Ca cervix evaluation and staging

Initial Evaluation, testing, pre-op evaluation and staging of Carcinoma Cervix

1. CARCINOMA CERVIX
INTRODUCTION AND EVALUATION
Student: Surg Lt Cdr Ankur Shah
Moderator: Lt Col Tony Jose

2. ●
References:
–Berek's and Novak's Gynaecology, 15
th
ed
–William's Gynaecology, 2
nd
ed
–DiSaia, Creasman Clinical Gynaecologic Oncology,
7
th
ed
–Berek and Hacker's Gynaecologic Oncology, 5
th
ed
–WHO Weekly Epidemiological Record, No 15 dated
10 April 2009

3. Introduction
●
Latin - “neck”, entry to womb
●
Anatomy
–2-4 cm in length
–Cervical canal – antomical external os to internal os
–Histologic internal os – transition from endocervical
to endometrial glands
●
Histology
–Exocervix – stratified squamous epithelium
●
Basal, parabasal, intermediate and superficial layers
–Endocervix – cylindrical epithelium, arranged in
branching folds
–Squamocolumnar junction
–Stroma – connective tissue with stratified muscle
fibers and elastic tissue

6. ●
Squamocolumnar junction
–Embryogenesis – upward migration of squamous
epi from vaginal plate replacing mullerian epi.
–Low vaginal pH stimulates squamous metaplasia
–Location of SCJ varies with age & hormonal status
●
Everts outwards during adolescence, pregnancy & OCP
use
●
Regresses into endocervix with menopause, low
estrogen states

8. ●
Transformation zone
–Adjacent to SCJ
–Most active zone of squamous metaplasia – prone
to carcinogenic effects
●
Risk factor for Cervical cancer
–Metaplasia, most active during adolescence and
pregnancy

10. Pre-invasive Lesions
●
Squamous epi lesions, considered to be
precursors, but lack features of invasive Ca
●
Cervical cytology – major tool to detect CIN
lesions early before onset of invasive Ca
●
Pap Smear

11. ●
Pap smear
–Conventional smear
●
Smear made directly on glass slide at time of sampling
–Liquid based Cytology
●
Cells collected in liquid transport medium, further
processed to produce a monoloayer of cells on slide
●
Advantage of LBC
–Most of the collected material available for sampling
–Abnormal cells, which are few, obscured, clustered
on conventional Pap are easily visible

13. ●
Before a Pap Smear, ensure:
–Avoid menstruation
–Abstain from intercourse, douching, use of vaginal
tampons, or contraceptive creams for min of 24-48
hrs
–Avoid touching the cervix before Pap smear
–Discharge from cervix may be removed with a swab
without touching the cervix

14. PAP Smear Classification
●
The Class System (I to IV)
●
The CIN System
–Based on degree of cellular abnormalities
●
The Bethesda System

15. ●
Bethesda (2001) reporting of Pap Smear:
–Specimen type – conventional, LBC
–Specimen adequacy – satisfactory, unsatisfactory
–General Categorisation:
●
Negative for intra-epithelial lesion
●
Epithelial cell abnormality
●
Other findings that may indicate increased risk
–Interpretation of results

18. Epidemiology & Risk Factors
●
'Preventable' disease
●
Third most frequently diagnosed carcinoma in
women
●
370,000 cases diagnosed annually
–78% in developing countries
–Lack of screening

19. ●
Risk factors
–HPV Infection
–Cigarette smoking
–Parity
–Oral Contraceptive use
–Early sexual activity, Multiple partners
–STDs
–Chronic Immunosuppression

20. ●
HPV Infection
–The initiating event in cervical dysplasia and
carcinogenesis
–DNA virus
–More than 100 subtypes
●
Low risk – 6, 11 – cause genital warts, rarely asso with
cancer
●
High risk – 16, 18, 45, 31 – asso with 95% of cervical
cancers
●
HPV 16 predominant subtype – 40-70% of invasive
cervical cancer
–Spread through sexual contact
●
Gains access to the basal layer of the cervical epithelium,
which becomes the viral reservoir

