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