DIVISI ONCOLOGY GYNECOLOGY

DEPARTEMENT OBSTETRI DAN GINEKOLOGI

Definition
Cancer primary that originated from the cells of the
cervix
Incidence
Globocan 2008:
530.000 new cases
275.000 deaths
80% occur in developing countries
Less cancer prevention program
Almost in late stage
Developed countries: death rate declining
Developing countries : still high
Etiology
HPV (human papillomavirus)
Persistent infection
70% resolve within 1 year
90% resolve within 2 years
High risk type
HPV type 16 and 18 responsible for 70% cervical cancer
99,7% HPV DNA detected in cervical cancer
HPV in double strand DNA virus
Family papovaviridae
Transmitted through sexual contact
Cervical Carsinogenesis
Viral reach basal cell through micro abrasion
Uncoated and release the genom
Latent period 2 5 years
No tissue reaction
Viral starts replicate
Infected basal cell push to suprabasal and enlarge
Cells have perinuclear halo called koilocyte
Cell also has nuclear enlargement and hyperchromatic
Viral genom integrated into host DNA
Over expression E6 and E7
E7 bind to pRb, E6 bind to p53
Leading loss cell-growth control and malignant transformation
Risk Factor
Cervical cancer considered as sexually transmitted disease
Early sexual activity
Multiple sexual partner ( 5)
Multi parity
Lower socio-economic
High risk sexual partner
Cigarette smoking
Oral contraceptive pills (increased sexual activity)
Immunodeficiency
DES exposure : clear cell adenocarsinoma
Clinical Manifestation
Early stage : asymptomatic
Most common : post coital spotting
Obstruction uterine flow : Hamatometra
Subsequently infection: Pyometra
Advanced stage :
Bad vaginal odor and bleeding
Pelvic pain
Urinary and bowel problems
Lymphatic obstruction
Constitutional symptom
Diagnosis
Suggestive cancer : complete physical and pelvic
examination
Biopsy : histological examination
Pouch or directed biopsy
Cone biopsy
Large lesion : biopsy at the edge of tumor
FIGO Staging
Provide uniform terminology
Provide appropriate prognosis
Improve treatment result
New revised 2009
Cervical cancer staging
Clinically staging
Chest X-ray
Under narcose examination
Cystoscopy and rectoscopy (for late stage)
Intravenous urogram
CT scan may replace intravenous urogram
FIGO Staging
Stage I : confined to the cervix (extension to the uterus should be
disregarded)
Stage IA : invasive cancer diagnosed only by microscopy. All visible lesion is
stage IB. Stromal invasion measured from the base of epithelium.
IA1
Diagnosed only by microscopy
Depth stromal invasion 3 mm
Lateral spread 7 mm
IA2
Diagnosed with microscopy
Depth stromal invasion > 3 mm and 5 mm
Lateral spread 7 mm
FIGO Stage
1B1
Clinically visible lesion
Greatest than IA2
Greatest dimension 4 cm
1B2
Clinically visible lesion
Greatest dimension > 4 cm
FIGO Stage
Stage II : invade the uterus, but not to the pelvic wall or to
lower vagina
IIA1
Involvement upper of vagina
No parametrium invasion
Greater dimension 4 cm
IIA2
IIA1 with tumor > 4 cm
IIB
Parametrium invasion
FIGO Stage
Stage III: extend to the pelvic wall and/or involves lower
vagina or causes hydronephrosis/non functioning kidney
IIIA
Involves lower of vagina
No extend to pelvic wall
IIIB
Extend to pelvic wall
Or causes hydronephrosis or non functioning kidney
FIGO Stage
Stage IVA
Invade bladder or rectum mucosa
Extend beyond the pelvic
Stage IVB
Distance metastase
Prognostic factors
Clinical stage is most important
Overall 5 year survival stage IA : 95%-100%
Five year survival stage IV only 5%
Depth or tumor invasion
Lymph-vascular invasion
Tumor volume
Endometrial extension
Lymph node involvement
Number of (+) node
Histology type (small cell neuroendocrine, sarcoma)
Age, general condition, nutritional status
Management
Depend on :
Stage / extend the disease
Fertility wishes
Age
Performance status
Co-morbidity
Patients personal choice
Facilities
Expertise
Treatment Option
Surgery
Radiation/chemoradiation
Combination
Curative and palliative
Early stage
Stage I IIA
Surgery equal radiation
Surgical advantages
Conserve ovary
Fertility conservation
Not exposure carsinogenic agent
No late effect radiation
Provide tissue for examination
Surgical for stage IA1
Cone biopsy
Fertility conservation
Young
Cold knife or LEEP/LLETZ
