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cervical-cancer-4-53

VIEWS: 6 PAGES: 38

									   Invasive
Cervical Cancer



    อ.จิรประภา นาที
    อ.สุทธา หามนตรี
Cervical Cancer in Thailand

Number               6192
Death                3166 (51%)
Death/day             ~9

Source : IARC 2001
   Cause of Cervical Cancer
HPV Prevalence in Cervical Cancer Worldwide
    (Walboomers JM, et al. J Pathol 1999 ; 189 : 12-9)


 Cervical Cancer Specimens ~ 1000+ cases
              (22 countries)


     Polymerase Chair Reaction (PCR)


          HPV-DNA Detection 99.7%
         Human Papilloma Virus
Double-stranded
     DNA                                      55 nm diameter




72 capsomers                                  8,000 base-pair
                                                  genome


                          8 genes
                  (E1,E2,E4,E5,E6,E7,L1,L2)
        Cause of Cervical Cancer
                Multiple sex partners
                    (male & female)
  Co-factors


Oral pills                              Early age of S.I.
               Persistent Infection
                        of
                Oncogenic HPV
Multiparity     (16,18,31,33,45,etc)       Smoking




                Immunosuppression
            Cervical Carcinogenesis
                                                              Koilocytes
           Intact Virions     Episomal HPV




                                                70-90%
Basal Cells or Immature         HPV Infection            Low-Grade SIL
 Squamous Metaplasia
                                                                  5-15%
                            Progression
                                                                  within 3-4 yrs
                             30-70%
                            within 10yrs




      Invasive CA                          High-Grade SIL
       Classification of HPV (> 100 types)
                (∗Oncogenic Potential∗)


Oncogenic      HPV types              Lesions
Risk

Low         6,11,42-44,53-55          Condyloma,
            62,66,70                  LSIL

High         16,18,31,33,35,39,45,    LSIL, HSIL,
             51,52,56,58,59,61, Invasive CA
             66-68
  HPV Type in Cervical Cancer Worldwide


   HPV Type                       Percent

   16                                         45-65
   16, 18                                     65-75
   16, 18, 31, 45                             75-80
   16, 18, 31, 33, 45                         90-95


Asia : 16,18,58,52, Others : 16,18,45,31,33
Facts About Cervical Cancer
1. HPV is a causal agent of cervical cancer.
2. Persistent HPV infection is the most
   important risk factors for development
   of cervical cancer.
3. Cervical cancer has all the epidemiologic
   characteristics of a sexually-transmitted dz.
4. Time frame to cervical cancer is 10–15 yrs.
5. Cervical cancer is completely preventable.
    Cervical Cancer Prevention
             (W.H.O.)
Primary prevention
     - Avoid HPV exposure
     - HPV vaccination
Secondary prevention        Cytology
     - Early detection
                            HPV test
Tertiary prevention
     - Treatment & Rehabilitation
 Cervical Cancer Screening Methods
∗ 1. Cytology (Conventional Pap vs. LBC)
∗ 2. HPV DNA test
 3. Colposcopy
 4. VIA
 5. Cervicography
 6. Chemiluminescent speculoscopy
 7. Infrared spectrophotometry
 8. Polar probe (Tru Scan)
 9. Fluorescence spectroscopy
 10. Direct visual inspection (DVI)
Symptoms of pre-invasive


 - ไมมีอาการหรือไมจําเพาะ เชน ตกขาวเปนมูกใส ,
  postcoiltal bleeding จาก erosion
 -PV : erosion , cervicitis
CIN classification   Bethesda system B2001

