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Cervical cancer
Fuat Demirkıran, MDIstanbul University, CerrahpaşaSchool Of Medicine, OB&GYNDepartment, Gyn Oncology
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Incidence of Cervical Cancer (GloboCan/IARC 2000) – in per 100 000
women
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Cervical cancer is a preventable cancer because it has a long preinvasive state. The incidence of CC is decreasing and it is being diagnosed earlier during last 50 years ..... due to cervical cytology screening programs
Mean age for cervical cancer is 50 years and it peaks at 35-40 years and 60-64 years.
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Risk factors for development of CC
sexuel intercourse at an early age
multiple sexuel partners
young age at first pregnancy
cigarette smoking
HSV infection
HPV infection
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HPV and Cervical Cancer
International collection of cervical tumor specimens
showed that HPV DNA is present in 99.7% of cases.
Relative risks for the association between HPV and cervical
cancer are in 50-150 range.
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The most important HPV types related to Cervical Preinvazive and invazive lesion
Schiffman, J Nat Cancer Inst, 85:958, 1993 and Liaw, J Nat Cancer Inst, 91:954, 1999
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Transmision: genital skin to skin contact
Transient HPV infection
Persistent infectionwith oncogenic
HPV types
LSIL/CIN I HSIL/CIN II - III
Invasive cervical cancer
Cofactors
HormonalInfluances
Parity
Other STIs
Smoking
Nutritions
Host genetics
Viral genetics
from Franco and Harper 2005, Trottier H ,Franco EL, Vaccine 2006
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HPV with the assistance of some cofactors can result in the development of CC. All of the invasive squamous CC develope at the end of progressive pathologic events. NNormal epithel CIN I CIN II CIN III Cancer
· Squamous carcinoma of the cervix arises at the active SCJ from pre-existing dysplastic lesion.
Briefly
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CIN I
%57
%11
%0.3
Normal
CIN II - IIICancer
n: 4504 Ostor AG, 1993
CIN II CIN III
%43
Regress
%22
CIN III-Kanser
%14
Cancer
%30%
35%56
CIN II CIN III
Michell MF., 1996 Wright TC., 2002
Regress
%31
CIN I
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HHISTOLOGIC TYPES OF CC1. squamous cell carcinoma ....most common type 2. adenocarcinoma (AC) ....in recent years, an increasing number of AC affecting young women ....AC are populated by musinous endocervical cells, endometroid cells, clear cells ....10%-15 of CC ....considered that AC is poorly prognostic tumor compared with squamous cell carcinoma 3. minimal deviation adenocarcinoma(adenoma malignum) .....extremely well-diferentiated form of AC 4. villoglandular papillary adenocarcinoma5. adenosquamous carcinom6. glassy cell carcinoma
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SYMPTOMS 1. 20% of patients are asymtomatic. . vaginal bleeding.......postcoital, irregular men, postmenopausal3 . vaginal discharge4.. pain
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Asymptomatic abnormal cytology
Symptomatic biopsy
Diagnosis
Colposcopic examination
Biopsy
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a. Conventional Pap test
b. Liquid-based cytology
Vaginal Cytology
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Colposcopy
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Punch biyopsy
Leep excision
Conization
Biopsy techniques for cervicalevaluation
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LEEP Excision - Conization
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Conizationend-point diagnostic work-up for cervical pathology
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PATTERNS OF SPREADING 1. Direct invasion into the cervical stroma, vagina, uterine corpus and parametrium2. Lymphatic metastases3. Hematologic metastases4. Intraperitoneal metastases
Predominanat spread patterns : direct extension and lymphatic dissemination
Malignant cells spread by way of paracervival
lymphatic cannels into the obturator, internal iliac, external iliac, common iliac and para-aortic lymph
nodes group.
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2009
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Pathologic Prognostic Factors Related to Cervical Cancer
Pelvic lymphatic status
Tumor size
Deep of invasion
LVSI
Close surgical margin
Positive surgical margin
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The Relationship of Pelvic Lymph Node Metastasis and 5-year Survival
Monoghan 1990 392 92% 102 50%
Delgado 1990 545 86% 100 83%
Kamura 1992 281 91% 64 63%
Lai 1999 610 87% 217 68%
n Survival n Survival
Node negative Node positive
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The Main Prognostic Factors in Cervical Cancer
Tumor size (cm)< 2 58 %94 <0.00001
2-3.9 48 %79>4 10 % 47
Depth of invasion(mm)<10 75 %94 <0.00001
11-15 27 %73 16-20 14 %57>20 9 %33
n 5-year survival p
Kristensen et al, Gynecol Oncol 1999
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The Influence of LVSI on Pelvic Lymph Node Metastasis and Survival in Early Stage Cervical Carcinoma
Crissman 1985 94 97% 8% 30 64% 17%
Delgado 1990 360 90% 8% 276 78% 25%
Roman 1998 32 - 0% 73 - 32%
n survival pel nod + n survival pel nod +
LVSI negative LVSI positive
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Molacular Prognostic Factors of Cervical Cancer
DNA cytometry
COX-2 expression
nm23 expression
Tymidine kinase
Beta-catanin
Id-1 protein
Matrix metaloproteinases
and others
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Treatment of Cervical Cancer
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The principles of treatment for cervical cancer composed of..
Sites of spread
Primary tumor
SurgeryRadiotherapy
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Surgery
Radiotherapy
Stage Ia-Ib1- II a
Stage Ib2-III-IV
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The results of surgery and radiotherapy are almost equal
Treatment of cervical cancer depends on patients age, sexual
status, fertilty status
If the patient is young and sexualy active , surgery is the
best choise
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Surgical TreatmentStage Ia1
Conization is adequate for women who desire fertility if there is no
lymphovascular space invasionor
Type I hysterectomy for women who not desire fertility
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Surgical TreatmentStage Ia2
Type II or III hysterectomy with pelvic lymphadenectomy
Stage Ib1- Stage IIa- Type III hysterectomy with pelvic
lymphadenectomy
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Radikal histerektomi and Lymphadenektomi
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Radical Hysterectomy(Type II-III)
for stage Ia2, Ib and IIa
immediate therapy
staging and tailoring of therapy
conservation of the ovaries
conservation of sexual function
The results of surgery and radiotherapy are almost equal
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After surgery if surgical margin
is positive or lymph node is
positive, postoperative RT is
mandatory
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Primer radio-chemotherapy is the
best choise
For stage Ib2 and > IIb diseases
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Results of Trachelectomy n:130
Ia1 17
Ia2 36
Ib1 74
IIa 3
Squamous 93
Adeno ca 37
< 2 cm 110
> 2 cm 10
Intraop complication %9
Postop “ %10
Positive node %2.4
Mean follow-up 27 ay
Tumor reccurrence %3.1
Pregnancy 54
Dargent 2000, Plante 1999, Covens 1999, Shepherd 1998
Fertility sparing surgery for cervical cancer