宫颈癌的诊断和治疗ppt课件.ppt

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1、 CERVICAL CANCER.CERVICAL CANCER.lThe most common malignancy in gynecological oncologylIncidence: 7.8/100,000lMortality: 2.7/100,000lDiagnosis: biopsylMain modality of treatment: surgery and radiationlGoal of treatment: cure, except stage 4b Special Casel38 yrs, G3/P1, nurselC/O: postcoital bleeding

2、 for 2 monthslMenstruation regular with 30 days cycle and 5 days duration. Abnormal discharge with bad smell. LMP: 12 days agolPap smear: squamous cell cancer lPV: Vulva : Normal, lVaginal: yellowish discharge with bloody stained, lCervix: growth with ulceration and contact bleeding.lUterus: N/S, mo

3、bile. lParametrium: thickening not to pelvic sidewall on both side CERVICAL CANCER. CERVICAL CANCER. lHow can we make a diagnosis? How can we make a diagnosis? lHow can we evaluate the patient?How can we evaluate the patient?lHow can we manage the patient? How can we manage the patient? lHow should

4、we explain to the patient? How should we explain to the patient? lCan we prevent cervical cancer?Can we prevent cervical cancer? How can we make a diagnosis?How can we make a diagnosis?SYMPTOMSSYMPTOMSlAbnormal vaginal bleeding Abnormal vaginal bleeding postcoital bleedingpostcoital bleeding* * cont

5、act bleeding contact bleeding lAbnormal vaginal dischargeAbnormal vaginal dischargelAsymptomatic, just abnormal Asymptomatic, just abnormal pap smearpap smearSYMPTOMSlThe classic symptom is intermittent, painless metrorragia or spotting only postcoitally or after douching.lProbably the first symptom

6、 of early cancer of the cervix is a thin, watery, blood-tinged vaginal discharge that frequently goes unrecognized by the patients.lAs the maligancy enlarges, the bleeding episodes become heavier and more frequent, and they last longer.SYMPTOMSlLate symptom or indicators of more advanced disease inc

7、lude the development of pain referred to the flank or leg.lMany patients c/o dysuria, hematuria or rectal bleeding or obstipation resulting from bladder or rectal invasion.lDistant metastasis and persistent edema of one or both lower extremities as a result of lymphatic and venous blockage by extens

8、ive pelvic wall disease are late manifestation of primary disease and frequent manifestations of recurrent disease.How can we make a diagnosis?How can we make a diagnosis?lSIGNSlVagina: mucous, fornixlCervix: erosion growth ulceration barrel-shapedlUterus: size, mobilitylParamet: thickening Gross ap

9、pearencelThree categories of gross lesions have traditionally been described.lThe most common is the exophytic lesion, which usually arises on the ectocervix and ofter grows to form a large, friable,polypoid mass, arises on the endocervical canal, creating barrel-shaped lesion.lLittle visible ulcera

10、tion or exophytic mass like a stone-hard cervix that regresses slowly with radiation therapy.lUlcerative tumor,usually erodes a portion of the cervix or replacing the cervix , erodes a portion of the upper vaginal vault with a large crate.How can we make a diagnosis?How can we make a diagnosis?CLINI

11、CAL TESTS:CLINICAL TESTS:lPap smearPap smearlColposcopy and target biopsyColposcopy and target biopsylEndocervical curettage (ECC)Endocervical curettage (ECC)lCone biopsyCone biopsylBiopsyBiopsyPap smearlPap smear is the most common and effective screening method.lExfoliated cervical cells are scrap

12、ed from the cervix by spatula. The entire T zone must be sampled. Incomplete sampling could produce a false-negative smear.lThe endocervical canal is also sampled with a swab or cytobrush.lCells are fixed immediately to avoid air-drying cytologic artifacts Colposcopy and directed biopsylA pap smear

13、is only a screening test. A definitive diagnosis requires inspection of a well-visualized cervix with a colposcope.lThe cervix is painted with 3% acetic acid solution to enhance surface alterations and vascular changes.lThe colposcope evaluation is considered adequate or satisfactory if the complete

14、 T zone and full extent of the lesions is visualized.lAreas of abnormality(e.g., White epithelium, mosaicism, and punctation) are selectively punch biopsied. Cone biopsylIndications for cone biopsy 1.The lesion cannot be fully visualized . 2.The ECC is posituve 3.There is significant discrepancy bet

