Download MBBS (Bachelor of Medicine and Bachelor of Surgery) OBG Management of carcinoma cervix PowerPoint PPT presentation
carcinoma cervix
Anil Joy P
Preventive
Curative
Preventive
Primary Prevention
Secondary prevention
Primary Prevention
Identifying `high-risk' female
Identifying `high-risk' males
Prophylactic HPV vaccine
Use of condom
Removal of cervix during hysterectomy
Identifying `high-risk' female
- Women with high risk HPV infection
- Early sexual intercourse.
- Early age of first pregnancy.
- Too many births/too frequent birth.
- Low socioeconomic status.
- Poor maintenance of local hygiene
Identifying `high-risk' males
- Multiple sexual partners.
- Previous wife died of cervical carcinoma.
Prophylactic HPV vaccine
Bivalent 0?2?6 month,
Quadrivalent 0?1?6 month
Secondary prevention
identifying and treating the disease earlier in the
more treatable stage
(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
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
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
Surgery ( stage I to I a)
Radiotherapy (all stages)
Combination of both
Management based upon stage
Ia1 ? cone biopsy or type I simple hysterectomy
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
(radical) hysterectomy with pelvic and
paraaortic lymphadenectomy
I b onwards ? primary chemoradiation
Treatment modalities of Carcinoma
Cervix
Primary surgery
Primary radiotherapy
Chemotherapy
Combination therapy
surgery
Radical Hysterectomy
Laparoscopic Radical Hysterectomy
Simple Hysterectomy
Cone biopsy
Radical Trachelectomy
Extenteration
Radical Hysterectomy
removal of the uterus, tubes and ovaries of both
the sides
upper half of vagina, parametrium (most of
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
sent for frozen section biopsy.
Dif erence between Radical
Hysterectomy Type I & I I
Type III
Described by Meigs
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
Ideal for stage Ib1
Dif erence between Radical
Hysterectomy Type I & I I
Type II
Described by Wertheim
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
Ideal for stage Ia2
Complications -Immediate
Haemorrhage
Injury to ureter , bladder or bowel,
Pulmonary embolism
Complications -Delayed
Bladder atony
Small intestinal obstruction
Vescovaginal fistula
Ureterovaginal fistulae
advantages of surgery over
radiotherapy
Spread of the disease can be determined more
thoroughly by surgicopathological staging
Surgical staging (Laparotomy or Laparoscopy)
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
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
for sexual function.
Psychologic benefit to the patient in that her
cancer bearing organ has been removed.
Simple Hysterectomy
Type I or extrafascial Hysterectomy
Stage Ia1
With out lymph node invovment
Women completed their family
Cone biopsy
Diagnostic & therapeutic
Stage Ia1
Microinvasive carcinoma definitely diagnosed
by this
Radical Trachelectomy
Cervix a & para cervical tissue are removed
Preserve the uterus
Ia2 and Ib1
First lymphadenectomy then Trachelectomy
Extenteration
Uterus and vagina removed
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
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
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
Dif erent methods of brachytherapy -- A. Stockholm technique,
B. Paris technique, C. Manchester technique
External beam or Teletherapy
Treating lymph node
Decrease tumour volume
Apparatus ? linear accelerator
Dose ? depend upon stage of disease
Advantages of Radiotherapy
- Wider applicability in all stages of carcinoma
cervix.
- Survival rate 85%, comparable with that of
surgery in early stages.
- Less primary mortality and morbidity.
- Individualization of dose
distributions/requirement possible.
Disadvantages of Radiotherapy
Intestinal and urinary strictures, fistula formation
(2?6%),
vaginal fibrosis and stenosis
Perforation of the uterus may result during
introduction of uterine tube
radiation menopause , fibrosis of bowel and
bladder.
Bleeding per rectum
Nausea, vomitting, abdominal cramps,
diarrhoea
CHEMORADIATION
Chemotherapy with radiation
Benefits of systemic chemotherapy with
regional radiation
Chemotherapy sensitize cells to radiation
Increases 5 year survival rate
Usually cisplatin used (40 mg/sq.m)
Combination therapy
In the form of surgery, radiotherapy and
chemotherapy may be done, one following the
other
Fol ow Up
3 monthly for first 2 year
6 monthly for next 3 year
There after annually
Counseling
Palliative treatment
Palliative treatment is primarily aimed to provide
comprehensive care for relief of symptoms
along with treatment of cancer in the
advanced stage.
Five year Survival Rates
I ? 85%
I ? 60 %
I I ? 45%
IV ? 18%
Conclusion
Surgery and radiotherapy have equal results in early
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
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
This post was last modified on 12 August 2021