                     WNL                  -
                     reactive or       ASC -US
                     reparative change       -H
CIN I                L-SIL
CIN II                      H-SIL
CIN III                     H-SIL
CIN III (CIS)               H-SIL
SCC                  SCC
                     AGUS              AGC - NOS
                                       - favor neoplasia
                                       - AIS
Adenocarcinoma       adenocarcinoma
Pap smear
- ประโยชน : secondary prevention
- ทําเมื่อมี SI หรืออายุมากกวา 35 ป
-ความถี่ : neg          1 ป x         3
    ทุก 3-4 ป
- วิธีทํา: V-C-E technique
           1. posterior fornix
         * 2. ectocervix
         * 3. endocervix
Slide fixation: fix ทันทีกอนสไลดแหง
1. wet fixative
   95% ethyl alcohol          15 min
2. coating fixative
   hair spray
ความแมนยํา :
    - false neg   16 – 36
      1. sampling error
      2. inadequacy of specimen
      3. การยอมและการอานสไลด
    - false pos   7%
Management of abnormal Pap
     Colposcopy
Or refer to gynecologist
Or repeat Pap smear in 4 mth,
 if low grade abnormality,
 eg ASC-US, L-SIL
    Colposcopy
-ไมนิยมใช screening , แพง ดูนาน ตองมีความชํานาญ
-ใชรวมกับ Pap smear, ใชหลังพบวามี abnormal
 Pap smear
     Colposcope                                      accuracy
80%
     Pap smear                                            87%
     Colposcope and Pap smear                              99%
Signs & symptoms
post coital bleeding
abnormal vaginal bleeding
foul smell vaginal discharge
pain, pelvic organ obstruction
*** no Pap smear if positive
    cervical lesions
Histologic diagnosis
 1. Endocervical curettage
 2. Punch biopsy
 3. Cervical conization
Histologic type of cervical
 carcinoma
 1. Squamous cell carcinoma
 85-90%
 2. Adenocarcinoma 8-14%
 3. Other epithelial carcinoma
 adenosquamous, small cell
 glassy cell,undifferentiated
FIGO staging 1995 of cervical cancer (
 International Federation of
 Gynecology and Obstetrics)

1. Clinical staging โดยการตรวจกอนการรักษา
2. หลังจาก clinical staging จะไมมีการเปลี่ยน stage
3. หากไมแนใจระหวาง 2 stage ใหจัดอยูใน stage ที่ต่ํากวา
  และรักษาใน stage ที่สูงกวา
4. Clinical staging การตรวจที่ยอมรับคือ คลํา, ดู
  ,colposcope, endocervical curette,
  hysteroscope, cysto-proctoscope, CXR,
  IVP, bone survey
5. CT, MRI, laparoscope, lymphangiogram
  ไมนํามา staging
6. หาก hysterectomy แลว พบ cervical cancer
  ไมสามารถ staging ได        undetermined
 staging
     Stage IA Cervical Cancer
Invasive carcinoma diagnosed only by
microscopy.
All macroscopically visible lesions are stage
IB
      Stage IA Cervical Cancer
IA1
  Stromal invasion 3.0 mm or less in depth and 7.0
  mm or less in horizontal spread
IA2
 Stromal invasion more than 3.0 mm and
 not more than 5.0 mm with a horizontal spread 7.0
 mm or less
                   Stage IA Cervical cancer


              Stage IA1                                              Stage IA2


   CKC                          TAH                        RHPL*             RT**
 Rating : BII              Rating : BII                   Rating : BII     Rating : BII

* RHPL = Radical Hysterectomy & Pelvic Lymphadenectomy
** RT        = Radiation therapy
   Ref : Diagnosis and treatment of cervical carcinomas. ACOG Practice
         Bulletin No 35. ACOG. Obstet Gynecol 2002 ; 99 : 855 - 67.
     Stage IB Cervical Cancer
IB
Clinically visible lesion confined to the cervix
or microscopic lesion greater than IA2
      Stage IB Cervical Cancer
IB1
  Clinically visible lesion 4.0 cm or less in greatest
  dimension
IB2
  Clinically visible lesion more than 4.0 cm in
  greatest dimension
         Treatment for Stage IB2 CA Cervix
         Treatment for Stage IB2 CA Cervix


Radical                                          Neoadjuvant
Surgery                        Radiation
                                                Chemotherapy
                               Therapy +
Rating : AI                      TAH


                Concurrent                 Radical    Radiation
              Chemoradiation               Surgery    Therapy
                 Rating : AI
      Stage II Cervical Cancer
Tumor invades beyond the uterus but not to
pelvic wall or lower third of the vagina
IIA
  Without parametrial invasion
IIB
  With parametrial invasion
       Stage III Cervical Cancer
Tumor extends to pelvic wall and/or involves
lower third of vagina and/or causes
hydronephrosis or nonfunctioning kidney
IIIA
  Tumor involves lower third of vagina, no extension
  to pelvic wall
IIIB
  Tumor extends to pelvic wall and/or causes
  hydronephrosis or nonfunctioning kidney
      Stage IV Cervical Cancer
IVA
 Tumor invades mucosa of bladder or rectum,
 and/or extends beyond true pelvis.
IVB
 Distant metastasis M1
      *Treatment for
       *Treatment for
Stage IIB -- IVA CA Cervix*
Stage IIB IVA CA Cervix*



        Concurrent
      Cisplatin - Based
      Chemoradiation
          *Rating : AI*
Thank you for your
    attention

								
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