Professional Documents
Culture Documents
Female Genital
Tumor
Dr. Yang
Section one
Premalignant
and Malignant
Disorders of the
Uterine Cervix
Dysplasia and Carcinoma in
Situ of the Cervix
•
• This is normal
cervical non-
keratinizing squamous
epithelium. The
squamous cells show
maturation from basal
layer to surface.
CIN
CIN I (mild dysplasia)– disordered
growth of the lower third of the
epithelial lining.
CIN II (moderate dysplasia) –
abnormal maturation of two-thirds of
the lining.
CIN III (severe dysplasia) –
encompasses more than two-thirds
of the epithelial thickness with
carcinoma in situ (CIS) representing
CIN I
CIN II
CIN III
Ca in situ
Bethesda System
Specimen type – conventional smear (Pap
smear); liquid-based; other
Result :
HPV45
8%
HPV31 HPV16
5% 50%
Pathology
Adenocarcinoma in situ(ACIS) – the
presence of endocervical glands
lined by atypical columnar epithelium
that cytologically resembles the cells
of endocervical adenocarcinoma, but
that occur in the absence of stromal
invasion.
Method– cone biopsy.
This is the gross Here is another cervical
appearance of a squamous cell carcinoma.
cervical Note the IUD string
squamous cell protruding from the cervix.
carcinoma that is This implies that someone
still limited to the could have done a Pap
cervix (stage I). smear when it was
The tumor is a inserted. There is a natural
fungating red to history of progression of
dysplasia to carcinoma, so
Clinical Findings
Symptoms and Signs – most people
no. People with sexually active
should be given cytologic exmination
once a year.
Special examination -- abnormal pap
smear should be done. eg. Repeat
cytology; HPV testing; the Schiller
test; colposcopy; directed biopsy;
endocervical curettage; cone biopsy.
Special examination
1 Repeat cytology. AUS-US – repeat
every 4-6 months; AUS-H –
colposcopy
2 HPV testing.
3 Schiller test. Glycogen + iodine ---
deep mahogany-brown color.
Nonstaining:
columnar\scar\cyst\cancer.
4 Colposcopic examination.
5 Cone biopsy.
Colposcopic examination
Normal findings:
original squamous epithelium;
transformation zone;
columnar epithelium.
Abnormal findings:
leukoplakia or hyperkeratosis;
acetowhite epithelium;
mosaicism or punctation reflecting
abnormal vascular patterns of the surface
capillaries
Treatment
Cryotherapy
Laser ablation
Cold knife conization
Laser cone excision
Leep– loop electro-surgical excision
procedure.
Figure 17-2
Cancer of the
Cervix
Cancer of the Cervix
The second common cause of
cancer-related morbidity and
mortality
The average age is 51
Over 95% of patients with early
cancer of the cervix can be cured
Etiology and
Epidemiology
Risk factors – the same with CIN
HPV – the central
HPV16 – the most prevalent in
squamous cell carcinoma
HPV18 – most prevalent in
adenocarcinoma
Others – immunosuppression \HIV
\STD \tobacco \high parity \oral
contraceptive use.
Pathogenesis and
natural history
HPV infection: asymptomatic latent
infection; active infection; neoplastic
transformation
Spread :
direct extension;
lymphatic spread –
main (parametrial, hypogastric, obturator,
external iliac, sacral); stage IIB –pelvic
lymph nodes 30-40% (+) para-aortic
nodes 15-30%(+). Stage IVA– para-aortic
45% (+) blood-borne
metastasis. (liver, lungs, others)
Pathology
Squamous cell carcinoma – 70-75%
Adenocarcinoma –20-25%
Adenosquamous – 3-5%
Undifferentiated carcinoma
Pathology
Squamous cell carcinomas and
verrucous carcinomas.
*3types:
large cell nonkeratinizing;
large cell keratinizing;
small cell carcinoma.– worse
prognosis.
Pathology
Adenocarcinoma :
types:
mucinous;
endometrioid;
clear cell;
Serous.
Clinical findings
Symptoms:
1.Abnormal vaginal bleeding:
blood-stained leukorrhea; scant
spotting or frank bleeding .
