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Cervical Lesions

Cervical Lesions. Maria Julieta V. Germar, FPOGS, FSGOP Section of Gynecologic Oncology UP College of Medicine-Philippine General Hospital The Medical City. Ateneo School of Medicine and Public Health 16 November 2011. Infectious Conditions of the Cervix. Condyloma Gonococcal Cervicitis

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Cervical Lesions

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  1. Cervical Lesions Maria Julieta V. Germar, FPOGS, FSGOP Section of Gynecologic Oncology UP College of Medicine-Philippine General Hospital The Medical City Ateneo School of Medicine and Public Health 16 November 2011

  2. Infectious Conditions of the Cervix Condyloma Gonococcal Cervicitis Chlamydial cervicitis

  3. Chlamydial Cervicitis In the United States, chlamydial genital infection is the most frequently reported infectious disease, and the prevalence is highest in persons aged ≤25 years MICROBIOLOGY: • Etiologic agent: Chlamydia Trachomatis • Obligatory intracellular bacteria • Infect COLUMNAR EPITHELIAL CELLS • Survive by replication that results in the death of the cell

  4. Chlamydial Cervicitis CLINICAL MANIFESTATIONS: • Majority (70%-80%) are asymptomatic • Local signs of infection, when present, include: • Mucopurulent endocervical discharge • Edematous cervical ectopy with erythema and friability

  5. Chlamydial Cervicitis DIAGNOSIS • Culture- gold standard • Non-culture tests • Nucleic Acid Amplification Tests (NAATs)-most sensitive • Non-Nucleic Acid Amplification Tests (Non-NAATs) • Serology- Rarely used for uncomplicated infections MANAGEMENT • Antibiotic treatment of patient and partner (within past 60 days)

  6. Treatment Recommended RegimensAzithromycin 1 g orally in a single doseORDoxycycline 100 mg orally twice a day for 7 days A recent meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline for the treatment of genital chlamydial infection demonstrated that the treatments were equally efficacious, with microbial cure rates of 97% and 98%, respectively Sexual abstinence for 7 days 35

  7. Symptoms

  8. Diagnostic Tests

  9. Treatment

  10. Lecture Outline • Review: Anatomy • Benign Lesions of the Cervix • Clinical Presentation, Diagnosis • Management • Infectious Conditions:Cervicitis • Clinical Presentation, Diagnosis • Management • Cervical Cancer • Prevention • Diagnosis • Staging • Management

  11. Lecture Outline • Review: Anatomy • Benign Lesions of the Cervix • Clinical Presentation, Diagnosis • Management • Infectious Conditions:Cervicitis • Clinical Presentation, Diagnosis • Management • Cervical Cancer • Diagnosis • Staging • Management • Prevention

  12. Asia-Oceania 268,000 women are diagnosed with cervical cancer 144,000 will die from the disease Burden of cervical cancer in the Asia-Oceania region • Cervical cancer incidence and mortality in Asia-Oceania accounts for > 50% of all cases and deaths from the disease worldwide1 < 6.8 < 9.9 < 16.8 < 21.6 < 42.8 Cervical cancer incidence rates in Asia-Oceania Cases per 100,000 women per year 1. Ferlay J, et al. GLOBOCAN 2008 Cancer Incidence, Mortality and Prevalence Worldwide. IARC CancerBase; Lyon, 2010

  13. WHO/ICO Information Centre on HPV and Cervical Cancer Summary report on HPV and cervical cancer statistics in the Philippines. Accessed September 2011

  14. A comparison of age-specific incidence rates and age-specific mortality rates of cervical cancer in the Philippines WHO/ICO Information Centre on HPV and Cervical Cancer Summary report on HPV and cervical cancer statistics in the Philippines. Accessed September 2011

  15. In the Philippines, 12 Filipinas die of cervical cancer each day. Philippine Cancer Facts and Estimates 2010

  16. Cervical Cancer Problem in the Philippines One out of three women diagnosed today will die of the disease within a year Philippine Cancer Facts and Estimates 2010

  17. Cervical Cancer Problem in the Philippines Three out of four women diagnosed today will die within 5 years Philippine Cancer Facts and Estimates 2010

  18. Endogenous Hormones Genetic Factors Cervical Cancer Coinfection With Other Sexually TransmittedInfections HIV High Parity Smoking OCs* Diet HPV High parity 7 or more OCP use of 5 years or more Early Coitus 14 or earlier EstablishedandPotentialCofactors Involved in HPV Carcinogenesis Adapted from Castellsagué X, Muñoz N. J Natl Cancer Inst Monogr. 2003;31:20–28 International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical carcinoma and reproductive factors: Collaborative reanalysis of individual data on 16,563 women with cervical carcinoma and 33,542 women without cervical carcinoma from 25 epidemiological studies. Int. J. Cancer 2006; 119: 1108-1124 SGOP Clinical Practice Guidelines 2010 .

