Cervical cancer

Assistant Professor Obstetrics & Gynaecology /Director Medical Education unit um Vision college of Medicine Riyadh, KSA
23. Jan 2019

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Cervical cancer

  1. Cervical cancer Dr. Shazia Iqbal
  2. OBJECTIVES  Understand the pathogenesis of lower genital tract malignancy  Understand primary prevention of cervical cancer through human papillomavirus (HPV) vaccinationand cervical screening.  Understand the diagnosis, International Federation of Gynecology and Obstetrics (FIGO) staging and management of premalignant and malignant disease of the Cervix
  3. Presentation Overview Cervical cancer ◦ Cause: Human Papilloma Virus (HPV) ◦ “Natural history” ◦ Treatment Preventing cervical cancer ◦ Avoiding exposure to HPV ◦ Current screening guidelines ◦ The new HPV vaccines
  4. Cervical Cancer Abnormal cell (Malignant) growth on cervix (lowest part of the uterus) Caused by HPV infection, especially during the first years after puberty Pre-cancerous changes long before invasive cancer develops A major cause of death worldwide Cervical screening has been shown to reduce both the incidence and the number of deaths from cervical cancer in higher income countries. It has been estimated that cervical screening prevents around 5,000 deaths every year in UK alone.
  5. Human Papillomavirus (HPV) known to cause warts Found in many cancers too Over 100 types identified Most benign, but 15-20 can cause cancers Very common ◦ 20,000,000 current cases in US ◦ 6,200,000 new cases annually ◦ 80% of women have HPV by age 50 ◦ 50% of college students are infected
  6. Common HPV Types and their effects HPV Types Lead to: Low-Risk High-Risk HPV 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81 HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82 Benign cervical changes Genital warts Precancer cervical changes Cervical cancer Anal and other cancers 1. Cox. Baillière’s Clin Obstet Gynaecol. 1995;9:1. 2. Munoz et al. N Engl J Med. 2003;348:518.
  7. Squamo-columnar junction (SCJ) Tubular cervix is composed of stromal tissue covered by squamous epithelium in the vagina (ectocervix) Columnar epithelium withinthe cervical canal (endocervix). The endocervix contains many deep folds, called crypts, that are lined by columnarepithelium. The meeting of the two types of epithelium is called the squamocolumnar junction (SCJ) and this is usually on the ectocervix (Figure 16.1). The position of the SCJ varies throughout life. In children it lies at the external cervical os, at puberty it extends outwards onto the ectocervix as the cervix enlarge.
  8. What is transformational zone? In adult life it returnsto the external cervical os through the process of metaplasia, which is the physiological transformation of columnar epithelium to squamous epithelium. The so-called ‘transformation zone’ (TZ) is defined as the area between the original SCJ and the current SCJ where the epithelium changes from columnar to squamous epithelium over time. Sometimes the columnar epithelium is covered by squamous epithelium, leading to retention of mucus this is called a nabothian follicle (Figure 16.2). The TZ is the site where premalignancy and malignancy develop
  9. Human Papillomavirus  Cancer of cervix 100%  Cancer of esophagus .  Cancer of skin .  Cancer of X,Y,Z…. .  Cancer of mouth 3%  Cancer of throat 12%  Cancer of penis 40%  Cancer of vulva, vagina 40%  Cancer of anus 90% Parkin DM et al. CA Cancer J Clin 2005; 55:74-108.
  10. Natural History of HPV Infections Sexually transmitted ◦ Usually no symptoms ◦ No treatment for HPV infection before symptoms ◦ Immune system clears most cases; some persist HPV present in >99% of cervical cancers ◦ High risk types (16, 18) associated with cancer ◦ Low risk types (6, 11) are associated with genital warts ◦ All can cause abnormal Pap tests Human Papillomavirus. ACOG Practice Bulletin No. 61. 2005; 105: 905-18.
  11. Regression and progression of CIN Spontaneous regression of low-grade disease is common and is likely to occurthrough the patient’s own cell- mediated immunity. This is the argument for observational follow-up in patients with low-grade abnormality. High-gradedisease is less likely to regress spontaneously and requires treatment,as there is a risk of progression to cancer. If left untreated, around 20% of patientswith high-grade abnormalities develop cancer of the cervix.
  12. Co-factors for HPV Infection ◦ Smoking ◦ HIV infection ◦ Other immune system defect ◦ Pregnancy ◦ Oral contraceptive use Ferris et al. Modern Colposcopy. 2004.
  13. History of the Conventional Pap Smear Developed by Dr. George N. Papanicolaou in 1940’s Most common cancer screening test Key part of annual gynecologic examination Has greatly reduced cervical cancer mortality in U.S. 14 Ferris et al. Modern Colposcopy. 2004: 2-4, 49. Photo accessed from
  14. Screening with the Conventional Pap Smear Widely available Inexpensive But not perfect Screening test – not diagnostic 7-10% of women need further evaluation Low sensitivity – need regular repeats 15Cervical Cytology Screening. ACOG Practice Bulletin No. 45. 2003; 102:417-27.
  15. New Liquid Pap Tests More accurate test Thin, uniform layer of cells Screening errors reduced by half Screening needed less often Can test for HPV with same specimen if abnormal cells found Expensive 16 Linder J. et al. Arch Pathol Lab Med. 1998; 122: 139-144.
  16. Preventing Cervical Cancer Screening for precancerous changes (and treatment if problems found) Vaccination against HPV 19
  17. Cervical Cancer Screening Guidelines RCOG First screen 3 years after first intercourse or by age 21 Women aged 25–64, Screen annually with regular Paps or every 3-5 years with liquid-based tests Stop at 65-70 years with history of negative tests
  18. Colposcopy
  19. NEW! The HPV Vaccine Gardasil ® (Merck) Protects against types 16, 18, 6, 11 FDA approved for use Prevents HPV infection; doesn’t treat existing infection Virus-like particles (VLP) Highly effective Safe, few serious adverse side effects Requires 3 injections Expensive ($360 + administrative fees)
  20. HPV Vaccine ACOG Recommendations VACCINATE all females 9-26 years old, regardless of sexual activity Less potential benefit with increasing age & number of sexual partners Special populations – vaccine less effective Previous abnormal Pap tests or genital warts Immunocompromised continue screening with Pap tests! Human Papillomavirus Vaccination. ACOG Committee Opinion No. 344. 2006; 108: 699-705.
  21. Cervical cancer
  22. Clinical presentaion
  23. Investigations