22. HPV and Ca Cervix

23. ●
Vaccination against HPV
–Recombinant vaccine
●
Prepared from purified structural proteins
–Two types of vaccine
●
Quadravalent – against HPV 6, 11, 16, 18
●
Bivalent – against HPV 16, 18
–Recommended age
●
Before initiation of sexual intercourse
●
Age between 9 – 26 yrs
●
Routine vaccination for girls aged 10-14 yrs
●
Catch-up vaccination for adolescent girls and older
women

24. ●
Dosage schedule
–Quadravalent vaccine – 3 doses 0, 2, 6 months
–Bivalent vaccine – 3 doses 0, 1, 6 months
●
Quadravalent vaccine approved for use in
males for prevention of anogenital warts
●
Duration of protection:
–Quadravalent – 5 yrs
–Bivalent – 6.4 yrs

25. Clinical Picture
●
Asymptomatic
●
Vaginal Bleeding
–Post coital
–Intermenstrual spotting
–Irregular or Postmenopausal bleeding
●
Discharge P/V
●
Pain referred to flanks
●
Dysuria, hematuria, rectal bleeding
●
Massive Haemorrhage, uraemia

26. Evaluation
●
Clinical Examination
–Per speculum
–Per rectal examination
–Presence of lymph nodes
–Colposcopy
–Cervical Biopsy

27. ●
Colposcopy
–Examination of cervical, vaginal or vulval epithelia
for identification and evaluation of suspected
malignant or pre-malignant changes
–Biopsy an integral part of the procedure
–Indications
●
In response to abnormal Pap Smear
●
Clinically suspicious cervical lesion
●
Abnormal/unexplained bleeding P/V
●
Persistent vaginal discharge

28. ●
ASCCP Guidelines for colposcopy
–Negative for intraepithelial abnormality – routine
cytological screening
–ASC-H, LSIL, HSIL – colposcopy and biopsy
–ASC-US – Repeat cytology, Reflex testing for HPV.
If still abnormal – colposcopy
–AGC – colposcopy, endocervical and endometrial
evaluation
–AIS – excision biopsy

29. ●
Solutions:
–Normal saline
–Acetic acid, 3 – 5%
–Lugol's iodine (Schiller's solution)
●
Colposcopic Grading – Reid's Colposcopic
Index
–Peripheral margin
–Color
–Vascular patterns
–Lugol's staining

31. ●
Colposcopic Findings of Invasion
–Abnormal blood vessels
–Irregular surface contour
–Color

32. ●
Confirmation by Cervical Biopsy
–Punch biopsy
–LEEP
●
Outpatient procedure
●
Diagnosis and therapy at same time
●
Main side effect – secondary haemorrhage
●
Endocervical location and incomplete excision predictors
for treatment failure (40% recurrence rate)

33. ●
Conization
–Cold knife
–Laser
–Curative procedure, with low recurrence rate (0.6%)
–If cut margins free from cancer, then almost 100%
disease free follow-up
–Post-conization, surgical margins show disease
●
No further treatment necessary, only regular follow up

36. ●
Histologic Subtypes
–Squamous Cell
–Adenocarcinoma
●
Adenoma malignum
●
Villoglandular
–Adenosquamous Carcinoma
●
Glassy cell
●
Adenoid basal cell
●
Adenoid cystic
●
Sarcoma
●
Malignant Melanoma
●
Neuroendocrine carcinoma

37. ●
Tumour Spread:
–Direct Invasion
●
Vaginal mucosa – microinvasive spread
●
Myometrium of lower uterine segment
●
Adjacent structures and parametrium, lateral pelvic wall

