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CFRvlCAl CAtCFR

SHAJAHAt C
< Squamous Cell Carcinoma 80-95%
< Adenocarcinoma 5-20%
< Other: Clear cell, sarcomas
1n.v.i.c .qvvnov. .c .v.inonv i. nc no.
.onnon .vic, o{ in.v.i.c .vn.c innc .c.i_.

1i.ooi.v,, .vivn. o{ .qvvnov. .c .v.inonv


in.vvc
N vc .c [cvini:in,
N vc .c non[cvini:in, vnv
N .nv .c ,c.
increasing numler oI cervicaI adenocarcinomas reorted in
vomen in their 2us and 3us.

< denocarcinoma 389:$


recursor oI invasive adenocarcinomathe tvo oIten
coexist
n addition to $ intraeitheIiaI or invasive squamous
neoIasia occurs in 3u% to 5u% oI cervicaI
adenocarcinomas
inimaI deviation adenocarcinoma adenoma
maIignum .
ViIIogIanduIar aiIIary adenocarcinoma
N . t rimariIy aIIects young vomen some oI
vhom are regnant or users oI oraI
contracetives.
N HistoIogicaIIy the tumors have smooth veII
deIined lorders areveII diIIerentiated and are
either 389:or suerIiciaIIy invasive.
mixture ol malignant glanJular anJ
squamous components
poorer prognosis than those vith pure
aJenocarcinoma or squamous carcinoma
Iassy ceII carcinoma poorly
JillerentiateJ
adenoid lasaI carcinoma
adenoid cystic carcinoma.
< mlryonaI rhaldomyosarcoma
chilJren anJ young aJults.
grapelike polypoiJ noJuleslotryoiJ sarcoma

< eiomyosarcomas anJ mixed mesodermaI


tumors
ay le primary lut are more likely to le
seconJary to uterine tumors.
< ervicaI adenosarcoma
lovgraJe tumor vith a gooJ prognosis .
< nvinvn ncvnonv nv, vi.c vc no.o in ni.
vcv
< 1i.ovnooi.v,, i .invvc. ncvnonv
c.c.ncc,
< ono.i. vccnv. on nc vcn o{ in.v.ion ino
nc .c.i.v .onv.
< {ov ni.ooi. .v,c.
< (i) .nv .c
(ii) vc .c
(iii) .v..i.v .v.inoiv
(i.) v,i.v .v.inoiv
.
< ancer oI the cervix sreads ly
(i) direcI invasion inIo Ihe cervical sIroma,
corpus,vagina, and parameIrium
(ii) lymphaIic meIasIasis
(iii) bloodborne meIasIasis
(iv) inIraperiIoneal implanIaIion.
< orbidity and ortality associated with regional
spread of the cancer
< Spreads to pelvic nodes, ureters, bladder, rectum
< Dangerous when cancer blocks ureters resulting
in uremia --> death
< CN: Asymptomatic
< nvasive Cancer
No classic presentation
ay present with abnormal vaginal bleeding
ay present with postcoital bleeding
< nonv ccvin
Between periods
With intercourse
After menopause
< &nv.vv .vinv vi..nvc
Other symptoms
WLeg pain
WPeIvic pain
WBIeeding from the rectum or
bIadder
Some women have no symptoms
< CN
Cervix appears normal to general inspection
< nvasive Cancer
Exophytic growth/
Cauliflower-like, friable/
Deeply ulcerated/
Flat,indurated
WAdvanced Cancer
Pelvic asses Palpable
Anemia
cachexia
< squamocolumnar unc|ion (SCJi
< Bclorc pubcr|v: SCJ loca|cd us| insidc |hc
ccrvical os
< A| pubcr|v- squamous mc|aplasia
< rcposi|ionin ol |hc SCJ lur|hcr |owards |hc
u|crus
< Iruntformution zone it the tite of 9s%
of the ceruicul cuncer deuelopment
< Iince zone it locuted within the ceruicul
ot, unuble to be uiewed during routine
peluic exum
xpoture of truntformution zone to
curcinogent begint procett of
intruepitheliul neoplutiu
While exuct role of curcinogent in thit
procett remuint poorly underttood, it it
cleur thut Hv und cigurette tmohing
cun cuute dytplutiu ut the
truntformution zone
< tervieal eaneer is the 2
nd
leading eaneer amongst
women worldwide
< >99% related to human papilloma virus (HPV)
infee.
< HPV infeet epithelial eells ineluding the genital traet
< HPV type 16 related to half of these eases
< HPV -18, -4, -81, -88, -2, -8 and -8 together
with HPV-16 responsible for 90% of all eervieal
eaneers worldwide
< ultiple sexual partners
< Promiscuous partner
< Age of first intercourse experience <18yrs
< Delivery of first baby before the age of 20 yrs
< Prior STDs (HSV , genital warts, vaginal
infections)
< Cigarette Smoking
< Oral Contraceptive usage
< ntrauterine exposure to DES
< mmunodeficiency
< More than 100 types
More than 60 cutaneous types
N Can Iead to skin warts
40 mucosaI types
N High risk types (particuIarIy 16 and 18)
N cervicaI ceII abnormaIities
N certain anogenitaI cancers
N Low risk types (particuIarIy 6 and 11)
N cervicaI ceII abnormaIities- usuaIIy resoIve
spontaneousIy and do not Iead to cancer
N genitaI warts
N respiratory papiIIomatosis
InitiaI
HPV
Infection
CIeared HPV Infection
Within 1 Year 1-5 Years
Up to Decades
Persistent
Infection
CIN
2/3
CervicaI
Cancer
CIN 1
HPv 16 and 18


