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Cervical cancer. Introduction. Cancer of the cervix is the most common female genital cancer in developing countries every year about 500,000 women , acquire the disease and 75% are from frame developing countries.

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introduction
Introduction
  • Cancer of the cervix is the most common female genital cancer in developing countries every year about 500,000 women , acquire the disease and 75% are from frame developing countries.
  • About 300,000 women also die from the disease annually and of these 75% are from developing countries
slide4

Finland which has an advanced population based screening program has one of the lowest rates in the world.

incidence
Incidence
  • 4-6 % of female genital cancers.
slide6
Age
  • 40-50 years old
risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology

Risk factors and aetiology
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
  • Coitus at young age: <16 years old increased risk by 50%
  • Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
  • Smoking

Smoking for> 12 years increase the risk by 12.7 folds.

  • Male related risk factors:

number of the partners previous sexual relationships is relevant .

cervical cancer risk increased if partners has penile cancer (circumcision)

Previous wife with cervical cancer.

  • Previous CIN
  • Poor uptake of screening program.
  • Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
  • Barrier method decrease the risk (condan)
  • Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
  • HPV (Human papilloma virus ) infection mainly 16,18

the main aetiological is infection with subtypes of HPV (16,18)

  • Low socioecomic class of
type of patient
Type of patient:
  • Multiparous.
  • Low socioeconomic class.
  • Poor hygiene.
  • Prostitutes.
  • Low incidence in Muslims and Jews.
predisposing factors
Predisposing factors:
  • Cervical dysplasia.
  • (Cervical intraepithelial neoplasia)
  • CIN III / CARCINOMA IN SITU
  • THE LESION PROCEEDS THE INVASION BY 10-12 YEARS
pathology type
Pathology type
  • Squamous cell carcinoma- 90%.
  • Adenocarcinoma- 10%.
types of growth
Types of growth
  • Exophytic: is like cauliflower filling up the vaginal vualt.
  • Endophytic: it appears as hard mass with a good deal of induration.
  • Ulcerative: an ulcer in the cervix.
diagnosis
DIAGNOSIS

1- History.

  • Many women are a symptomatic .
  • Presented with abnormal routine cx smear
  • Complain of abnormal vaginal bleeding
  • I M bleeding
  • post coital bleeding
  • perimenopausal bleeding
  • postmenopausal bleeding
  • blood stain vaginal discharge
slide21

2- Examination:

  • Mainly vaginal examination using cuscu’s speculem nothing is found in early stage .
  • Mass ,ulcerating fungating in the cervix
  • P/V P/R is very helful.
slide22

Cytology

Histology

calposcopy

preoperative evaluation
Preoperative evaluation
  • Review her history.
  • General examination:
  • Anaemia.
  • Lymphadenopathy-Supraclavicular LN.
  • Renal area.
  • Liver or any palpable mass.
  • Oedema.
  • Laboratory tests:
  • CBC, LFT, RFT, Urine analysis.
  • Tumour markers.
  • Chest X- ray, abdominal X- ray, IVU.
  • CAT, MRI, if necessary.
  • Ultrasound.
  • Lymphography, if necessary.
staging
Staging

Best to follow FIGO system.

  • Examination under anaesthesia.
  • Bimanual palpation.
  • P/V, P/R.
  • Cervical biopsy, uterine biopsy.
  • Cystoscopy, Proctoscopy, if necessary.
stages of cancer cervix
STAGES OF CANCER CERVIX
  • Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging.
  • TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.
differential diagnosis
DIFFERENTIAL DIAGNOSIS
  • Cervical ectropion.
  • Cervical tuberculosis.
  • Cervical syphilis, Schistosomiasis, and Choriocarcinoma are rare causes.
treatment
TREATMENT
  • Surgical.
  • Radiotherapy.
  • Radiotherapy & Surgery.
  • Radiotherapy and Chemotherapy followed by Surgery.
  • Palliative treatment.
the choice of treatment will depend on
The choice of treatment will depend on
  • Fitness of the patients
  • Age of the patients
  • Stage of disease.
  • Type of lesion
  • Experience and the resources avalible.
surgical procedure
Surgical procedure
  • The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient
werthemeim s hystrectomy
Werthemeim’s hystrectomy
  • Total abdominal hystrectomy including the parametrium.
  • Pelvic lymphadenectomy
  • 3 cm vaginal cuff
  • The original operation conserved the ovaries ,since squamouss cell carcinoma does not spread dirctly to the ovaries.
  • Oophorectomy should be performed in cases of adenocarcinoma as there is 5-10% of ovarian metastosis
surgery offers several advantage
Surgery offers several advantage
  • It allows presentation of the ovaries (radiotherapy will destroythem).
  • There is better chance of preserving sexual function.
  • (vaginal stonosis occur in up 85% of irradiates.
  • Psychological feeling of removing the disease from the body .
  • More accute staging and prognsis
complications of surgery
COMPLICATIONS OF SURGERY
  • Haemorrhage: primary or secondary.
  • Injury to the bladder, uerters.
  • Bladder dysfunction.
  • Fistula.
  • Lymphocele.
  • Shortening of the vagina.
slide42

