Cervical Lesions

Cervical LesionsMaria Julieta V. Germar, FPOGS, FSGOP Section of Gynecologic OncologyUP College of Medicine-Philippine General HospitalThe Medical City

Ateneo School of Medicine and Public Health 16 November 2011

Normal Cervix Cervical Cancer

How do we diagnose cervical cancer ?

Squamous Cell CarcinomaHPV 16, 18

Cervical AdenocarcinomaHPV 16,18, 45

How is it staged ?

IIIB

CLINICAL STAGING

Bimanual examination of the pelvis, which includes palpation of the uterus and ovaries.

Rectovaginal Exam- to assess the parametria

parametriaparametria

Rectovaginal Exam- to assess the parametria

October 2009 Update:New Cervical Cancer Staging

1988 FIGO 1988 FIGO STAGING OF STAGING OF

CERVICAL CANCER CERVICAL CANCER STAGSTAG

E 0E 0 Carcinoma in situCarcinoma in situ

cervical intraepithelial neoplasia cervical intraepithelial neoplasia grade IIIgrade III

STAGSTAGE IE I

The carcinoma is strictly The carcinoma is strictly confined to the cervixconfined to the cervix

IAIA invasive carcinoma that can be invasive carcinoma that can be diagnosed only microscopically, with diagnosed only microscopically, with deepest invasion of <5mm and largest deepest invasion of <5mm and largest extension of >7mmextension of >7mm

IA1IA1 Measured stromal invasion of Measured stromal invasion of <3mm in depth and extension of <7mm<3mm in depth and extension of <7mm

1A21A2 Measured stromal invasion of Measured stromal invasion of <3mm and not >5mm with an <3mm and not >5mm with an extension of >7mmn depth and extension of >7mmn depth and extension of <7mmextension of <7mm



E 0E 0 deleteddeleted

STAGSTAGE IE I

The carcinoma is strictly The carcinoma is strictly confined to the cervixconfined to the cervix

IAIA invasive carcinoma that can be invasive carcinoma that can be diagnosed only microscopically, with diagnosed only microscopically, with deepest invasion of <5mm and largest deepest invasion of <5mm and largest extension of >7mmextension of >7mm

IA1IA1 Measured stromal invasion of Measured stromal invasion of <3mm in depth and extension of <7mm<3mm in depth and extension of <7mm

1A21A2 Measured stromal invasion of Measured stromal invasion of <3mm and not >5mm with an <3mm and not >5mm with an extension of >7mmn depth and extension of >7mmn depth and extension of <7mmextension of <7mm

STAGING Revised October 2009



E IBE IB Clinically visible lesions limited to Clinically visible lesions limited to

the cervix uteri or subclinical cancers the cervix uteri or subclinical cancers greater than stage IAgreater than stage IA

IB1IB1 clinically visible lesions not large clinically visible lesions not large than 4 cmthan 4 cm

IB2IB2 clinically visible lesions larger clinically visible lesions larger than 4 cmthan 4 cm



E IBE IB Clinically visible lesions limited to Clinically visible lesions limited to

the cervix uteri or subclinical cancers the cervix uteri or subclinical cancers greater than stage IAgreater than stage IA

IB1IB1 clinically visible lesions not large clinically visible lesions not large than 4 cmthan 4 cm

IB2IB2 clinically visible lesions larger clinically visible lesions larger than 4 cmthan 4 cm


1988 FIGO 1988 FIGO STAGING STAGING

STAGSTAGE IIE II

The carcinoma extends beyond The carcinoma extends beyond the cervix but has not extended to the the cervix but has not extended to the pelvic wall. The carcinoma involves the pelvic wall. The carcinoma involves the vagina but not as far as the lower thirdvagina but not as far as the lower third

