Menagement Dile in cervical cancer

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Management

Dilemmas in Cervical

Cancer

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

• 500,000 new cases identified each year
• 80% of the new cases occur in

developing countries

• At least 200,000 women die of cervical

cancer each year

• Cervical cancer is the third most

common cancer worldwide

• YET - Cervical cancer is a preventable

disease

Magnitude of the Problem: -

Please see notes
page.

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

Incidence and Death in relation to

Incidence and Death in relation to

detection of CIS

detection of CIS

*Please see notes
page..

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

• Symptoms: -

– Asymptomatic in early cases/ preclinical

stage

– Haemorrhage- Metrorrhagia / Post coital.

• Bleeding is usually severe in cauliflower like

exophytic growths.

– Discharge- watery, offensive, blood

stained

– Cachexia and Pain-In advanced cases.

Clinical Features: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

• Signs: -

– An obvious growth may or may not be

present

– When an obvious growth is present, it may

be exophytic cauliflower like or endophytic,

ulcerative and scirrhous

– Cervix is usually indurated and hard to

feel, friable, easily bleeds on touch and its

mobility may be restricted or lost.

– In cases of endocervical growths, the Cx is

expanded, firm and feels barrel shaped.

Clinical Features: -

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

• PAP smear examination
• Colposcopy
• Biopsy: -

– Excisional biopsy is preferable to punch

biopsy

– Employing Schiller’s test / Acetic acid test

helps in selecting the biopsy site where

the growth is not obvious.

– Cone biopsy in early cases

• Endocervical curettage

Diagnosis: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

• Squamous Cell (>90%)
• Adenocarcinoma (5%)
• Clear Cell
• Mesonephric

Histopathology

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

• 0:Carcinoma-in-situ
• Ia:Microinvasive (Ia1, Ia2)
• Ib:Invasive (>5mm FIGO, >3mm SGO)
• IIa:Upper 2/3 of vagina
• IIb:Parametrial involvement (not to PSW)
• IIIa:Lower 1/3 of vagina
• IIIb:PSW or hydronephrosis/nonfunctional

kidney

• IVa:Bladder or rectal mucosa
• IVb:Distant metastases

Staging: -Always Clinical

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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• Complete physical Exam, Pelvic Exam ,

Rectal Exam.

– if needed, examination under anaesthesia,

should be done.

• Ultrasonography
• Chest X ray
• IVP
• Cystoscopy
• Proctosigmoidoscopy

Staging: -Techniques

Cervical Cancer

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

SURGERY

RADIOTHERAPY

THE TREATMENT DILEMMA

THE TREATMENT DILEMMA

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Treatment of Cervical

Cancer

• Stage I A-I. (<1mm).

– Conization
– Simple Hysterectomy -- vaginal / abdominal
– Type I Hysterectomy (Extra fascial)

• Stage I A-II. (1 – 3mm, Lymph node -

1%).

– Type II Hysterectomy (Modified radical

Hysterectomy-Removal of medial half of
uterosacral and cardinal ligaments and
smaller margin of vagina)

Options: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Treatment of Cervical

Cancer

• Stage I B & II A.

– Type III Hysterectomy (Radical

hysterectomy with removal of most of utero
sacral and cardinal ligaments, upper 1/3 rd
of vagina, pelvic lymphadenectomy)
followed by

– Post operative irradiation

• Bulky Lesions & stage II B

– Full irradiation followed 3 - 4 weeks later by
– Type II Hysterectomy

Options: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Treatment of Cervical

Cancer

• Recurrent disease: -as per previous

treatment

– RT  Exenteration
– Surgery  RT

• Stage III & IV: - Radiation / ??Exenteration
• Radiation, as primary treatment is an

option in all stages.

