cervicalcancer.ppt

CERVICAL CANCER.Diagnosis TreatmentCERVICAL CANCER.lThe most common malignancy in gynecological oncologylIncidence:7.8/100,000lMortality:2.7/100,000lDiagnosis:biopsylMain modality of treatment:surgery and radiationlGoal of treatment:cure,except stage 4b Special Casel38 yrs,G3/P1,nurselC/O:postcoital bleeding for 2 monthslMenstruation regular with 30 days cycle and 5 days duration.Abnormal discharge with bad smell.LMP:12 days agolPap smear:squamous cell cancer lPV:Vulva:Normal,lVaginal:yellowish discharge with bloody stained,lCervix:growth with ulceration and contact bleeding.lUterus:N/S,mobile.lParametrium:thickening not to pelvic sidewall on both side CERVICAL CANCER.lHow can we make a diagnosis?lHow can we evaluate the patient?lHow can we manage the patient?lHow should we explain to the patient?lCan we prevent cervical cancer?How can we make a diagnosis?SYMPTOMSlAbnormal vaginal bleeding postcoital bleeding*contact bleeding lAbnormal vaginal dischargelAsymptomatic,just abnormal pap smearSYMPTOMSlThe classic symptom is intermittent,painless metrorragia or spotting only postcoitally or after douching.lProbably the first symptom of early cancer of the cervix is a thin,watery,blood-tinged vaginal discharge that frequently goes unrecognized by the patients.lAs the maligancy enlarges,the bleeding episodes become heavier and more frequent,and they last longer.SYMPTOMSlLate symptom or indicators of more advanced disease include the development of pain referred to the flank or leg.lMany patients c/o dysuria,hematuria or rectal bleeding or obstipation resulting from bladder or rectal invasion.lDistant 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 manifestations of recurrent disease.How can we make a diagnosis?lSIGNSlVagina:mucous,fornixlCervix:erosion growth ulceration barrel-shapedlUterus:size,mobilitylParamet:thickening Gross appearencelThree categories of gross lesions have traditionally been described.lThe most common is the exophytic lesion,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.lLittle visible ulceration or exophytic mass like a stone-hard cervix that regresses slowly with radiation therapy.lUlcerative tumor,usually erodes 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:lPap smearlColposcopy and target biopsylEndocervical curettage(ECC)lCone biopsylBiopsyPap smearlPap smear is the most common and effective screening method.lExfoliated cervical cells are scraped from the cervix by spatula.The entire T zone must be sampled.Incomplete sampling could produce a false-negative smear.lThe endocervical canal is also sampled with a swab or cytobrush.lCells are fixed immediately to avoid air-drying cytologic artifacts Pap Smear Show Squamous Cell CarcinomaPap Smear Show Squamous Cell CarcinomaColposcopy and directed biopsylA pap smear is only a screening test.A definitive diagnosis requires inspection of a well-visualized cervix with a colposcope.lThe cervix is painted with 3%acetic acid solution to enhance surface alterations and vascular changes.lThe colposcope evaluation is considered adequate or satisfactory if the complete T zone and full extent of the lesions is visualized.lAreas of abnormality(e.g.,White epithelium,mosaicism,and punctation)are selectively punch biopsied.Colposcopy ExaminationCone biopsylIndications for cone biopsy 1.The 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 situHow can we make a diagnosis?lA pap smear is only a screening test!lDefinitive diagnosis of cervical cancer requires a BIOPSY!How can we evaluate the patient?Histologic type:lSqumous cell carcinoma(SCC)80%lAdenocacinoma 10%-15%lOthers 5%-10%Routes of spreadlInto the vaginal mucosa,extending microscopically down beyond visible or palpable disease;lInto the myometrium of the low uterine segment and corpus,particularlly with lesions arising from the endocervix.lInto the paracervical lymphatics and from there to the most common involved lymph nbodes(the obturator;hypogastric,and external iliac nodes).lDirect extesion into adjacent structures or parametria,reaching to the obturator fascia and the wall of the true pelvisHow can we evaluate the patient?lStage:Pelvic examination,Rectovaginal examination,Intravenous pyelography(IVP)Ultrasonography or CTlStaging is clinical,but can use IVP and CTlCervical cancer is the only gynecologic malignancy that is not surgically stagedClinical Staging for Cervical CarcinomalStage 0Carcinoma-in situ;Confined to the epithelium onlyClinical Staging for Cervical CarcinomalStage I Invasion is strictly confined to the cervixIa:Invasive cancer identified only microscopically.Ia1:Minimal microscopically evident stromal invasion=3mm in depth and no wider than 7mm.Ia2:Microscopic invasion 50%lPV:Vulva and vaginal:normal Cervix:erosion with contact bleeding,Uterus:N/S,mobile.Parametrium:clear lWants to preserve her reproductive function Treatment strategy for CINCase discussion l48 yrs,G3/P1,midlife lC/O:postcoital bleeding for 4 monthslMenstruation irregular with 30-60 days cycle and 5-20 days duration.Abnormal discharge with bad smell.LMP:2 months agolPap smear:squamous cell cancer lPV:Vulva:Normal,vaginal:right fornix involved by cervical growth.Cervix:growth with ulceration and contact bleeding.Uterus:N/S,mobile.Parametrium:nodular thickening to pelvic sidewall on rightlBiopsy:SCC.IVP:nonfunctional kidneyTreatment strategy for Invasive Cervical CancerHow can we explain to the patient?lWhat is cervical cancer?lHow many treatment mode for cervical cancer?lWhy we choose surgery or RT for the patient?lWhat is the side-effect of the treatment?lWhat is the prognosis and survival rate?Cervical cancerlCervical cancer is the most common gynecologic malignancy.lThe most common tumor type is squamous cell carcinoma(80%)lA pap smear is only a screening test!lDefinitive diagnosis of cervical cancer requires a tumor BIOPSY!lRadiation and operation are both effective treament.lGoal of the treatment:cure,except stage IV