Download MBBS OBG Management of carcinoma cervix Lecture PPT

management of
carcinoma cervix
Anil Joy P

---

Preventive
Curative

--- Content provided by​ FirstRanker.com ---

---

Preventive
Primary Prevention
Secondary prevention

---

Primary Prevention
Identifying `high-risk' female

--- Content provided by‍ FirstRanker.com ---

Identifying `high-risk' males
Prophylactic HPV vaccine
Use of condom
Removal of cervix during hysterectomy

---

Identifying `high-risk' female

--- Content provided by​ FirstRanker.com ---

- Women with high risk HPV infection
- Early sexual intercourse.
- Early age of first pregnancy.
- Too many births/too frequent birth.
- Low socioeconomic status.

--- Content provided by‍ FirstRanker.com ---

- Poor maintenance of local hygiene

---

Identifying `high-risk' males
- Multiple sexual partners.
- Previous wife died of cervical carcinoma.

---

Prophylactic HPV vaccine

--- Content provided by‌ FirstRanker.com ---

Bivalent 0?2?6 month,
Quadrivalent 0?1?6 month

---

Secondary prevention
identifying and treating the disease earlier in the
more treatable stage

--- Content provided by⁠ FirstRanker.com ---

(This is done by screening procedures)
Down staging screening (Who 1986)
Down staging procedure

---

Downstaging screening (Who 1986)
Detection is done by nurses and other

--- Content provided by‍ FirstRanker.com ---

paramedical health workers using a simple
speculum for visual inspection of the cervix
it can minimize the cancer death through early
detection

---

Down staging procedure

--- Content provided by⁠ FirstRanker.com ---

A female primary health care worker is trained
for 2?3 weeks to perform speculum examination
Distinguish a normal cervix from an abnormal
one

---

Definitive treatment

--- Content provided by‍ FirstRanker.com ---

Surgery ( stage I to I a)
Radiotherapy (all stages)
Combination of both

---

Management based upon stage
Ia1 ? cone biopsy or type I simple hysterectomy

--- Content provided by FirstRanker.com ---

Ia2- Type I (modified radical) hysterectomy and
pelvic lymphadenectomy
Ib1- Type I I (radical) hysterectomy and pelvic
lymphadenectomy
Ib2&Iiba- Primary chemoradiation or Type I I

--- Content provided by⁠ FirstRanker.com ---

(radical) hysterectomy with pelvic and
paraaortic lymphadenectomy
I b onwards ? primary chemoradiation

---

Treatment modalities of Carcinoma
Cervix

--- Content provided by‌ FirstRanker.com ---

Primary surgery
Primary radiotherapy
Chemotherapy
Combination therapy

---

surgery

--- Content provided by‌ FirstRanker.com ---

Radical Hysterectomy
Laparoscopic Radical Hysterectomy
Simple Hysterectomy
Cone biopsy
Radical Trachelectomy

--- Content provided by⁠ FirstRanker.com ---

Extenteration

---

Radical Hysterectomy
removal of the uterus, tubes and ovaries of both
the sides
upper half of vagina, parametrium (most of

--- Content provided by⁠ FirstRanker.com ---

cardinal and uterosacral ligaments)
obturator, internal and external iliac groups and
sometimes common iliac
Paraaortic lymph node evaluation is done. Any
enlarged paraaortic lymph node is sampled and

--- Content provided by‌ FirstRanker.com ---

sent for frozen section biopsy.

---

Dif erence between Radical
Hysterectomy Type I & I I
Type III
Described by Meigs

--- Content provided by‍ FirstRanker.com ---

Uterine artery ligated at the internal iliac
Cardinal ligament divided at pelvic wall
Uterosacral divided close to sacrum
3-4 cm of vaginal cuff removed
More post operative problems

--- Content provided by​ FirstRanker.com ---

Ideal for stage Ib1

---

Dif erence between Radical
Hysterectomy Type I & I I
Type II
Described by Wertheim

--- Content provided by FirstRanker.com ---

Uterine artery ligated as it crosses the ureter
Medial half of Cardinal ligament only removed
Uterosacral divided more anteriorly
2-3 cm of vaginal cuff removed
Less post operative problems

--- Content provided by⁠ FirstRanker.com ---

Ideal for stage Ia2

---

Complications -Immediate
Haemorrhage
Injury to ureter , bladder or bowel,
Pulmonary embolism

--- Content provided by​ FirstRanker.com ---

---

Complications -Delayed
Bladder atony
Small intestinal obstruction
Vescovaginal fistula
Ureterovaginal fistulae

--- Content provided by​ FirstRanker.com ---

---

advantages of surgery over
radiotherapy
Spread of the disease can be determined more
thoroughly by surgicopathological staging
Surgical staging (Laparotomy or Laparoscopy)

--- Content provided by⁠ FirstRanker.com ---

and assessment of paraaortic and pelvic nodes,
can predict the survival rate accurately
Preservation of ovarian function, if desired,
specially in a young woman.