• Chemotherapy - as adjunct to RT or for

palliation

Options: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Radical Hysterectomy

• Removes corpus, cervix, parametria,

upper third of vagina

• Uterine arteries divided at origin
• Ureters dissected through tunnel
• Uterosacral ligaments divided near

rectum

• Typically combined with LND
• Oophorectomy not mandatory

Key Points: -

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Radical Hysterectomy

• Abdominal exploration
• Assessment of operability
• Ligation and section of ovario pelvic fold

and round ligament

• Dissection of pelvic lymphnodes
• Dissection of ureter
• Separation of bladder
• Ligation of uterine vessels

Technique: -

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Radical Hysterectomy

• Dissection of ureter from cardinal ligament
• Cleaning of paravescial and pararectal

fossa

• Opening of rectovaginal septum
• Clamping and transection of uterosacral

and cardinal ligament

• Transection of vagina
• Hemostasis and drainage
• Reperitonisation

Technique: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Radical Hysterectomy

• Acute:  Hemorrhage, Trauma, Sepsis,

Thrombophlebitis, Pulmonary Embolism,
Small Bowel obstruction, Febrile
Morbidity, UVF - 1-2%, V V F - < 1%,

• Primary mortality- 1%
• Sub Acute: 

Neurogenic bladder

dysfunction

• ChronicLymphocyst, Ureteral stricture

Complications: -

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Radical Hysterectomy

• More thorough assessment of the spread

and type of lesion

• ? Preservation of ovaries if desired
• Retention of more functional vagina
• Less morbidity and less recurrence
• Special conditions like

– Large Adnexal masses
– Fibromyoma
– Radioresistatnt growth
– Unsuitable for intracavitary irradiation
– Central recurrence after radiotherapy

Advantages: -

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Schauta Operation

• Adopted as Mitra’s Operation In India as an

alternative to Wertheim’s Hysterectomy.

• Its an extended Vaginal Hysterectomy.
• Comprises of removal of entire Uterus and

Adenexae with most of the vagina and medial
portion of parametria, by vaginal route

• Though primary mortality is low (<1%)

lymph nodes cannot be removed. So it should
be followed by

– Post operative radiation or
– Taussig’s extra peritoneal Lymphadenectomy

An Alternative surgery: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Radiation

Acute: -

• Perforation
• Fever
• Diarrhea
• Bladder spasm

Chronic: -

• Proctitis
• Cystitis-UTI
• Fistula
• Enteritis
• Femoral head

necrosis

• Ureteric stenosis
• Rectal stricture

Complications: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Special Category

• Invasive Cancer discovered on Cone

Biopsy

• Cervical Stump Carcinoma
• Invasive Carcinoma found after

simple hysterectomy

• Cervical Cancer in Pregnancy
• Large Barrel shaped lesion

Difficult to deal: -

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Follow Up

• At 2-3 Months interval ---- 2year
• At 3-4 Months interval ---- Next 2- 4

year

• At 6 Monthly interval ----- Rest of the

life

• ?Tumour markers

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Cervical Cancer

0

20

40

60

80

100

%

IA

IB

IIA

IIB

III

Stage

SCCA
AdenoCA

from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988

from Grigsby, P.W., et.al Radiother Oncol 12:289, 1988

Five-Year Survival: -

Please see notes
page.

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02-11-02

03:24 A
M

Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Conclusion

• “Prophylaxis - better than cure” - Never more

True

• Pre treatment evaluation and Proper staging is a

must.

• Surgery and radiation are complimentary. So

proper team is essential- Surgeon and

Radiotherapist should join hands.

• Stage for stage, little progress has been made in

lowering mortality rates.

• However, the overall mortality rate is decreasing

because more patients are having their cancers

diagnosed in early states of disease.

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Conclusion

Five year survival - stage IA – 100 %, IB - 85 - 90
% , stage IIA- 70 - 75 %

Many physicians are discouraged with the
results of cancer therapy.

However, the opportunity is there for all
physicians to make an early diagnosis in Ca Cx
and to protect the women from this dreadful
disease.

Those women saved from the ravages of cervical
cancer shall call their physicians blessed.

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02-11-02

03:24 A
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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Conclusion

“Days are gone when a patient with

gynaecological malignancy could be

treated by a surgeon or a radiotherapist

in isolation”. -Stallworthy

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02-11-02

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Management Dilemmas in Cervical Cancer- Prof. S.N.Panda

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Thank You

Thank You

At the service of

women


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