Carcinoma cervix an overview of awareness

carcinoma cervix in detail

1. CARCINOMA CERVIX Presented by- Dr Sunitha C Consultant OBGYN,Columbiaa Hospital

2. INCIDENCE According to data from GLOBOCAN 2018- cervical cancer is the fourth most common cancer worldwide and the second most common cancer in low and middle income countries In India cervical cancer is the second most common cancer after breast cancer with an incidence of 20.2/1,00,00 (23.8 for breast ) In 2018 , an estimated 5,69,847 new cases annually and 3,11,365 deaths worldwide annually Second most common cause of cancer related death in woman in developing countries.

3. RISK FACTORS Age - mean age 47 years Bimodal distribution with one peak between 35-39 years Second peak between 60-64 years Race – more common in black and Hispanic women compared to white Socio-economic factors -low standards of hygiene( including penile hygiene), low education. HIGH RISK MALE

4. Cigarette smoking- twice likely to develop cervical cancer. Coitus - sexually active women is 2-4 times at higher risk than in sexually inactive Age of first intercourse <16 years Multiple sexual partners –having more than 6 sexual partners elevates the risk Abstinence from sexual intercourse and barrier protection- decrease cervical cancer incidence ( International Collaboration of Epidemiological study of cancer 2006) Multiparity- women with 7 prior full term deliveries – 4 fold risk1 1 or 2 deliveries- 2 fold risk ( Munoz 2002) High parity- frequent coitus , starting at a younger age and is often associated with poor socio-economic status

5. Immune system deficiency- AIDS defining illness. The standardised (SIR) incidence ratio of developing this cancer in HIV infected patients is 5.82 For transplant recipients SIR is 2.013 Women on immunosuppressants do not have an increased risk except azathioprine users ( Dugue 2015) Oral contraceptive pills - excessive and unbalanced estrogen favours the development of cancer Diethylstilbesterols (DES) exposure- women whose mothers were given this drug during pregnancy have an increased risk . Clear cell adenocarcinoma – maybe associated with exposure

6. HPV infection and cervical cancer- MOST IMPORTANT RISK FACTOR HPV 6 and 11 – non oncogenic subtypes responsible for 90% genital warts HPV 16 and 18- accounts for 80% cervical cancer in India

7. HISTOLOGICAL SUBTYPES A) SQUAMOUS CELL CARCINOMA MOST COMMON VARIETY OF INVASIVE CANCER OF THE CERVIX Histological variants include- large cell keratinizing, large cell non keratinizing and small cell types. Other less common variants - verrucous carcinoma and papillary carcinoma

8. Invasive squamous cell carcinoma of cervix- large cell non- keratinizing type

9. B) ADENOCARCINOMA An increasing number of cervical adenocarcinomas in women between 20-30 years Although the total number is relatively stable , it is occurring more frequently in young women, especially as the number of cases of invasive squamous cell carcinoma decreases. Adenocarcinoma in situ (AIS) – PRECURSOR OF INVASIVE ADENOCARCINOMA and these two often coexist In addition to AIS, intraepithelial or invasive squamous neoplasia occurs in 30- 50% adenocarcinoma About 80% of cervical adenocarcinomas consist predominantly of the endocervical type cells with mucin production. The remaining tumors - endometroid cells, intestinal cells or mixture of more than one cell type.

10. Special variants Minimal deviation adenocarcinoma ( adenoma malignum )- extremely well differentiated form in which the branching glandular pattern strongly simulates that of the normal endocervical glands. Villoglandular papillary adenocarcinoma

11. Invasive adenocarcinoma of cervix- well differentiated

12. C ) ADENOSQUAMOUS CARCINOMA Mixture of malignant glandular and squamous component In mature type- the glandular and squamous carcinomas are identified on routine histology In poorly differentiated or immature type- glandular differentiation can appreciated only with special stains, such as mucicarmine and PAS VARIANTS Glassy cell carcinoma Adenoid basal Adenoid cystic

13. D) SARCOMA Most important sarcoma of cervix- embryonal rhabdomyosarcoma- occur in children and young adults Leiomyosarcomas and mixed mesodermal tumors of cervix- usually secondary to uterine tumors Cervical adenosarcoma- low grade tumor with good prognosis E ) MALIGNANT MELANOMA- May arise de novo . Simulates melanoma elsewhere and prognosis depends on depth of invasion into the cervical stroma.

