Management Dilemmas in Cervical Cancer

1. Management Dilemmas in Cervical Cancer Prof. Surendra Nath Panda, M.S. Dept. of Obstetrics and Gynecology M.K.C.G.Medical College Berhampur, Orissa, India

2. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 2 Cervical Cancer 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 It had been anticipated that widespread implementation of screening programs and treatment of cervical precancers would lead to the virtual elimination of invasive cervical cancer. Large segments of the population who do not undergo regular screening account for most of the patients with invasive cancers worldwide. However, invasive squamous cervical cancers develop even in screened populations, and adenocarcinoma of the cervix, is on the rise. Thus, given present methodology, it is unlikely that invasive cervical cancer is an entirely preventable disease. The screening-prevention system for cervical neoplasia is prone to several sources of error: the false-negative rate of the Pap smear; precancers and cancers arising high in the endocervical canal that may escape sampling; a rapid transit from a preinvasive to an invasive lesion in some cases; and de novo development of invasive cancers without a preliminary preinvasive state. It is within our grasp to make cervical cancer a largely preventable disease. Future directions in cervical cancer screening should include efforts at inclusion of the entire population at risk and improvements in screening methodology. Incorporating the unscreened population into screening programs will involve resource allocation and education. Methods that will reduce the false-negative and false-positive rates to more acceptable levels are needed to improve the effectiveness of screening. Biochemical changes in the cervix develop prior to the development of the earliest histopathologic change, but so far, a test based on biochemical indicators such as pentose shunt enzymes has eluded us. It had been anticipated that widespread implementation of screening programs and treatment of cervical precancers would lead to the virtual elimination of invasive cervical cancer. Large segments of the population who do not undergo regular screening account for most of the patients with invasive cancers worldwide. However, invasive squamous cervical cancers develop even in screened populations, and adenocarcinoma of the cervix, is on the rise. Thus, given present methodology, it is unlikely that invasive cervical cancer is an entirely preventable disease. The screening-prevention system for cervical neoplasia is prone to several sources of error: the false-negative rate of the Pap smear; precancers and cancers arising high in the endocervical canal that may escape sampling; a rapid transit from a preinvasive to an invasive lesion in some cases; and de novo development of invasive cancers without a preliminary preinvasive state. It is within our grasp to make cervical cancer a largely preventable disease. Future directions in cervical cancer screening should include efforts at inclusion of the entire population at risk and improvements in screening methodology. Incorporating the unscreened population into screening programs will involve resource allocation and education. Methods that will reduce the false-negative and false-positive rates to more acceptable levels are needed to improve the effectiveness of screening. Biochemical changes in the cervix develop prior to the development of the earliest histopathologic change, but so far, a test based on biochemical indicators such as pentose shunt enzymes has eluded us.

3. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 3 Cervical Cancer It had been anticipated that widespread implementation of screening programs and treatment of cervical precancers would lead to the virtual elimination of invasive cervical cancer. Large segments of the population who do not undergo regular screening account for most of the patients with invasive cancers worldwide. However, invasive squamous cervical cancers develop even in screened populations, and adenocarcinoma of the cervix, is on the rise. Thus, given present methodology, it is unlikely that invasive cervical cancer is an entirely preventable disease. The screening-prevention system for cervical neoplasia is prone to several sources of error: the false-negative rate of the Pap smear; precancers and cancers arising high in the endocervical canal that may escape sampling; a rapid transit from a preinvasive to an invasive lesion in some cases; and de novo development of invasive cancers without a preliminary preinvasive state. It is within our grasp to make cervical cancer a largely preventable disease. Future directions in cervical cancer screening should include efforts at inclusion of the entire population at risk and improvements in screening methodology. Incorporating the unscreened population into screening programs will involve resource allocation and education. Methods that will reduce the false-negative and false-positive rates to more acceptable levels are needed to improve the effectiveness of screening. Biochemical changes in the cervix develop prior to the development of the earliest histopathologic change, but so far, a test based on biochemical indicators such as pentose shunt enzymes has eluded us. It had been anticipated that widespread implementation of screening programs and treatment of cervical precancers would lead to the virtual elimination of invasive cervical cancer. Large segments of the population who do not undergo regular screening account for most of the patients with invasive cancers worldwide. However, invasive squamous cervical cancers develop even in screened populations, and adenocarcinoma of the cervix, is on the rise. Thus, given present methodology, it is unlikely that invasive cervical cancer is an entirely preventable disease. The screening-prevention system for cervical neoplasia is prone to several sources of error: the false-negative rate of the Pap smear; precancers and cancers arising high in the endocervical canal that may escape sampling; a rapid transit from a preinvasive to an invasive lesion in some cases; and de novo development of invasive cancers without a preliminary preinvasive state. It is within our grasp to make cervical cancer a largely preventable disease. Future directions in cervical cancer screening should include efforts at inclusion of the entire population at risk and improvements in screening methodology. Incorporating the unscreened population into screening programs will involve resource allocation and education. Methods that will reduce the false-negative and false-positive rates to more acceptable levels are needed to improve the effectiveness of screening. Biochemical changes in the cervix develop prior to the development of the earliest histopathologic change, but so far, a test based on biochemical indicators such as pentose shunt enzymes has eluded us.

4. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 4 Cervical Cancer 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.

5. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 5 Cervical Cancer 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.

6. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 6 Cervical Cancer 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

7. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 7 Cervical Cancer Squamous Cell (>90%) Adenocarcinoma (5%) Clear Cell Mesonephric

8. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 8 Cervical Cancer 0:Carcinoma-in-situ Ia:Microinvasive (Ia1, Ia2) Ib:Invasive (>5mm FIGO, >3mm SGO) IIa:Upper 2/3 of vagina IIb:Parametrial involvement (not to PSW) IIIa:Lower 1/3 of vagina IIIb:PSW or hydronephrosis/nonfunctional kidney IVa:Bladder or rectal mucosa IVb:Distant metastases

9. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 9 Complete physical Exam, Pelvic Exam , Rectal Exam. if needed, examination under anaesthesia, should be done. Ultrasonography Chest X ray IVP Cystoscopy Proctosigmoidoscopy Cervical Cancer

10. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 10 Cervical Cancer

11. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 11 Treatment of Cervical Cancer Stage I A-I. (<1mm). Conization Simple Hysterectomy -- vaginal / abdominal Type I Hysterectomy (Extra fascial) Stage I A-II. (1 – 3mm, Lymph node - 1%). Type II Hysterectomy (Modified radical Hysterectomy-Removal of medial half of uterosacral and cardinal ligaments and smaller margin of vagina)

12. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 12 Treatment of Cervical Cancer Stage I B & II A. Type III Hysterectomy (Radical hysterectomy with removal of most of utero sacral and cardinal ligaments, upper 1/3 rd of vagina, pelvic lymphadenectomy) followed by Post operative irradiation Bulky Lesions & stage II B Full irradiation followed 3 - 4 weeks later by Type II Hysterectomy

13. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 13 Treatment of Cervical Cancer Recurrent disease: -as per previous treatment RT ? Exenteration Surgery ? RT Stage III & IV: - Radiation / ??Exenteration Radiation, as primary treatment is an option in all stages. Chemotherapy - as adjunct to RT or for palliation

14. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 14 Radical Hysterectomy Removes corpus, cervix, parametria, upper third of vagina Uterine arteries divided at origin Ureters dissected through tunnel Uterosacral ligaments divided near rectum Typically combined with LND Oophorectomy not mandatory

15. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 15 Radical Hysterectomy Abdominal exploration Assessment of operability Ligation and section of ovario pelvic fold and round ligament Dissection of pelvic lymphnodes Dissection of ureter Separation of bladder Ligation of uterine vessels

16. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 16 Radical Hysterectomy Dissection of ureter from cardinal ligament Cleaning of paravescial and pararectal fossa Opening of rectovaginal septum Clamping and transection of uterosacral and cardinal ligament Transection of vagina Hemostasis and drainage Reperitonisation

17. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 17 Radical Hysterectomy Acute: ? Hemorrhage, Trauma, Sepsis, Thrombophlebitis, Pulmonary Embolism, Small Bowel obstruction, Febrile Morbidity, UVF - 1-2%, V V F - < 1%, Primary mortality- 1% Sub Acute: ? Neurogenic bladder dysfunction Chronic?Lymphocyst, Ureteral stricture

18. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 18 Radical Hysterectomy More thorough assessment of the spread and type of lesion ? Preservation of ovaries if desired Retention of more functional vagina Less morbidity and less recurrence Special conditions like Large Adnexal masses Fibromyoma Radioresistatnt growth Unsuitable for intracavitary irradiation Central recurrence after radiotherapy

19. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 19 Schauta Operation Adopted as Mitra’s Operation In India as an alternative to Wertheim’s Hysterectomy. Its an extended Vaginal Hysterectomy. Comprises of removal of entire Uterus and Adenexae with most of the vagina and medial portion of parametria, by vaginal route Though primary mortality is low (<1%) lymph nodes cannot be removed. So it should be followed by Post operative radiation or Taussig’s extra peritoneal Lymphadenectomy

20. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 20 Radiation Acute: - Perforation Fever Diarrhea Bladder spasm Chronic: - Proctitis Cystitis-UTI Fistula Enteritis Femoral head necrosis Ureteric stenosis Rectal stricture

21. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 21 Special Category Invasive Cancer discovered on Cone Biopsy Cervical Stump Carcinoma Invasive Carcinoma found after simple hysterectomy Cervical Cancer in Pregnancy Large Barrel shaped lesion

22. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 22 Follow Up At 2-3 Months interval ---- 2year At 3-4 Months interval ---- Next 2- 4 year At 6 Monthly interval ----- Rest of the life ?Tumour markers

23. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 23 Cervical Cancer The extent of reduction in cervical cancer mortality is in proportion to the number of women being screened, with no decrease in incidence or mortality in unscreened populations. The reasons for the reduction in cervical cancer mortality in screened populations are not clear. Although identification of invasive cancer at an earlier and more curable stage certainly contributes to the lower rate, most of the benefit is thought to be the result of identification and treatment of precancerous cervical lesions, thereby preventing invasive disease. The extent of reduction in cervical cancer mortality is in proportion to the number of women being screened, with no decrease in incidence or mortality in unscreened populations. The reasons for the reduction in cervical cancer mortality in screened populations are not clear. Although identification of invasive cancer at an earlier and more curable stage certainly contributes to the lower rate, most of the benefit is thought to be the result of identification and treatment of precancerous cervical lesions, thereby preventing invasive disease.

24. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 24 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. However, the overall mortality rate is decreasing because more patients are having their cancers diagnosed in early states of disease.

25. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 25 Conclusion Five year survival - stage IA – 100 %, IB - 85 - 90 % , stage IIA- 70 - 75 % Many physicians are discouraged with the results of cancer therapy. However, the opportunity is there for all physicians to make an early diagnosis in Ca Cx and to protect the women from this dreadful disease. Those women saved from the ravages of cervical cancer shall call their physicians blessed.

26. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 26 Conclusion “Days are gone when a patient with gynaecological malignancy could be treated by a surgeon or a radiotherapist in isolation”. -Stallworthy

27. 7:01 PM Management Dilemmas in Cervical Cancer- Prof. S.N.Panda 27 Thank You