INDICATIONS OF P/O XRT FOLLOWING WERTHEIM’S HYSTERECTOMY (STAGE I , IIa):

  • Positive pelvic lymph nodes.
  • Tumour close to resection margins and/or parametrial extension.
radiotherapy
Radiotherapy
  • Stage IIb and III
  • Radical Radiotherapy
  • External irradiation (Teletherapy).
  • Intracavitary radiation (Brachytherapy).
  • In some cases of stage IIa or b radio and chemotherapy to be given then followed by simple hysterectomy -------
palliative therapy
Palliative therapy
  • For stage IV – individualized therapy.
  • Some suitable for palliative XRT ( usually intracavitary Caesium).
  • Some suitable for extensive surgery.
  • Some suitable for chemotherapy.
  • Good nursing care.
  • Analgesia-must be used in sufficient amount to ----- pain (Codein sulfate, Pethidine, Morphine, Diamorphine).
  • Antiemetic if necessary.
  • IV drip, entral, and parentral feeding.
  • Urinary Catheterization.
  • Other measures for symptom relief.
prognosis
PROGNOSIS

Depends on:

  • Age of the patient.
  • Fitness of the patient.
  • Stage of the disease.
  • Type of the tumour.
  • Adequacy of treatment.
slide46

THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY:

  • Stage I -------80%
  • Stage II-------50-60%
  • Stage III-------30-40%
  • Stage IV-------4%
management of recurrent disease
MANAGEMENT OF RECURRENT DISEASE
  • 1. Local recurrence:

Radiation – if not used.

Pelvic exenturation.

  • 2. Distant disease

Chemotherapy.

follow up policy
Follow up policy
  • On completion of treatment all patients are given a vaginal dilator to use until vaginal mucosa healed, this prevents vaginal stenosis.
  • Premenopausal patients commenced on HRT:
  • post hysterectomy-Extraderm skin patches 50 meg twice weekly.
  • No hysterectomy- Cycloprogyn 1mg daily.
  • The patient to be seen 1/12 post-treatment.
  • 3 monthly for 2 years.
  • 4 monthly for 3rd year.
  • 6 monthly until 5years.
  • Then yearly all her life.
  • Patients with stage I and II disease treated with radical radiotherapy will be assessed by EUA approximately 3 months after completing treatment.
objective
Objective
  • Cancer of the cervix is still quite common, reduction in incidence depends on the quality of the screening program.
slide50

The aetiology appears to be multifactorial the prime oncogenic agent is probably [HPV-16,18].

  • Clinical presentation is with inermenstrul,postcoital, postmenospausal bleeding or following abnormal cytology.
  • Tumour spreads locally to involve the uterus bladder , vagina, parametrium, ureters, rectum and bone.
slide51

Spread also to the internal and external iliac , obdurater and common iliac nodes then to para- aortic nodes.

  • Blood borne metastasis spread to liver, lung and bone occur .
  • Microinvasion squamous tumour carry a good prognosis allowing conservative treatment initially if required.
slide52

Early invasive squamous cell disease (stage Ib,IIa and in some cases of IIb) may be treated by either a wertheimes hysterectomy or radiotherapy as first line treatment.

  • Advanced stage (IIb, III,IV) treated by radio or chemotherapy.
slide53

Glandular tumours (adenocarcinomas) are not detectable by screening are associated with skip lesions and require radical surgery.