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Cervical cancer. Fuat Demirkıran, MD Istanbul University, Cerrahpaşa School Of Medicine, OB&GYN Department, Gyn Oncology. Incidence of Cervical Cancer (GloboCan/IARC 2000) – in per 100 000 women. Cervical cancer is a preventable cancer because it has a long preinvasive state.

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Cervical cancer

Cervical cancer

Fuat Demirkıran, MD

Istanbul University, Cerrahpaşa

School Of Medicine, OB&GYN

Department, Gyn Oncology


Cervical cancer

Incidence of Cervical Cancer (GloboCan/IARC 2000) – in per 100 000 women


Cervical cancer

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.


Cervical cancer

Risk factors for development of CC long preinvasive state.

sexuel intercourse at an early age

multiple sexuel partners

young age at first pregnancy

cigarette smoking

HSV infection

HPV infection


Cervical cancer

HPV and Cervical Cancer long preinvasive state.

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.


Cervical cancer

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


Cervical cancer

Transmision: and invazive lesiongenital skin to skin

contact

Cofactors

Hormonal

Influances

Parity

Other STIs

Smoking

Nutritions

Host genetics

Viral genetics

Transient

HPV infection

Persistent infection

with oncogenic

HPV types

LSIL/CIN I

HSIL/CIN II - III

Invasive cervical cancer

from Franco and Harper 2005, Trottier H ,Franco EL, Vaccine 2006


Cervical cancer

Briefly and invazive lesion

·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 IICIN III Cancer

·Squamous carcinoma of the cervix arises at the active SCJ from pre-existing dysplastic lesion.


Cervical cancer

Normal and invazive lesion

%

57

Regress

CIN I

%

43

Regress

%

31

CIN II

CIN III

%

30

%

35

%

56

CIN I

CIN II

CIN III

%

22

%

11

%

14

%0.3

Cancer

CIN II - III

Cancer

CIN III-Kanser

n: 4504 Ostor AG, 1993

Michell MF., 1996 Wright TC., 2002


Cervical cancer

H and invazive lesionHISTOLOGIC TYPES OF CC

1.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 adenocarcinoma

5.adenosquamous carcinom

6.glassy cell carcinoma


Cervical cancer

S and invazive lesionYMPTOMS

1.20% of patients are asymtomatic

.

. vaginal bleeding.......postcoital, irregular men, postmenopausal

3

. vaginal discharge

4

.. pain


Cervical cancer

Diagnosis and invazive lesion

Symptomatic biopsy

Asymptomatic abnormal cytology

Colposcopic examination

Biopsy


Cervical cancer

Vaginal Cytology and invazive lesion

a. Conventional Pap test

b. Liquid-based cytology


Cervical cancer

Colposcopy and invazive lesion


Cervical cancer

Biopsy techniques for and invazive lesioncervical

evaluation

Punch biyopsy

Leep excision

Conization


Cervical cancer

LEEP Excision and invazive lesion-Conization


Cervical cancer

Conization and invazive lesion

end-point diagnostic work-up for cervical pathology


Cervical cancer

PATTERNS OF SPREADING and invazive lesion

1.Direct invasion into the cervical stroma, vagina, uterine corpus and parametrium

2.Lymphatic metastases

3.Hematologic metastases

4.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.


Cervical cancer

2009 and invazive lesion


Cervical cancer

Pathologic and invazive lesionPrognostic Factors Related to Cervical Cancer

Pelvic lymphatic status

Tumor size

Deep of invasion

LVSI

Close surgical margin

Positive surgical margin


Cervical cancer

The Relationship of Pelvic Lymph Node Metastasis and 5-year Survival

Node negative Node positive

n Survival n 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%


Cervical cancer

The Main Prognostic Factors in Cervical Cancer Survival

n 5-year survival p

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

Kristensen et al, Gynecol Oncol 1999


Cervical cancer

The Influence of LVSI on Pelvic Lymph Node Metastasis and Survival in Early Stage Cervical Carcinoma

LVSI negative LVSI positive

n survival pel nod + n survival pel nod +

Crissman 1985 94 97% 8% 30 64% 17%

Delgado 1990 360 90% 8% 276 78% 25%

Roman 1998 32 - 0% 73 - 32%


Cervical cancer

Molacular Prognostic Factors of Cervical Cancer Survival in Early Stage Cervical Carcinoma

DNA cytometry

COX-2 expression

nm23 expression

Tymidine kinase

Beta-catanin

Id-1 protein

Matrix metaloproteinases

and others


Cervical cancer

Treatment of Cervical Cancer Survival in Early Stage Cervical Carcinoma


Cervical cancer

The principles of treatment for cervical cancer composed of..

Sites of spread

Primary tumor

Surgery

Radiotherapy


Cervical cancer

Surgery of..

Radiotherapy

Stage Ia-Ib1- II a

Stage Ib2-III-IV


Cervical cancer

The results of surgery and radiotherapy are almost equal of.. Treatment of cervical cancer depends on patients age, sexual status, fertilty statusIf the patient is young and sexualy active , surgery is the best choise


Cervical cancer

Surgical Treatment of.. Stage Ia1Conization is adequate for women who desire fertility if there is no lymphovascular space invasionorType I hysterectomy for women who not desire fertility


Cervical cancer

Surgical Treatment of.. Stage Ia2Type II or III hysterectomy with pelvic lymphadenectomyStage Ib1- Stage IIa- Type III hysterectomy with pelvic lymphadenectomy



Cervical cancer

Radical Hysterectomy of.. (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


Cervical cancer
After surgery if surgical margin is positive or lymph node is positive, postoperative RT is mandatory


Primer radio chemotherapy is the best choise
Primer radio-chemotherapy is the best choise is positive,

For stage Ib2 and > IIb diseases


Cervical cancer

Fertility is positive, sparing surgery for cervical cancer

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