactured by Merck & Comanufactured by Merck & Co. .

in USAin USA

• the first the first vaccine developed to prevent genital vaccine developed to prevent genital lesions and genital warts due to human lesions and genital warts due to human papillomavirus (HPV) types 6, 11 (warts), 16 papillomavirus (HPV) types 6, 11 (warts), 16 and 18 (cervical cancer).and 18 (cervical cancer).

• Vaccine is approved for use in females 9-26 Vaccine is approved for use in females 9-26 years of ageyears of age

• HPV types 16 and 18, cause approximately 70 HPV types 16 and 18, cause approximately 70 percent of cervical cancers and against HPV percent of cervical cancers and against HPV types 6 and 11, cause approximately 90 types 6 and 11, cause approximately 90 percent of genital wartspercent of genital warts.


HPV Vaccine cont’d..HPV Vaccine cont’d..• Gardasil is a recombinant vaccine Gardasil is a recombinant vaccine

(contains no live virus)(contains no live virus)• Given as three injections over a Given as three injections over a

(6/12)six-month period (6/12)six-month period • Females are not protected if they Females are not protected if they

have been infected with that HPV have been infected with that HPV type(s) prior to vaccinationtype(s) prior to vaccination

• Immunization before potential Immunization before potential exposure to the virusexposure to the virus


• Gardasil does not protect against Gardasil does not protect against less common HPV types not less common HPV types not included in the vaccine, therefore included in the vaccine, therefore routine and regular Pap screening routine and regular Pap screening remain critically important to remain critically important to detect precancerous changes in detect precancerous changes in the cervix to allow treatment the cervix to allow treatment before cervical cancer develops.before cervical cancer develops.


• Cervarix- Cervarix- second vaccine being second vaccine being researchedresearched

• Studies suggest that the vaccine Studies suggest that the vaccine may prevent infection against may prevent infection against HPV-31 and HPV-45 in addition HPV-31 and HPV-45 in addition to HPV strains 16 and 18. to HPV strains 16 and 18.

• Vaccine has not yet been Vaccine has not yet been approved for use in the general approved for use in the general population in the United Statespopulation in the United States.

Thank YouThank You

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Management of Cervical Cancers Dr. H. Osore Shesor Clinic Gaborone