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Treatment for Cervical Cancer

Treatment for Cervical Cancer. Dr Sai Daayana Clinical Lecturer in Gynaecology Oncology St Mary’s Hospital, Manchester. Malignant Transformation. HPV types 16, 18, 31, 33 & 45 are ‘high risk’ Most HPV infections are transient & disappear without ever causing dysplasia

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Treatment for Cervical Cancer

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  1. Treatment for Cervical Cancer Dr Sai Daayana Clinical Lecturer in Gynaecology Oncology St Mary’s Hospital, Manchester

  2. Malignant Transformation • HPV types 16, 18, 31, 33 & 45 are ‘high risk’ • Most HPV infections are transient & disappear without ever causing dysplasia • Persistent high risk HPV infection is linked to cervical carcinogenesis • Only 30% CIN 3 lesions progress to cervical squamous cell cancer, if left untreated, over 10-15 years • Unable to distinguish lesion that will regress from one that will progress • Therefore need to treat all high grade CIN

  3. CERVICAL INTRAEPITHELAIL NEOPLASIA Abnormalities in the surface cells of the cervix that may become cancerous. CIN is not a cancer. There are 3 grades of CIN -

  4. Cervical Glandular Intraepithelial Neoplasia • Pre-invasive disease of the endocervix (pre-cursor of adenocarcinoma of the cervix) • CGIN graded 1-3 similar to CIN • May be detected by smear showing ‘abnormal glandular cells’ • More commonly detected at colposcopy where there is co-existing CIN • Or in the LLETZ or cone biopsy specimen performed for a high grade CIN lesion

  5. HISTOLOGY HSIL HSIL LSIL

  6. Colposcopic pictures of CIN CIN 3 CIN 1 CIN 2

  7. Cervical Cancer (1) • Epidemiology • Second most common cause of cancer related death in women world wide • Median age at diagnosis 52 years • Aetiology • Persistent infection with high risk HPV subtypes (HPV 16, 18, 31, 33 & 45 linked to 85% cancer cervix) • Immunosuppression • Smoking • Sexual promiscuity, early age at first coitus, multiple partners • Use of combined oral contraceptive pill

  8. Cervical Cancer (2) • Clinical features • Post coital, intermenstrual or persistent vaginal bleeding • Friable, papillary or polypoid mass • Hard, bulky, nodular mass which eventually ulcerates • Pathology • Squamous Cell Carcinoma -70% • Adenocarcinoma • Adenosquamous carcinoma - rare, poor prognosis

  9. Cervical Cancer (3):Squamous Cell Carcinoma • Invades locally into uterine body, vagina, parametrial tissues, bladder & rectum • Lymph node spread to pelvic, iliac & aortic nodes occurs early • Metastasis to liver, lungs & bone by blood occurs late • 5 year survival rate for Stage I disease is 85%, falling to 50-75% for Stage II+

  10. Cervical Cancer (4):Adenocarcinoma • Clear Cell type occurs in young girls exposed prenatally to DES (diethylstilbesterol) • Increasing in incidence but relatively uncommon • Associated with especially HPV 18 infection • Grows in endocervix & is commonly well differentiated • Spreads upwards into the myometrium & outwards into the pelvis • 5 year cure rate is relatively poor

  11. Squamous cell carcinoma of the cervix

  12. FIGO Staging of Cervical Cancer I Carcinoma strictly confined to cervix IA Diagnosed only by microscopy with deepest inv 5mm and largest ext 7mm 1A1 Stromal inv of  3mm in depth and extension of  7 mm 1A2 Stromal inv of 3-5mm with extension of not 7mm IB Clinically visible lesions limited to cervix or preclinical cancers IA IB1 Clinically visible lesion 4cm in greatest dimension IB2 Clinically visible lesion 4cm in greatest dimension II Carcinoma invades beyond the uterus, but not to pelvic wall or to the lower third of the vagina IIA without parametrial invasion IIA1 Clinically visible lesion  4cm in greatest dimension IIA2 Clinically visible lesion  4 cm in greatest dimension IIB with obvious parametrial invasion IIIA Extends to lower third of vagina IIIB Extension to pelvic side-wall and/or hydronephrosis or non-functioning kidney IV Biopsy proven carcinoma extended beyond true pelvis/mucosa of bladder or rectum

  13. Stage I Cervical Cancer

  14. Treatment for CIN2/3, Stage Ia Cervical Carcinoma – LLETZ (large loop excision of the transformation zone) Usually performed in the colposcopy clinic under local anaesthesia Cone biopsy Performed in the operating theatre under general anaesthesia

  15. Stage IB Cervical Cancer

  16. Stage IIA Cervical Cancer

  17. Treatment for Stage Ib, IIa Cervical Carcinoma – Trachelectomy, performed open, laparoscopic or vaginal

  18. TRACHELECTOMY

  19. Cerclage placed after trachelectomy

  20. Radical hysterectomy performed open or laparoscopic Complete removal of uterus, cervix, upper vagina and parametrium. Pelvic lymph nodes, fallopian tubes and ovaries are also usually removed

  21. Total vs. Radical hysterectomy

  22. Stage III Cervical cancer

  23. Radiotherapy treatment for Cervical cancer Can be administered externally, internally or both External beam radiotherapy – beams are directed at the body in the radiotherapy department, usually once a day, five days a week for four weeks Internal radiotherapy – in pt treatment - radioactive source is put into the vagina (if uterus removed) or into the uterus for 14 – 24 hours usually. Treatment may be repeated a week later. Usually given 1-2 weeks following external beam radiotherapy Side-effects from pelvic radiotherapy Diarrhoea, Irritable bladder Nausea, Perineal soreness and redness Long-term side effects Menopause, Vaginal stenosis Long-term bladder / bowel side-effects

  24. Intracavity Radiotherapy

  25. External Beam Radiotherapy

  26. Radiotherapy burns to the perineum

  27. Stage IVA Cervical cancer

  28. Stage IVB Cervical cancer

  29. Chemotherapy for Cervical cancer In cervical cancer most commonly cisplatin chemotherapy may be given –intravenously, once a week or once every 3-4 weeks for several cycles With radiotherapy – this is chemoradiation If the cancer has spread – to control it and reduce symptoms Before surgery or radiotherapy to shrink the size of a tumour Side-effects of cisplatin Drop in blood cell count, increased risk of infection, bleeding, anaemia Nephrotoxicity, Neurotoxicity, Ototoxicity Fatigue, Nausea and vomiting Electrolyte disturbance

  30. Intravenous chemotherapy administration

  31. Intravenous chemotherapy administration

  32. 5-year Survival Rates for Cervical Cancer The numbers below come from the National Cancer Data Base, and are based on people diagnosed between 2000 and 2002 Stage5-Year Survival Rate 0 93% IA 93% IB 80% IIA 63% IIB 58% IIIA 35% IIIB 32% IVA 16% IVB 15%

  33. TREATMENT OF CERVICAL CANCER Treatment depends on the stage of the disease Treatment options: LLETZ Cone biopsy Total hysterectomy Radical trachelectomy Radical abdominal hysterectomy External beam & intracavity radiotherapy Chemotherapy Stage IA Stage IB, IIA Stage IIB or more, high grade disease with other stages

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