14. SYMPTOMS Vaginal bleeding- MOST COMMON SYMPTOM Can be postcoital, irregular or postmenopausal Vaginal discharge – malodorous / blood stained Pain- pelvic pain, low back ache, pain radiating to lower thigh Weight loss , cachexia, oedema of legs, anorexia, malaise Urinary symptoms- increased frequency, urinary incontinence , hematuria Asymptomatic- most commonly identified through evaluation of abnormal cytologic screening tests.

15. GENERAL PHYSICAL EXAMINATION Look for – pallor, pedal edema , supraclavicular and inguinal nodes Systemic examination- for any metastasis Abdominal examination- any tenderness, enlarged uterus ascites hepatomegaly Local examination

16. LOCAL EXAMINATION In early stages- cervix maybe normal, eroded or chronically infected On examination – hardness , irregularity and bleeding In established disease- cervix maybe enlarged, ulcerated and completely destroyed or replaced by a hypertrophic mass. Cardinal signs- hardness, visible growth,friability , fixation and bleeding on examination Diagnosis is difficult if the growth is entirely endocervical. External os may look normal but cervix feels big, broad and barrel shape Fixation occurs relatively early but bleeding on touch is not a prominent sign Rectal examination- to determine the extent of spread

17. COMPLICATIONS Pyometra-especially with endocervical variety Intractable haemorrhage Vesicovaginal fistulas Rectovaginal fistula- in untreated cases Uremia – MAIN CAUSE OF DEATH Intestinal obstruction- rarely due to widespread metastases leading to bowel obstruction

18. SCREENING Screening tests – PAP smear cytology, visual inspection on acetic acid (VIA) , HPV DNA tests are available for early detection Cervical cytology is the most used method of cervical cancer screening in developed countries

19. SCREENING GUIDELINES Age < 21 years – not recommended 21-29 years- cytology alone every 3 years 30-65 years- cytology and HPV co testing every 5 years If HPV is not available, cytology alone is done every 3 years Screening with HPV alone – not recommended >65 years- no screening necessary if no abnormal pap tests in 10 years Routine age based screening is continued for 20 years after positive cytology

20. Screening Cytological methods PAP smear Thin layer PAP Liquid based cytology VISUAL INSPECTION METHODS UNAIDED NAKED EYE VISUALIZATION VISUAL INSPECTION UNDER LUGOL’S IODINE VISUAL INSPECTION UNDER ACETIC ACID COLPOSCOPY CERVICOGRAPHY MOLECULAR BIOLOGY METHODS HPV-DNA GENOTYPING

21. PAP smear test Papincolau test Exfoliative vaginal cytology Sensitivity- 51% for precursor lesions and 47-62% for CIN 2/3 Specificity is 60-95% for CIN 2/3 Liquid based cytology has improved the sensitivity to 80% Test is started 3 years after onset of vaginal intercourse but no longer than 21 years. It is repeated annually for 3 consecutive years. Negative Repeated at 3-5 years interval till 65 years After 65 years the incidence of CIN drops to 1%

22. COLPOSCOPY SWEDE SCORE-a score of 5 or more – indicates HSIL

23. COLPOSCOPIC FINDINGS OF INVASION Abnormal blood vessels- MOST COMMON colposcopic finding and arise from the punctated and mosaic vessels present in CIN Abnormal reticular vessels represent the terminal capillaries of the cervical epithelium B)- Irregular surface contour- can be confused with benign HPV papillary growth on the cervix. For this reason , biopsies should be performed on all papillary cervical growths to avoid missing invasive disease C) Color tone - yellow orange ADENOCARCINOMA- DOES NOT HAVE A SPECIFIC COLPOSCOPIC APPEARANCE

24. INVESTIGATIONS

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