---

advantages of surgery over

--- Content provided by⁠ FirstRanker.com ---

radiotherapy ? cont....
Ovaries may be transposed out of the radiation
field if radiation is considered in the
postoperative period.
Retention of more functional and pliable vagina

--- Content provided by⁠ FirstRanker.com ---

for sexual function.
Psychologic benefit to the patient in that her
cancer bearing organ has been removed.

---

Simple Hysterectomy
Type I or extrafascial Hysterectomy

--- Content provided by​ FirstRanker.com ---

Stage Ia1
With out lymph node invovment
Women completed their family

---

Cone biopsy
Diagnostic & therapeutic

--- Content provided by‌ FirstRanker.com ---

Stage Ia1
Microinvasive carcinoma definitely diagnosed
by this

---

Radical Trachelectomy
Cervix a & para cervical tissue are removed

--- Content provided by FirstRanker.com ---

Preserve the uterus
Ia2 and Ib1
First lymphadenectomy then Trachelectomy

---

Extenteration
Uterus and vagina removed

--- Content provided by⁠ FirstRanker.com ---

Bladder or rectum or both removed
After primary radiotherapy and no metastasis

---

Primary Radiotherapy
All stages
In early stage, results of both more or less same

--- Content provided by‌ FirstRanker.com ---

1. Brachytherapy or intracavitary
2.external beam or teletherapy

---

Brachytherapy
Intra uterine and intra vaginal tubes are used
Small radioactive sources, mainly radium sulphate is mixed withsome inert

--- Content provided by​ FirstRanker.com ---

powder and packed in small needles or tubes
Radiation sources for intracavitary radiation are Radium (226Ra), Cesium
(137Cs) or Cobalt (60Co).
The container is made up of platinum, gold or alloy steel to absorb alpha
and beta particles and allowing the gamma rays to sterilize the cancer cells

--- Content provided by FirstRanker.com ---

---

Dif erent methods of brachytherapy -- A. Stockholm technique,
B. Paris technique, C. Manchester technique

---

External beam or Teletherapy
Treating lymph node

--- Content provided by‍ FirstRanker.com ---

Decrease tumour volume
Apparatus ? linear accelerator
Dose ? depend upon stage of disease

---

Advantages of Radiotherapy
- Wider applicability in all stages of carcinoma

--- Content provided by⁠ FirstRanker.com ---

cervix.
- Survival rate 85%, comparable with that of
surgery in early stages.
- Less primary mortality and morbidity.
- Individualization of dose

--- Content provided by FirstRanker.com ---

distributions/requirement possible.

---

Disadvantages of Radiotherapy
Intestinal and urinary strictures, fistula formation
(2?6%),
vaginal fibrosis and stenosis

--- Content provided by FirstRanker.com ---

Perforation of the uterus may result during
introduction of uterine tube
radiation menopause , fibrosis of bowel and
bladder.
Bleeding per rectum

--- Content provided by FirstRanker.com ---

Nausea, vomitting, abdominal cramps,
diarrhoea

---

CHEMORADIATION
Chemotherapy with radiation
Benefits of systemic chemotherapy with

--- Content provided by‌ FirstRanker.com ---

regional radiation
Chemotherapy sensitize cells to radiation
Increases 5 year survival rate
Usually cisplatin used (40 mg/sq.m)

---

Combination therapy

--- Content provided by‍ FirstRanker.com ---

In the form of surgery, radiotherapy and
chemotherapy may be done, one following the
other

---

Fol ow Up
3 monthly for first 2 year

--- Content provided by​ FirstRanker.com ---

6 monthly for next 3 year
There after annually
Counseling

---

Palliative treatment
Palliative treatment is primarily aimed to provide

--- Content provided by‍ FirstRanker.com ---

comprehensive care for relief of symptoms
along with treatment of cancer in the
advanced stage.

---

Five year Survival Rates
I ? 85%

--- Content provided by‌ FirstRanker.com ---

I ? 60 %
I I ? 45%
IV ? 18%

---

Conclusion
Surgery and radiotherapy have equal results in early

--- Content provided by⁠ FirstRanker.com ---

stages cancer
Surgery may preferred up to stage Ib1
Primary chemo radiation preferred from Ib2 onwards
Survival depends upon lymph node status
Radiotherapy is a combination of brachytherapy and

--- Content provided by‌ FirstRanker.com ---

external radiation
It is proved that 100% squamous cervical cancer due to
HPV, HPV vaccines are available.
Survival rate of stage I is 85%.

---

Thank you

--- Content provided by⁠ FirstRanker.com ---

---