E6 protein E7 protein

+ +

pS3 retinoblastoma
tumor suppressor tumor suppressor
gene product gene product



increased cellular proliferation
54%
14%
9%
6%
3%
14%
HPV 16
HPV 18
HPV 45
HPV 31
< HistopathoIogicaI discription in which a part or
the fuII thickness of the stratified sqamous
ep.is repIaced by ceIIs showing varying
degrees of dyspIasia
< MetapIasia
< DyspIasia
< MiId dyspIasia (CIN-I ) :
- undifferentiated ceIIs are confined to the
Iower 1/3 of epitheIium
< aIso caIIed LSIL a/c to Bethesda cIassfn
< Undifferentiated ceIIs occupy the Iower
50-75% of the ep.thickness
< Moderate nucIear enIargment,hyperchromasia
< IrreguIar chromatin & muItipIe nucIeation
< ntire thicknes of ep.is repIaced by abnormaI
ceIIs
< The besement memb. WiiI b intact & no
stromaI invasion
<a/c to Bethesda cIassfn:
< CIN-I _Low grade Squamous IntrepitheIiaI
Lesions/ LSIL
< CIN-II&III _HSIL
<Diagnosis
Screening for Cervical Cancer
- Why get screened?
- Screening was developed to detect
abnormal cervical cells in the early stages
when it is easy to remove them
< Strong sensitivity and specificity
< Accuracy of Smear Requires
adequate sample
presence of enough inflamation and dysplasia
quick fixation of specimen to glass slide
< ACOG Recommendations
1st Pap Smear at age when patient becomes sexually
active (or by age 18)
Yearly pap smears thereafter
< Others contend that monogamous women with no
history of abnormal pap smears can have them
done every 3 years
< Patient asked to lie on her back at edge of exam
table with feet in stirrups
< etal or plastic speculum is inserted into vagina to
expand the wall of vagina to enable access to cervix
< Cells are collected using cotton swab, wooden
spatula, or cervical brush and smeared onto glass
slide
< Preservative sprayed to prevent cells from drying and
artifacts from forming
< Slide evaluated by lab technician who looks for
abnormalities in the 50,000 to 300,000 cells on slide
< The Class System ( to V)
< The CN System (CN to )
characterizes the degree of cellular abnormalities
< The SL System (Bethesda System)
Lesions characterized as LGSL or HGSL
Presence of HPV noted
This scheme is most widely used system these
days
< No douching or usage of vaginal medications,
lubricants, or spermicides within 2-3 days of exam
(these products may hide abnormal cells)
< Schedule Pap Smear between days 12-16 of
menstrual cycle, if possible
< Abstain from intercourse 1-2 days prior to smear
< ndocervicaI scrape cytoIogy by endocervicaI
brush/curettage
< Incorporating HPV testing by hybridisation/PCR in
young woman
< Liquid based cytoIogy: spatuIa is pIaced in a Iiquid
fixative instead of smearing
< This removes the bIood,mucus & infIammatory
ceIIs
< Suspended ceIIs gentIy sucked to the fiIter
membrane > pressed onto gIass sIide>stained
< Automated computerized image processor
eIiminates 25 % most IikeIy negative smears
< VisuaI inspection of acetowhite areas (VIA)
- seIect abnormaI areas on cervix by appIying
5% acetic acid -acetic acid dehydrates the
abnormaI areas containing increased nucIear
materiaI & protien which turn acetowhite
VILI- VisuaI inspection with IugoIs iodne
< SpecuIoscopy - a speciaI disposabIe Iow
intencity bIue white magnifying device
< Spectroscopy -specific,sensitive &
provides instant resuIt
CoIposcopy:
< Use of a
magnifying
instrument
< AppIication of 3 %
acetic acid onto
the cervix
< See the
acetowhite areas
Scurce: Ihi: i: c ccpyrighIec imcge cf Ihe Cc|ifcrnic
Fcmi|y Hec|Ih Ccunci|, lnc. cnc mcy ncI Le
reprccucec in cny wcy wiIhcuI Ihe expre::ec wriIIen
permi::icn cf Ihe Cc|ifcrnic Fcmi|y Hec|Ih Ccunci|.
Cc|ifcrnic DepcrImenI cf Hec|Ih Service: WhcI Ycu
Shcu|c Kncw if ycur Fcp Ie:I i: /Lncrmc|- Ycu|
Cc|pc:ccpy Fxcn, Dcnnc 8e|| Scncer: {EcuccIicn
Frcgrcm: /::ccicIe: 15: CcmpLe||, C/).
< AbnormaI areas reveaIed under coIposcpy
are
acetowhite areas,mosaics,punctuation &
abnormaI vesseIs
< Where as pap smear detects abnormaI
ceIIs,coIposcopy detects abnormaI Iesion
<
Cone biopsy:
-both diagnostic &
theraputic
-a wide cone excision
incIuding the entire
outer margine of
Iesion &
endocervicaI Iining
is obtained using
'coId knife
technique'