IIAIIA no obvious parametria no obvious parametria involvementinvolvement

IIBIIB with obvious parametria with obvious parametria involvementinvolvement

2009 FIGO 2009 FIGO STAGING STAGING

STAGSTAGE IIE II

The carcinoma extends beyong The carcinoma extends beyong the uterus but has not extended to the the uterus but has not extended to the pelvic wall or to the lower third of the pelvic wall or to the lower third of the vaginavagina

IIAIIA Without parametrial invasionWithout parametrial invasion

IIA1IIA1 clinically visible lesion less than clinically visible lesion less than or equal to 4cm in greatest dimensionor equal to 4cm in greatest dimension

IIA2IIA2 Clinically visible lesion >4 cm in Clinically visible lesion >4 cm in greatest dimensiongreatest dimension

IIBIIB With obvious parametrial With obvious parametrial involvementinvolvement


1995 FIGO STAGING FOR CERVICAL CANCERSTAGE IIA The carcinoma extends beyond the uterus but has The carcinoma extends beyond the uterus but has not extended to the pelvic wall or to the lower third of the vagina with not extended to the pelvic wall or to the lower third of the vagina with NO parametrial involvementNO parametrial involvement

1995 FIGO STAGING FOR CERVICAL CANCERSTAGE IIB The carcinoma extends beyond the uterus but has not The carcinoma extends beyond the uterus but has not extended to the pelvic wall or to the lower third of the vagina With extended to the pelvic wall or to the lower third of the vagina With obvious parametrial involvementobvious parametrial involvement



E IIIE III The carcinoma extends beyond The carcinoma extends beyond

the cervix but has not extended to the the cervix but has not extended to the pelvic wall. The carcinoma involves the pelvic wall. The carcinoma involves the vagina but not as far as the lower third. vagina but not as far as the lower third. The carcinoma has extended to the The carcinoma has extended to the pelvic wall. On rectal examination, pelvic wall. On rectal examination, there is no cancer free space between there is no cancer free space between the tumor and the pelvic wall. The the tumor and the pelvic wall. The tumor involves the lower third of the tumor involves the lower third of the vagina. All cases of hydronephrosis or vagina. All cases of hydronephrosis or nonfunctioning kidney are included, nonfunctioning kidney are included, unless they are known to be due to unless they are known to be due to other causesother causes

IIIAIIIA no extension to the pelvic wallno extension to the pelvic wall

IIIBIIIB extension to the pelvic wall extension to the pelvic wall and/or hydronephrosis or non and/or hydronephrosis or non functioning kidneysfunctioning kidneys

2009FIGO 2009FIGO STAGING OF STAGING OF


E IIIE III The carcinoma extends beyond The carcinoma extends beyond

the cervix but has not extended to the the cervix but has not extended to the pelvic wall. The carcinoma involves the pelvic wall. The carcinoma involves the vagina but not as far as the lower third. vagina but not as far as the lower third. The carcinoma has extended to the The carcinoma has extended to the pelvic wall. On rectal examination, pelvic wall. On rectal examination, there is no cancer free space between there is no cancer free space between the tumor and the pelvic wall. The the tumor and the pelvic wall. The tumor involves the lower third of the tumor involves the lower third of the vagina. All cases of hydronephrosis or vagina. All cases of hydronephrosis or nonfunctioning kidney are included, nonfunctioning kidney are included, unless they are known to be due to unless they are known to be due to other causesother causes

IIIAIIIA no extension to the pelvic wallno extension to the pelvic wall

IIIBIIIB extension to the pelvic wall extension to the pelvic wall and/or hydronephrosis or non and/or hydronephrosis or non functioning kidneysfunctioning kidneys


1995 FIGO STAGING FOR CERVICAL CANCERStage III The cancer extends to the pelvic wall. The tumor involves the lower third of the vagina. All cases of hydronephrosis or non-functioning kidneys are included.

IIIA Without extension to the pelvic wall

IIIB With extension to the pelvic wall and/or hydronephrosis or non-functioning kidney.


