Carcinoma of the CervixJacqui Morgan

March 4, 2020

Case 1⚫25yo, G2P1

⚫Here for WWE, no problems, healthy, needs refill on OCPs.

⚫Pap- Abnormal Glandular Cells-NOS

⚫Now What??

Case 1⚫Colposcopy

⚫What findings?

Case 1⚫ECC

⚫Cervical Biopsy

⚫HPV testing if not already done

Case 1⚫Bx and ECC- negative for abnormal glandular

pathology

⚫Now What?

Case 1⚫Review cytology

⚫If AGC- NOS

⚫Cotest in 12 and 24 months

⚫If AGC favour neoplasia or AIS

⚫Conisation

⚫Endometrial sampling, Pelvic U/S

Case 2⚫37yo, G3P2

⚫Here for WWE, Fluffy, “Pre-diabetic”

⚫Regular periods, every 4 months

⚫Pap- Abnormal Glandular Cells

⚫Now What??

Case 2⚫ECC

⚫Cervical Biopsy

⚫EMBx

⚫HPV testing

Case 2⚫ECC- Adenocarcinoma in situ

⚫Cervix biopsy CIN I-II

⚫EMBx- Proliferative endometrium

Case 2⚫Diagnostic Excisional Procedure

⚫“Why can’t I just have a partial hysterectomy”

Case 2⚫Cannot diagnose ACIS from ECC alone

⚫“Skip lesions”

⚫Margins

ACIS⚫1/3 of patients with ACIS on cytology, will have an

invasive carcinoma found on excisional procedure.

Case 2⚫Hysterectomy- Residual ACIS

⚫6-25% of hysterectomy specimens performed for ACIS with negative margins will have residual ACIS

Case 3⚫29 yo seen in outside ER for fatigue, back pain.

⚫Hb 6.2

⚫Cr 7.0

⚫Non contrast CT- Poor image quality due to habitus and lack of contrast. Uterine mass, possible fibroid, recommend pelvic U/S. Bilateral hydronephrosis.

⚫Transferred to local facility with ICU.

Case 3⚫Transfused 3 U PRBC

⚫Dialysis catheter inserted

⚫Started on dialysis.

⚫Renal sono- hydonephrosis/hydroureters bilaterally

⚫Seen by medicine, nephrology, surgery

⚫Urology consulted for ureteric stent placement, they recommended ……

Case 3⚫Gyn consult, Day 4 in ICU

Case 3⚫History

⚫Postcoital bleeding for 3 months

⚫Heavy bleeding last 2 weeks to point that boss threatened to fire her for amount of time spent in bathroom/off work

⚫Last pelvic/pap, cant remember

Case 3⚫Exam

⚫9cm friable mass replacing entire cervix. Extending to both sidewalls.

Case 3⚫Biopsy⚫Poorly differentiated SCC

⚫Ureteric stents placed

⚫Stage?

⚫Treatment?

Case 3⚫What stage?

⚫What treatment?

Case 3⚫What can be done if Urology were unable to insert

stents?

Case 3⚫Related pt- What happens when you live in a tent by the river

with bilateral nephrostomy tubes?

Case 4⚫30yo G4P2

⚫Pap HGSIL

⚫Colpo & Biopsy CIN II-III

Case 4⚫LEEP- CIN III and Invasive adenocarcinoma 2.5mm

depth, 3mm lateral spread

⚫Stage?

⚫Treatment?

Case 5⚫47yo G 3 P3 referred from Family Physician

⚫HGSIL Pap

⚫Colposcopy- Acetowhite changes and mosaicism

⚫Biopsy CIN III

⚫What next?

Case 5⚫Exam- 1x1cm lesion on anterior cervix

⚫Plan?

Case 5⚫Excisional procedure

⚫Pathology- Squamous cell carcinoma. Depth of invasion 1.5mm. Lesion 5mm width. Margins negative for invasive disease. CIN III extending to ecto-cervical margin.

⚫Stage?

⚫Treatment plan?

Cervical Cancer⚫Approx 14,000 cases annually in US

⚫4,500 deaths

⚫Mean age 51

⚫Internationally much higher incidence.

⚫Second most common cancer and leading cause of cancer death in women in developing world

Presentation⚫Asymptomatic, pap only abnormality

⚫Abnormal bleeding

⚫Postcoital bleeding

⚫Vaginal discharge

⚫Pelvic pain

⚫Renal failure

Cervical Cancer⚫Squamous

⚫Adenocarcinoma

⚫Adenosquamous

⚫Melanoma

⚫Clear cell

⚫Small cell

⚫Sarcoma

⚫Lymphoma etc…

Staging⚫Clinical, not surgical.

⚫Why?

Clinical staging⚫Most disease is not treated surgically

⚫Limitations on imaging/testing to be applicable to areas with higher disease burden.