< AgNOR is a new tumour marker which stands


for siIver stained NucIeoIar Organizer Regions
< CeIIs are coIIected just Iike a Pap test
< It checks for high-risk HPV
< Incorporating HPV testing in cytoIogy
screaning improves the predictive vaIue
CFRvlCAl CAtCFR
SHAJAHAt C
< Squamous Cell Carcinoma 80-95%
< Adenocarcinoma 5-20%
< Other: Clear cell, sarcomas
1n.v.i.c .qvvnov. .c .v.inonv i. nc no.
.onnon .vic, o{ in.v.i.c .vn.c innc .c.i_.

1i.ooi.v,, .vivn. o{ .qvvnov. .c .v.inonv


in.vvc
N vc .c [cvini:in,
N vc .c non[cvini:in, vnv
N .nv .c ,c.
increasing numler oI cervicaI adenocarcinomas reorted in
vomen in their 2us and 3us.

< denocarcinoma 389:$


recursor oI invasive adenocarcinomathe tvo oIten
coexist
n addition to $ intraeitheIiaI or invasive squamous
neoIasia occurs in 3u% to 5u% oI cervicaI
adenocarcinomas
inimaI deviation adenocarcinoma adenoma
maIignum .
ViIIogIanduIar aiIIary adenocarcinoma
N . t rimariIy aIIects young vomen some oI
vhom are regnant or users oI oraI
contracetives.
N HistoIogicaIIy the tumors have smooth veII
deIined lorders areveII diIIerentiated and are
either 389:or suerIiciaIIy invasive.
mixture ol malignant glanJular anJ
squamous components
poorer prognosis than those vith pure
aJenocarcinoma or squamous carcinoma
Iassy ceII carcinoma poorly
JillerentiateJ
adenoid lasaI carcinoma
adenoid cystic carcinoma.
< mlryonaI rhaldomyosarcoma
chilJren anJ young aJults.
grapelike polypoiJ noJuleslotryoiJ sarcoma