CERVICAL CANCERCERVICAL CANCERSTAGSTAG

E IVE IV The carcinoma has extended The carcinoma has extended

beyond the true pelvis or has clinically beyond the true pelvis or has clinically involved the mucosa of the bladder or involved the mucosa of the bladder or rectum. A bullous edema as such does rectum. A bullous edema as such does not permit a case allotted to be stage not permit a case allotted to be stage IVIV

IVAIVA spread of growth to the adjacent spread of growth to the adjacent organsorgans

IVBIVB spread to distant organsspread to distant organs



E IVE IV The carcinoma has extended The carcinoma has extended

beyond the true pelvis or has clinically beyond the true pelvis or has clinically involved the mucosa of the bladder or involved the mucosa of the bladder or rectum. A bullous edema as such does rectum. A bullous edema as such does not permit a case allotted to be stage not permit a case allotted to be stage IVIV

IVAIVA spread of growth to the adjacent spread of growth to the adjacent organsorgans

IVBIVB spread to distant organsspread to distant organs


1995 FIGO STAGING FOR CERVICAL CANCERStage IV The cancer extends beyond the true pelvis or involves the mucosa of the bladder or the rectum.

IVA Spread to adjacent organs

IVB Spread to distant organs

Cervical cancer

n = 532

VIV

I

IIIII

14%

38%41%

2%5%

Section of Gynecologic Oncology Annual Report 2008. UP-PGH Department of Obstetrics and Gynecology Staff Conference. 2009 (unpublished)

Majority of Filipina women we see ( 40-60 %) are in stage III disease

IIIB

SURGERYCHEMOTHERAPY

AND RADIOTHERAPY

Early Stage (Stage I-IIA)-SURGERYRADICAL HYSTERECTOMY

Late stage II-IV3-4 months txCHEMOTHERAPYevery week for 6 cycles

RADIATION THERAPYLinear accelerator25-28 days

Brachytherapy 4 sessions

Cervical cancer

n = 270

Lost to follow-up

Section of Gynecologic Oncology Annual Report 2008. UP-PGH Department of Obstetrics and Gynecology Staff Conference. 2009 (unpublished)

Cancer of the CervixCancer of the CervixSUMMARYSUMMARY

Total Cost of Primary TreatmentTotal Cost of Primary Treatment

COST IN COST IN PESOSPESOS

COST IN USDCOST IN USD

Diagnosis and Diagnosis and Pre-treatment Pre-treatment EvaluationEvaluation

30,865 -91,130 700-2100700-2100

SurgerySurgery 98,560 - 376,635

2200-87002200-8700

ChemoradiationChemoradiation 111,201-398,236 2600-92002600-9200

Germar, JV, Manalo, A. The Cost of Being Sick with Gynecologic Cancer in the Philippines. Germar, JV, Manalo, A. The Cost of Being Sick with Gynecologic Cancer in the Philippines. SGOP Annual Convention 2007. (unpublished) REVISED 2011SGOP Annual Convention 2007. (unpublished) REVISED 2011

Minimum Wage : Php 404.00/day (USD 9.31)= USD 214 per monthMinimum Wage : Php 404.00/day (USD 9.31)= USD 214 per month

CERVICAL CANCER IS PREVENTABLE

Prevention of Cervical Cancer:

Primary Prevention: Monogamous sexual relationship between husband and wife

Delay in onset of sexual intercourse Use of barrier contraceptives Prompt and adequate treatment of STDs Prompt and adequate treatment of Pre-invasive disease (CIN)

HPV vaccination

Prevention of Cervical Cancer Secondary Prevention:

Cytologic Screening/Pap smear

The Pap Smear Begin at age 21 or at the onset of sexual

activity, if earlier, and continue every year

National Cancer Institute. Screening for cervical cancer. 2008.

The risk of developing Cervical Cancer is 5 times higher in women who are not regularly screened.1

The Pap Smear Begin at age 21 and continue every two years

National Cancer Institute. Screening for cervical cancer. 2008.


New 2010 New 2010 recommendationsrecommendations

Cervical Lesions

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