Tissue Diagnosis⚫Biopsy required⚫Cytology not sufficient from Pap

⚫Tischler biopsy⚫LEEP⚫Glove

⚫Monsel’s⚫Pressure⚫Cautery⚫Packing if needed

Imaging⚫PET/CT or CT alone

⚫Used as substitute for cystoscopy, barium enema and IVP

FIGO 2009⚫ Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would ⚫ be disregarded)⚫ IA Invasive carcinoma which can be diagnosed only by microscopy, with deepest⚫ invasion <5 mm and the largest extension >7 mm⚫ IA1 Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mm⚫ IA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of ⚫ not >7.0 mm⚫ IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers ⚫ greater than stage IA⚫ IB1 Clinically visible lesion <4.0 cm in greatest dimension⚫ IB2 Clinically visible lesion >4.0 cm in greatest dimension

⚫ Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower⚫ third of the vagina⚫ IIA Without parametrial invasion⚫ IIA1 Clinically visible lesion <4.0 cm in greatest dimension⚫ IIA2 Clinically visible lesion >4.0 cm in greatest dimension⚫ IIB With obvious parametrial invasion

FIGO 2009⚫Stage III The tumour extends to the pelvic wall and/or

involves lower third of the vagina and/orcauses hydronephrosis or non-functioning kidney

IIIA Tumour involves lower third of the vagina, with no extension to the pelvic wallIIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney

Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the

mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to

be allotted to Stage IVIVA Spread of the growth to adjacent organsIVB Spread to distant organs

Early Stage Disease⚫Surgical Mx over Primary chemoradiation if a

suitable surgical candiate

⚫Lymph node dissection if above

stage IA1

⚫Ovaries

⚫Squamous vs adenocarcinoma

Stage IA1⚫<3mm depth, 7mm width.

⚫Negative margins on excisional specimen

⚫Cervical conisation if fertility desired

⚫Extrafascial hysterectomy

Stage IA 2⚫3-5mm depth, 7mm width

⚫No visible lesion

⚫Modified Radical hysterectomy and pelvic lymph node assessment

⚫If fertility desired- Radical trachelectomy and LNs

Stage IB1⚫Confined to cervix, 4cm or less tumor

⚫Radical hysterectomy and pelvic LNs

⚫Equivalent survival with chemoradiation, but different long term toxicities.

Radical Hysterectomy⚫Incorporation of parametrial tissues, cardinal

ligaments, uterosacral ligaments and upper vagina

⚫Initially assess lymph nodes, any suspicious nodes assessed intraoperatively.

⚫If nodal disease, abort procedure.

⚫Assess parametrial tissue for disease

⚫What spaces are developed?

Radical Hysterectomy⚫3 separate studies have identified decreased PFS with

robotic approach in cervical cancer

⚫Uterine cancer showed no such difference in surgical approach

⚫Open approach standard of care

Paravescial space⚫Obliterated umbilical artery

⚫Obturator internus

⚫Cardinal ligament

⚫Pubic symphysis

Pararectal space⚫Rectum

⚫Hypogastric artery

⚫Cardinal ligament

⚫Sacrum

Radical Hysterectomy

Radical Hysterectomy

Stage IB2 and aboveOr Not a surgical candidate⚫Pelvic radiation

⚫Concurrent cisplatin chemotherapy

⚫+/- paraaortic radiation

⚫Radiation will rapidly control bleeding

⚫ Initial fractions given at higher dose, then more detailed planning can be performed.

Pelvic Radiation⚫5-6 weeks external beam treatments

⚫28-30 Fractions

⚫3-5 internal brachytherapy treatments

Radiation toxicity⚫GI- diarrhea, urgency, nausea, colitis, fistula

⚫GU- Frequency, pain, dysuria, fistula

⚫Sexual function- Ovarian ablation, atrophy, vaginal stenosis

⚫General- fatigue

⚫Bone- sacral insufficiency fractures

⚫Heam- bone marrow suppression

⚫Lymph- lymphedema

⚫Secondary malignancies

Concurrent Cisplatin Chemotherapy⚫IV weekly treatment during radiation

⚫Toxicity

⚫Renal impairment

⚫Substitute carboplatin if elevated Cr.

⚫Nausea

⚫Myelosuppresion

⚫Neurotoxicity

⚫Hypokalemia, Hypomagnesemia

Distant metastatic Disease⚫Systemic chemotherapy

⚫Carboplatin/Paclitaxel/Bevacizumab

⚫PD1, Keytruda

⚫Palliative radiation

⚫Potential benefit of treating pelvic disease with radiation

⚫Palliative only care

Cervical cancer⚫Most advanced disease presents in unscreened or

inadequately screened population

⚫No matter how frequent pap screening is performed, some rapid developing disease will arise between tests.