< eiomyosarcomas anJ mixed mesodermaI


tumors
ay le primary lut are more likely to le
seconJary to uterine tumors.
< ervicaI adenosarcoma
lovgraJe tumor vith a gooJ prognosis .
< nvinvn ncvnonv nv, vi.c vc no.o in ni.
vcv
< 1i.ovnooi.v,, i .invvc. ncvnonv
c.c.ncc,
< ono.i. vccnv. on nc vcn o{ in.v.ion ino
nc .c.i.v .onv.
< {ov ni.ooi. .v,c.
< (i) .nv .c
(ii) vc .c
(iii) .v..i.v .v.inoiv
(i.) v,i.v .v.inoiv
.
< ancer oI the cervix sreads ly
(i) direcI invasion inIo Ihe cervical sIroma,
corpus,vagina, and parameIrium
(ii) lymphaIic meIasIasis
(iii) bloodborne meIasIasis
(iv) inIraperiIoneal implanIaIion.
< orbidity and ortality associated with regional
spread of the cancer
< Spreads to pelvic nodes, ureters, bladder, rectum
< Dangerous when cancer blocks ureters resulting
in uremia --> death
< CN: Asymptomatic
< nvasive Cancer
No classic presentation
ay present with abnormal vaginal bleeding
ay present with postcoital bleeding
< nonv ccvin
Between periods
With intercourse
After menopause
< &nv.vv .vinv vi..nvc
Other symptoms
WLeg pain
WPeIvic pain
WBIeeding from the rectum or
bIadder
Some women have no symptoms
< CN
Cervix appears normal to general inspection
< nvasive Cancer
Exophytic growth/
Cauliflower-like, friable/
Deeply ulcerated/
Flat,indurated
WAdvanced Cancer
Pelvic asses Palpable
Anemia
cachexia
< squamocolumnar unc|ion (SCJi
< Bclorc pubcr|v: SCJ loca|cd us| insidc |hc
ccrvical os
< A| pubcr|v- squamous mc|aplasia
< rcposi|ionin ol |hc SCJ lur|hcr |owards |hc
u|crus
< Iruntformution zone it the tite of 9s%
of the ceruicul cuncer deuelopment
< Iince zone it locuted within the ceruicul
ot, unuble to be uiewed during routine
peluic exum
xpoture of truntformution zone to
curcinogent begint procett of
intruepitheliul neoplutiu
While exuct role of curcinogent in thit
procett remuint poorly underttood, it it
cleur thut Hv und cigurette tmohing
cun cuute dytplutiu ut the
truntformution zone
< BOPSY & HSTOPATHOLOGY.
SUSPCOUS GROWTH,EDGE OF
ULCER
COLPOSCOPY DRECTED BOPSY
FRO
SUSPECOUS AREAS.
< BASC
CBC,URNE,FBS,PPBS,LFT,RFT,SE,ABO,Rh
< CYSTOSCOPY
< PROCTOSCOPY
< XRAY CHEST
< ECG
< CT&R
< FDG-PET:F-18 flouro-2-deoxy-D-glucose.
< LVS ABSENT-CERVVAL CONSATON.
< SPLE HYSTERECTOY
< EXTENDED HYSTERECTOY &
LYPHADENECTOY.
< LAPROSCOPC LYPHADENECTOY
,VAGNAL TRACHELECTOY.
< LV-STAGE 1B
< SURGERY:WERTHES HYSTERECTOY.
TRA VAGNAL HYSTERECTOY
& LAPROSCOPC
LYPHADENECTOY.
< RADOTHERAPY.
< COBNED
< WERTHES HYSTERECTOY:
LAPAROTOY,UTERUS,ADNEXA,PELVC
LNs,
EDAL 1/3
rd
PARAETRU,UPPER 1/3
rd
VAGNA.OVARES RETANED F HEALTHY
N
YOUNG.
< TRAS OPERATON:LAPROSCOPC PELVC
LYPHADENECTOY,EXTENDED VAG
HYSTERECTOY.
SURGERY RT
< ACCURATE SURG
STAGNG.
< PELVC LYPHATC
GLANDS CAN BE
REOVED.
< CONSERVATON OF
OVARES
< ORE PLABLE BUT
SHORT VAGNA
RETANED.
< FBROD ADNEXAL ASS.
< FALED SURG CAN BE
WTH RT.
< SURVVAL FOR BOTH
SAE.
< ALL STAGES B/W 1B&4.
