Management Dilemmas in Cervical Cancer

Magnitude of the Problem

- 500,000 new cases identified each year

- 80% of the new cases occur in developing countries

- At least 200,000 women die of cervical cancer each year

- Cervical cancer is the third most common cancer worldwide

- YET-Cervical cancer is a preventable disease

Relative percentage of common cancers

Cervix 12

Breast 30

Oral cavity 13

Ovary

Leukaemia/Lymphoma 5

Oesophagus 4

Others 31

What is cervical Cancer?

- It is a cancer of the Female reporductive tract

- It is the most common cause of cancer death in the world where Pap tests are not available VIA

- It is the easiest gynecologic cancer to prevent through screening.

What is the female reproductive tract?

- Vulva

- Vagina

- Cervix

- Uterus

- Fallopian tubes Ovaries

What is the cervix?

- Opening of the uterus (womb) into the vagina

- Two cell types present (squamous and glandular)

- Cervical cancers tend to occur where the two cell types met

What causes cervical cancer?

The central cause of cervical cancer is human papillomavirus or HPV:

HPV is sexually transmitted

The HPV detected today could have been acquired years ago

There are many different types of HPV

Low-risk types can cause warts

High-risk types can cause precancer and cancer of the cervix

If I have HPV, does it mean I will get cancer?

- NO!

- In most cases HPV goes away75% of all cancer are due to HPV there is a vacuam

- Only women with persistent HPV (where the virus does not go away) are at risk for cervical cancer

Who is at risk?

- Women who have ever had sex

- Women who have had more than one partner

- Women whose partner(s) has had more than one sexual partner

- Women with other sexually transmitted diseases

How do I lower my risk?

- Delay onset of sexual activity

- Know your sexual partner

- Do not smoke

- Maintain a healthy diet and lifestyle

- Practice safe sex

Clinical Features

- Symptoms :

Asymptomatic in early cases/preclinical stage

Haemorrhage-Metrorrhagia/Post coital.

Bleeding is usually severe in cauliflower like exophytic growths.

Discharge-watery, offensive, blood stained

Cachexia and Pain-In advanced cases.

Clinical Features

- Signs :

An obvious growth may or may not be present

When an obvious growth is present, it may be exophytic cauliflower like or endophytic, ulcerative and scirrhous

Cervix is usually indurated and hard to feel, friable, easily bleeds on touch and its mobility may be restricted or lost.

In cases of endocervical growths, the Cx is expanded, firm and feels barrel shaped.

Diagnosis

- PAP smear examination

- Colposcopy

- Biopsy:

- Excisional biopsy is preferable to punch biopsy.

- Employing Schiller's test/Acetic acid test helps in selecting the biopsy site where the growth is not obvious.

- Cone biopsy in early cases.

- Endocervical curettage

Histopathology

- Squamous Cell (>90%)

- Adenocarcinoma (5%)

- Clear Cell

- Mesonephric

Staging : Always Clinical

- 0: Carcinoma-in-situ

- Ia: Microinvasive (Ia1, la2)

- Ib: Invasive (>mm FIGL, ?3mm SGO)

- IIa: Upper 2/3 of vagina

- IIb: Parametria involvement (not to PSW)

- IIIa: Lower 1/3 of vagina

- IIIb: PSW or hydronephrosis/nonfunctional kidney

- IVa: Bladder or rectal mucosa

- IVb: Distant metastases

Treatment of cervical cancer

- Surgery

Total hysterectomy

Bilateral salpingo-oophorectomy:

Radical hysterectomy

Laser surgery

Chemotherapy

- Inj. TAXOTERE (75mg/m2)

- Inj. cisplatin (75mg/m2)

- 3-6 Cycles at 3 weeks interval.

- Overall response rate was 80.6% (29.36), with complete remission in 15 pts (41.6%).

- 1 year survival was 90%.

- 5 year survival was 75%

Radiotherapy

- 3-D Conformal Radiation

- External Beam Radiation

- HDR Brachytherapy (High Dose Radio)

- IMRT (Intensity Modulated Radiation Therapy)

- Tomo Therapy HI-ART

What is new in screening and prevention?

- Liquid cytology-thin layer cytology

- Combination of HPV test and Pap is now available for women 30 years of age and older

- Pap test computer reviews

- Vaccines for HPV currently being tested

- VILI (Visual inspection with Lugol's iodine)

- Colposcopy

What is a Colposcopy

Colposcopy:

- Use of a magnifying instrument

- Application of a vinegarlike solution onto the cervix

- See abnormalities that can't be seen with the naked eye

- Feels like getting a Pap test, but lasts longer

What is a cervical biopsy?

Biopsy:

- Removal of a small piece of tissue from the cervix

- May feel like getting a Pap test or like a menstrual cramp that lasts a few seconds

Visual inspection with Lugol's iodine (VILI)

- Visual inspection with Lugol's iodine (VILI), also known as Schiller's test, uses Lugol's iodine instead of acetic acid.

- Visual inspection with acetic acid (VIA) can be done with the naked eye (also called ceroscopy direct visual inspection, [DVI]), or with low magnification (also called gynoscopy, aided VI, or VIAM).

What infrastructure does VILI require?

- Private exam room

- Examination table

- Trained health professionals

- Adequate light source

- Sterile vaginal speculum

- New examination gloves, or HLD surgical gloves

- Large cotton swabs

- Lugol's iodine solution and a small bowl

- Containers with 0.5% chlorine solution

- A plastic bucket with a plastic bag

- Quality assurance system to maximize accuracy

VILI: test-positive

- Well-defined, bright yellow iodine non-uptake areas touching the squamocolumnar junction (SCJ).

- Well-defined, bright yellow iodine non-uptake areas close to the so if SCJ is not seen, or covering the entire cervix.

VILI: Suspicious for cancer

- Clinically visible ulcerative, cauliflower-like growth or ulcer; oozing and/or bleeding on touch.

VILI: test-negative

- The squamous epithelium turns brown and columnar epithelium does not change color.

- There are scattered and irregular, partial or non-iodine uptake areas associated with immature squamous metaplasia or inflammation.

VILI test performance:

- Sensitivity = 87.2%

- Specificity = 84.7%

- These results are from a cross-sectional study involving 4,444 women. (Sankaranarayanan et al., 2003).

Conclusion

- "Prophylaxis-better than cure" - Never more True

- Pre treatment evaluation and Proper staging is a must.

- Surgery and radiation are complimentary. So proper team is essential-Surgeon and Radiotherapist should join hands.

- Stage for stage, little progress has been made in lowering mortality rates.

o However, the overall mortality rate is decreasing because more patients are having their cancers diagnosed in early stages of disease.

Submitted By:
ASSOC. PROF. DR. (MED) NASEEM RAHMAN

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