38. ●
Lymphatic Spread
–Primary Group
●
Parametrial nodes
●
Paracervical/ureteral nodes
●
Obturator nodes
●
Hypogastric nodes
●
External iliac nodes
●
Sacral nodes
–Secondary Group
●
Common Iliac nodes
●
Inguinal nodes (deep and superficial)
●
Periaortic nodes

39. Staging Investigations
●
Physical Examination
–Lymphnode examination
–Per Vaginum
–Bimanual rectovaginal examination
●
Radiology
–IVP
–Barium Enema
–X Ray Chest
–Skeletal X Ray

40. ●
Procedures
–Biopsy, Conization
–Hysteroscopy
–Endocervical Curettage
–Cystoscopy, Proctoscopy
●
Optional Investigations
–CT Scan
–MRI
–USG
–Laparoscopy
–Radionuclide Scanning
–PET Scanning

41. Non-invasive diagnostic testing
●
CT Scan-
–Evaluation of lymphnodes, liver, urinary tract and
bony structures
–Can detect only changes in size of nodes, < 1cm
considered as positive
●
MRI-
–Valuable modality to determine tumour size, degree
of stromal invasion, vaginal/corpus extension,
parametrial involvement, lymph node status
–LN evaluation was comparable to CT Scan

42. ●
PET Scan
–Use of radionuclides, which decay with emission of
positrons
–Most commonly used is Fluoro-deoxy-glucose
–Tumour cells actively use glucose, detected on
scanning as area of increased glycolysis
–Delineates extent of disease more accurately, esp
nodes which are not enlarged and distant sites not
picked up by conventional radiology

43. Pre-Operative Evaluation
●
NICE guidelines for pre-op testing
●
Patients categorised based on
–Age
–Surgical grade (minor, intermediate, major, major+)
–ASA grade
●
Recommended investigations
–Blood counts
–Renal/Liver function tests
–Blood sugar levels
–Xray Chest
–ECG
–Coagulation studies
–Urinalysis
–Blood gas analysis (optional)
–PFT (optional)

44. Staging
●
Clinically staged disease
●
In case of doubt, earlier stage should be
allotted
●
Stage must not be changed because of
subsequent findings on extended clinical
findings or surgical findings

45. FIGO Staging (2009)
●
Stage I – carcinoma confined to cervix
–IA: invasive carcinoma diagnosed microscopically.
Stromal invasion depth upto 5 mm and width less
than 7 mm
●
IA1 – stromal invasion <3mm depth and <7mm width
●
IA2 – stromal invasion 3-5 mm and <7mm width
–IB: clinically visible lesion confined to the cervix
●
IB1 – lesion <4 cm or less
●
IB2 – lesion >4 cm

47. ●
Stage II – carcinoma invading beyond uterus
but not to pelvic wall or lower 1/3 of vagina
–IIA – Tumour without parametrial invasion
●
IIA1 – lesion < 4 cm
●
IIA2 – lesion > 4 cm
–IIB – Tumour with parametrial invasion

49. ●
Stage III – tumour extending to lateral pelvic
wall/lower third of vagina/causing
hydronephrosis or non-functioning kidney
–IIIA – Tumour involves lower 1/3 of vagina, no
extension to pelvic wall
–IIIB – Tumour extends to pelvic wall or causing
hydronephrosis/non-functioning kidney

51. ●
Stage IV
–IVA – Tumour invades mucosa of bladder or rectum
or extends beyond true pelvis
–IVB – Distant metastasis

53. ●
All macroscopically visible lesions, even with
superficial invasion – allot stage Ib
●
Diagnosis of Ia1 and Ia2 should be based on
microscopic examination of tissue, preferably,
cone
●
Vascular space involvement does not alter the
stage of disease
●
Extension of disease to corpus uteri should be
disregarded since it cannot be assessed
clinically
●
Growth fixed to pelvic wall by short and
indurated parametrium – allot stage IIb
●
Presence of hydronephrosis or nonfunctioning
kidney allot stage III even if other findings
suggest stage I or II

54. THANK YOU