Simple hysterectomy
Post menopause
With lyomioma
Lymph vascular invasion : + pelvic lymphadenectomy
Surgical for stage IA2
Radical trachelectomy
Radical hysterectomy
+ pelvic lymphadenectomy
Surgical for stage IB1 - IIA
Radical hysterectomy
Radical trachelectomy : < 2 cm
+ pelvic lymphadenectomy
Bulky tumor : preferred radiation
Radiation
All stages
Curative or palliative
Combine with chemotherapy : radio sensitizer
Adjuvant post radiation : with risk factor
External and brachytherapy
Radiation
External beam, irradiate:
Whole pelvic
Parametrium
Pelvic and para-aortic lymphnode
Given in fractions
Brachytherapy = intracavitary
Cervix
Vagina
Medial parametrium
Follow Up
Follow up include :
Complication related to treatment
Event of recurrence disease
Follow up protocol are variable
Diagnostic can be problematic
Post radiation : fibrosis or recur
Site of recurrence
Surgical treated recur 15%
Located :
Central pelvic
Lateral pelvic
Extra pelvic site : 26% - 44%
Surveillance focused on pelvic
Local recurrence early than distance
Risk factor:
Pelvic node metastases
Bulky tumor
Close free margin
Site of recurrence
Irradiated cases, few recur pelvis only
Perez reported 7% central pelvic only
half : distance metastases
Complete response less recur
Time to recurrence
70% - 89% within first 2 year
Relates to :
Original lesion
Tumor size
Node metastases
Examination interval
Every 3 months for first 2 year
Every 6 months for next 3 year
Yearly thereafter
Or unusual symptoms or signs :
Vaginal bleeding
Lower extremity edema
Pelvic leg pain
Examination at visit
Recurrence : asymptomatic at beginning
Need appropriate examination
Care with symptom
Thorough physical examination
Other studies
Cervicovaginal cytology
Tumor marker (optional) SCC
Chest x ray
Intravenous pyelogram
CT scan abdomen and pelvic
Pertinent symptoms of patients with persistent or recurrence
disease
General Genitourinary
Weight loss or gain Dysuria
Fatigue Frequency of urination
Weakness Urinary incontinence
Pulmonary Hematuria
Cough Difficulty in emptying
Hemoptysis bladder
Dyspnea Vaginal bleeding or discharge
Chest pain Musculoskeletal
Gastrointestinal Extremity or back pain
Abdominal pain Swelling in legs or arm
Nausea and vomiting
Change in bowel movement
Constipation
Diarrhea
Blood in stool
Surveillance after treatment for cervical cancer
History
Vaginal bleeding or discharge
Back, sciatic or pelvic pain
Weight loss, anorexia
Cough, dyspnea, hemoptysis
Lower extremity swelling
Physical examination
Weight, blood pressure
Nodal palpation ( supraclavicular and inguinal)
Abdominal palpation
Vaginal speculum examination
Bimanual rectovaginal examination
Check for lower extremity edema
Vaginal cytology
The value is varying
Detect central pelvic recurrence
Simple technique
Inexpensive
After radiation : difficult differentiated dysplastic,
invasive or repair cells
Physical examination
Node palpation:
Supra clavicular
Inguinal
Abdominal palpation : hepatic enlargement
Bimanual pelvic examination
Biopsy suspicious lesion
Careful : fistula after biopsy
FNAB : central or extra pelvic
Imaging studies and other test
IVP and chest X-ray can used routinely
Multiple lung metastases : poor
Ureteral obstruction : pelvic side wall recurrence
Routine CT-scan : value ?
MRI or PET may have benefit
Tumor marker
SCC : high specificity, low sensitivity
Not used widely
Other marker play little role
Adenocarsinoma : CA 125 and CEA
Benefit : elevated pre treatment
Treatment for recurrence
Depends on :
Mode of primary treatment
Site of recurrence
Number of recurrence
Disease free interval
Performance status
Local central pelvic recurrence : potentially cured
Mode of treatment :
Surgical
Radiation
Chemotherapy
Primary treatment : surgical
Local pelvic recurrence : radiation
Salvage option : pelvic exenteration
Distance recurrence:
Resectable : resection
Unresectable : radiation
Primary treatment : radiation
Limited in cervix : radical hysterectomy or exenterative
High morbidity
May with stoma
Re-radiation in selected patient :
Inoperable
Refuse exenterative surgery
Limited radiation volume and dose
Chemotherapy
Merely palliative
Relieve symptoms
Prolong life
Usually lung metastases
Cisplatin : single active agent