15、ween the Pap smear and biopsy. 4.A biopsy reveals microinvasive squamous cell carcinoma 5.A biopsy reveals adenocarcinoma in situHow can we make a diagnosis?How can we make a diagnosis?lA pap smear is only a A pap smear is only a screening test! screening test! lDefinitive diagnosis of Definitive di

16、agnosis of cervical cancer cervical cancer requires a BIOPSY!requires a BIOPSY!How can we evaluate the patient?Histologic type:Histologic type:lSqumous cell carcinoma ( SCC) 80%Squmous cell carcinoma ( SCC) 80%lAdenocacinoma 10%-15%Adenocacinoma 10%-15%lOthers 5%-10%Others 5%-10%Routes of spreadlInt

17、o the vaginal mucosa,extending microscopically down beyond visible or palpable disease;lInto the myometrium of the low uterine segment and corpus, particularlly with lesions arising from the endocervix.lInto the paracervical lymphatics and from there to the most common involved lymph nbodes ( the ob

18、turator; hypogastric,and external iliac nodes).lDirect extesion into adjacent structures or parametria, reaching to the obturator fascia and the wall of the true pelvisHow can we evaluate the patient?lStage:Stage: Pelvic examination, Pelvic examination, Rectovaginal examination, Rectovaginal examina

19、tion, Intravenous pyelography(IVP) Intravenous pyelography(IVP) Ultrasonography or CTUltrasonography or CTlStaging is clinical, but can use IVP and CTStaging is clinical, but can use IVP and CTlCervical cancer is the only gynecologic Cervical cancer is the only gynecologic malignancy that is not sur

20、gically stagedmalignancy that is not surgically stagedClinical Staging for Cervical CarcinomalStage 0Carcinoma-in situ; Confined to the epithelium onlyClinical Staging for Cervical CarcinomalStage I Invasion is strictly confined to the cervix Ia: Invasive cancer identified only microscopically . Ia1

21、: Minimal microscopically evident stromal invasion =3mm in depth and no wider than 7mm. Ia2: Microscopic invasion 50%lPV: Vulva and vaginal: normal Cervix: erosion with contact bleeding,Uterus: N/S, mobile. Parametrium: clear lWants to preserve her reproductive function Treatment strategy for CINLee

22、p (ectocervix),CO2 laser therapy,CryotherapyNo suspicion of invasionCone biopsy,cold knife cone, Laser cone,LEEP cone (ecto and endocervix)Suspicion of invasionBiopsyEndocervical currettageRepeat Pap smearSuspicion of CIN/SILPap smear result abnormalCase discussion l48 yrs, G3/P1, midlife lC/O: post

23、coital bleeding for 4 monthslMenstruation irregular with 30-60 days cycle and 5-20 days duration. Abnormal discharge with bad smell. LMP: 2 months agolPap smear: squamous cell cancer lPV: Vulva : Normal, vaginal: right fornix involved by cervical growth. Cervix: growth with ulceration and contact bl

24、eeding.Uterus: N/S, mobile. Parametrium: nodular thickening to pelvic sidewall on rightlBiopsy:SCC. IVP:nonfunctional kidneyTreatment strategy for Invasive Cervical CancerCone Biopsy orSimply hysterectomyMicroinvasive invasion (less than 3mm)Radical Hysterectomy andPelvic LymphadenectomyorPelvic Rad

25、iationEarly Stage IB or IIAMultimodality TherapyPelvic Radiation Therapyor Invastigational ProtecolsAdvanced or Bulky DiseaseStagingInvasive cervical cancerHow can we explain to the patient?lWhat is cervical cancer?lHow many treatment mode for cervical cancer?lWhy we choose surgery or RT for the pat

26、ient?lWhat is the side-effect of the treatment?lWhat is the prognosis and survival rate?Cervical cancerlCervical cancer is the most common gynecologic malignancy.lThe most common tumor type is squamous cell carcinoma (80%) lA pap smear is only a screening test! lDefinitive diagnosis of cervical cancer requires a tumor BIOPSY!lRadiation and operation are both effective treament .lGoal of the treatment: cure, except stage IV