< OPD PROCEDURE.
SURG
RT
< SUG ORTALTY-1%
< ANAESTHESA COPL.
< HAEORRHAGE,TRAUA
.
< SEPSS
< BLADDER
DYSFN,FSTULA,URETER
C NJ
< PARALYTC
LEUS,EBOLS
THROBOPHLBTS
< LYPHOCYST
< POST OP RT
< ANAEA
< OVARAN DESTRUCTON
< PYOETRA
< VAGNAL STENOSS
< CYSTTS,FSTULA,URET
STENOSS
< C/C
DARRHOEA,PROCTS
< AVASCULAR NECR FE
HEAD
< NT N ADNEX
ASS,FBROD
OVARAN TUOR.
< RADOTHERAPY:COBNED TELE&BRACHY.
< COBNED:
POST OP -LN ETS,CHEORADATON ,
ENDOCERVCAL CA.
RECURREENCE.
< CHEORADOTHERAPY:
TELE&BRACHY.CSPLATN
CONTANNG REGEN.
< EXENTERATON OPERATON:
CENTRELLY PLACED
GROWTH,BLADDER OR RECTAL FSTULA.
< FOLLOWNG RT S TREATED WTH
HYSTERECTOY OR EXENTERATON.
< PREVOUS SURGCAL CASE ANAGED BY
RADOTHERAPY.
< PAN:ORPHN,TRAADOL
< VOTNG:CORRECT
DEHYDRATON,ELECTROLYTE BLNC.
HALOPERDOL,ETOCLO,DOPR.
CORTCOSTERODS.
< ASCTES:DURETCS,SPRONOLACTONE.
< VAGNAL DSCHARGE:BETADNE DOUCHE.
SHAHEE.N
< Ablative
< Excisional provides specimenfor biopsy
< diagnostic as well as curative
< ABLATVE
A. Cryotherapy
B. Laser ablation
< EXCSONAL
A. Leep
B. Conisation
C. Hysterectomy
< nvasive cancer to be completely exclude by
cytology,colposcopy & histology
< Colposcopy satisfactoru & entire lesion should be
visible
< Endocervical curettage should be negative
< No suspicion of adenocarcinome in situ
< Adequate follow up possible
< 60-80% regress spontaneously
immediate Rx
< f histologically proven;x
follow up
if patient compliant
6 monthly follow up
< Significant chance of progression to invasive Ca
immediate Rx
< Excisional Rx must
LEEP Conisation
(if limits visible) (if limits not visible)
< CRYOTHERAPY
< echanism crystallisation of intracellular
H2O destruction of cell
< Temp: -20 to -30 degree C
< N2O & CO2 used
< Good for CN-1
< Lesion should be entirely located on ectocervix
< Should not extend to endocervical canal
< Endocervical curette negative
< ndications same as cryotherapy
Disadvantages are:
1. Expensive
2. Need special training
< Loop electrosurgical
excision(LEEP)
< Simple and safe procedure
< Procedure of choice in CN-2 & CN-3
< Specimen for histopathology
< ETHOD radiofrequency electric current
used for a large loop excision of the
transformation zone under colposcopic
control
1. ntra & post op hemorrhage
2. cervical stenosis
3. preterm delivery & PPRO
< NDCATONS
1. Limits of lesion not visible
2. SCJ not seen at colposcopy
3. Endocervical curettage +ve for CN-2 or 3
4. Suspicion of microinvasion on
cytology,colposcopy or biopsy
< Done using a cold knife,electrosurgical wire(as in
LEEP) or LASER
< Entire transformation zone including the cervical
lesion is removed by a scalpel
< After conisation,margins of cone must free of CN
Same as that of LEEP
1. ntra & post op hemorrhage
2. cervical stenosis
3. preterm delivery & PPRO
NDCATONS
< icro invasive Ca
< CN-3 at the limits of conisation
< Poor compliance
< Associated gynaecological problems