  19. ESTABLISHED CO-FACTORS High Parity :Parity of 7 or more increases the risk for cervical cancer. Women who reported 7 or more full-term pregnancies and were HPV positive had a 4-fold increase in risk of cervical cancer compared with nulliparous HPV-positive women with similar characteristics (OR, 3.8; 95% CI, 2.7---5.5). Highparity increase the risk of cervical cancer because it maintainsthe transformation zone on the exocervix for many years facilitating the direct exposure to HPV and, possibly, to othercofactors. Level II-2,Grade A International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical carcinoma and reproductive factors: Collaborative reanalysis of individual data on 16,563 women with cervical carcinoma and 33,542 women without cervical carcinoma from 25 epidemiological studies. Int. J. Cancer 2006; 119: 1108-1124 Society of Gynecologic Oncologists of The Philippines Clinical Practice Guidelines 2010

  20. ESTABLISHED CO-FACTORS Oral Contraceptive use Long-term use of oral contraceptives could increase the risk of cervical cancer by up to fourfold in women with HPV infection. An analysis of pooled data from ten case-control studies of patients with invasive cervical cancer or CIS showed that among current users of oral contraceptives the risk of invasive cervical cancer increased with increasing duration of use (relative risk for 5 or more years' use versus never use, 1.90 [95% CI 1.69-2.13]). Hormone-related mechanismsmay influence the progression from premalignant to malignantcervical lesions by promoting integration of HPV DNA into thehost genome, specifically estradiol Level II-2 Grade A International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical cancer and hormonal contraceptives: collaborative reanalysis of individual data for 16,573 women with cervical cancer and 35,509 women without cervical cancer from 24 epidemiological studies. Lancet 2007; 370:1609-1621 Society of Gynecologic Oncologists of The Philippines Clinical Practice Guidelines 2010

  21. ESTABLISHED CO-FACTORS Smoking The risk of squamous cell carcinoma increases in current smokers with the number of cigarettes smoked per day and with younger age at starting smoking. Current smokers had a significantly increased risk of squamous cell carcinoma of the cervix compared to never smokers (RR = 1.60 (95% CI: 1.48-1.73), p<0.001). Malignant transformation of HPV16-immortalized human endocervicalcells by cigarette smoke condensate has been proven . nicotine and tobacco-specific carcinogens have beendetected in the cervical mucus of smokers International Collaboration of Epidemiological Studies of CervicalCancer. Carcinoma of the cervix and tobacco smoking: collaborative re-analysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. International Journal of Cancer 2006; 118:1481-1495 Level II-2 Grade A Society of Gynecologic Oncologists of The Philippines Clinical Practice Guidelines 2010

  22. ESTABLISHED CO-FACTORS Early coitus Early age at first intercourse increases the risk for cervical cancer (age 14 and below) The relative risk for age at first intercourse < or =14 versus > or =25 years, conditioned on age, study, and lifetime number of sexual partners was 3.52 (95% CI, 3.04-4.08), which decreased to 2.05 (95% CI, 1.54-2.73) after additional conditioning on reproductive factors. International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical carcinoma and sexual behaviour: collaborative reanalysis of individual data on 15,461 women with cervical carcinoma and 29,164 women without cervical carcinoma from 21 epidemiological studies. Cancer Epidemiol Biomarkers Prev. 2009 Apr;18(4):1060-9. Level II-2 Grade A Society of Gynecologic Oncologists of The Philippines Clinical Practice Guidelines 2010

  23. Association of HPV Types with Cervical Cancer Worldwide HPV 16 53.5% 71% 17.2% HPV 18 6.7% HPV 45 HPV types in cervical cancer 80% 2.9% HPV 31 19.7% Others 0 10 20 30 40 50 60 Association of HPV types with cervical cancer, % Adapted from Muňoz N, et al. Int J Cancer 2004; 111:278–285.

  24. Lancet Oncol. 2010 Nov;11(11):1048-56. Epub 2010 Oct 15.

  25. HPV Genotypes in cases of invasive cervical cancer De Sanjose S, Quint WGV, Alemany L et al . HPV genotype attribution in invasive cervical cancer: a retrospective cross sectional study. RIS HPV TT STUDY GROUP. Lancet Oncol. 2010 Nov;11(11):1048-56. Epub 2010 Oct 15.

  26. HPV Genotypes in cases of invasive cervical cancer De Sanjose S, Quint WGV, Alemany L et al . HPV genotype attribution in invasive cervical cancer: a retrospective cross sectional study. RIS HPV TT STUDY GROUP. Lancet Oncol. 2010 Nov;11(11):1048-56. Epub 2010 Oct 15.

  27. As the cancer progresses, these signs and symptoms may appear: Early cervical cancer generally produces NO signs or symptoms. • Abnormal vaginal bleeding, usually postcoital • Vaginal discomfort, malodorous discharge, and dysuria • The triad of leg edema, pain, and hydronephrosis suggests pelvic wall involvement

  28. How do we diagnose cervical cancer ? • Pelvic exam- mass is PALPABLE • Punch biopsy is done

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