2. leukorrhea: sanguineous or
purulent, odorous, and nonpruritic.
Postcoital bleeding.
3.Others: pelvic pain; fistula
formation; weakness; weight loss;
anemia.
Clinical findings
Physical signs:
barrel-shaped enlarge; friable;
cauliflower-like; ulceration; necrotic;
adjacent vaginal fornices be
involved; extensive parametrial;
uterosacral and cardinal ligaments
loss mobility and fixation.
Clinical findings
Biopsy:
adequate– schiller-positive areas;
ulcerative; granular; nodular;
papillary leision.colposcopy;
endocervical curettage; conization.
Conization: mark the area
Clinical staging
Is staged by clinical examination, and
evaluation of the bladder, ureters,
and rectum.
Chest x-ray; IVP; CT; cystoscopy;
proctoscopy; PET; MRI;
lymphangiography
CT and surgicopathologic can not
change the stage by examination
before.
FIGO staging of cervical
cancer
Stage o: carcinoma in situ
Stage I A: invasive Cx Ca by
microscopy only
Stage I A1: deeper ≤3mm,
wider≤7mm
Stage I A2: 3mm<deeper<5mm
Stage I B: visible lesion or
microscopic than IA.
Stage I B1:<4cm
FIGO staging of cervical
cancer
Stage II: extend not to pelvic sidewall or lower
third of vagina
Stage IIA: vaginal involvement without
parametrial.
Stage IIB: parametrial involvement
Stage III: extend to pelvic sidewall or/and lower
third of vagina and/or hydronephrosis
Stage IIIA: lower third of vagina
Stage IIIB: pelvic sidewall
Stage IV: extension beyond the true pilvis or
mucosa of rectum or bladder
Stage IVA: adjacent organ
Stage IVB: distant metastases
Differential diagnosis
Cervical ectropion
Cervicitis
Condyloma acuminata
Tuberculosis
Ulceration (syphilis,
lymphogranuloma, chancroid)
Prevention
Risk factors
Screening treatment intervention
education
Treatment one
-- Early stage( stage IA2 to IIA):
Radical hysterectomy and pelvic
lymphadenecomy
Primary radiation with concomitant
chemotherapy
Ovaries may be left intact and be
transposed
Early stage A
Stage IA1 – extrafascial
hysterectomy ; conization for
wishing preserve fertility
Stage IA2 – modified radical
hysterectomy (ligated uterine artery
where it crosses over the ureter;
divided uterosacral and cardinal
ligaments midway towards their
attachment to sacrum and pelvic
sidewall and resected upper third of
Early stage A
Stage IB-IIA– type III hysterectomy
(ligated uterine artery at its origin
from the superior vesical or internal
iliac artery; resected uterosacral and
cardinal ligaments at their
attachments to the sacrum and
pelvic sidewall and resected upper
half of the vagina.
Lymphadenectomy.)
Early stage B
Postoperative adjuvant radiation with
concomitant chemotherapy ---
Positive lymph nodes; positive or
close resection margins or
microscopic parametrial
involvement.
Large tumor size; deep cervical
stromal invasion; lymphovascular
space invasion. -- benefit
Early stage C
Primary radiaton with concomitant
chemotherapy
External beam radiation is generally
used in combination with
intracavitary irradiation.
The superiority of radiation with
concomitant platinum-based
chemotherapy over radiation alone
Treatment two
Locally advanced disease( stage
IIB to IVA): Primary radiaton with
concomitant chemotherapy
Extended field radiation – para-aortic
lymph node metastases.
Treatment three
Disseminated primary ( stage
IVB ) and persistent or recurrent
disease. -- radiaton with
concomitant chemotherapy
Treatment four
Total pelvic exenteration for isolated
central pelvic recurrence of disease
Postreatment
Invasive cervical cancer – 35%
recurrent or persistent
50% death in the first year; 25%
second year; 15% third year.
Prognosis
Factors : stage; lymph node status;
tumor volume; depth of cervical
stromal invasion; lymphovascular
space invasion; lesser extent;
histologic type; grade.
Survival rate 5 years: stage O 99-
100%; IA >95%; IB-IIA 80-90%; IIB
65%; III 40%; IV <20%
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