宮頸癌的診斷和治療

1、 CERVICAL CANCER.Diagnosis Treatment12CERVICAL CANCER.The most common malignancy in gynecological oncologyIncidence: 7.8/100,000Mortality: 2.7/100,000Diagnosis: biopsyMain modality of treatment: surgery and radiationGoal of treatment: cure, except stage 4b 3Special Case38 yrs, G3/P1, nurseC/O: postc

2、oital bleeding for 2 monthsMenstruation regular with 30 days cycle and 5 days duration. Abnormal discharge with bad smell. LMP: 12 days agoPap smear: squamous cell cancer PV: Vulva : Normal, Vaginal: yellowish discharge with bloody stained, Cervix: growth with ulceration and contact bleeding.Uterus:

3、 N/S, mobile. Parametrium: thickening not to pelvic sidewall on both side4 CERVICAL CANCER. How can we make a diagnosis? How can we evaluate the patient?How can we manage the patient? How should we explain to the patient? Can we prevent cervical cancer? 5How can we make a diagnosis?SYMPTOMSAbnormal

4、vaginal bleeding postcoital bleeding* contact bleeding Abnormal vaginal dischargeAsymptomatic, just abnormal pap smear6SYMPTOMSThe classic symptom is intermittent, painless metrorragia or spotting only postcoitally or after douching.Probably the first symptom of early cancer of the cervix is a thin,

5、 watery, blood-tinged vaginal discharge that frequently goes unrecognized by the patients.As the maligancy enlarges, the bleeding episodes become heavier and more frequent, and they last longer.7SYMPTOMSLate symptom or indicators of more advanced disease include the development of pain referred to t

6、he flank or leg.Many patients c/o dysuria, hematuria or rectal bleeding or obstipation resulting from bladder or rectal invasion.Distant metastasis and persistent edema of one or both lower extremities as a result of lymphatic and venous blockage by extensive pelvic wall disease are late manifestati

7、on of primary disease and frequent manifestations of recurrent disease.8How can we make a diagnosis?SIGNSVagina: mucous, fornixCervix: erosion growth ulceration barrel-shapedUterus: size, mobilityParamet: thickening 9Gross appearenceThree categories of gross lesions have traditionally been described

8、.The 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.Little visible ulceration or exophytic mass like a stone-hard cervix that regresses slowly with rad

9、iation therapy.Ulcerative tumor,usually erodes a portion of the cervix or replacing the cervix , erodes a portion of the upper vaginal vault with a large crate.1011121314How can we make a diagnosis?CLINICAL TESTS:Pap smearColposcopy and target biopsyEndocervical curettage (ECC)Cone biopsyBiopsy15Pap

10、 smearPap smear is the most common and effective screening method.Exfoliated cervical cells are scraped from the cervix by spatula. The entire T zone must be sampled. Incomplete sampling could produce a false-negative smear.The endocervical canal is also sampled with a swab or cytobrush.Cells are fi

11、xed immediately to avoid air-drying cytologic artifacts 16Pap Smear Show Squamous Cell Carcinoma17Colposcopy and directed biopsyA pap smear is only a screening test. A definitive diagnosis requires inspection of a well-visualized cervix with a colposcope.The cervix is painted with 3% acetic acid sol

12、ution to enhance surface alterations and vascular changes.The colposcope evaluation is considered adequate or satisfactory if the complete T zone and full extent of the lesions is visualized.Areas of abnormality(e.g., White epithelium, mosaicism, and punctation) are selectively punch biopsied. 18Col

13、poscopy Examination19Cone biopsyIndications for cone biopsy 1.The lesion cannot be fully visualized . 2.The ECC is posituve 3.There is significant discrepancy between the Pap smear and biopsy. 4.A biopsy reveals microinvasive squamous cell carcinoma 5.A biopsy reveals adenocarcinoma in situ202122How

14、 can we make a diagnosis?A pap smear is only a screening test! Definitive diagnosis of cervical cancer requires a BIOPSY!23How can we evaluate the patient?Histologic type:Squmous cell carcinoma ( SCC) 80%Adenocacinoma 10%-15%Others 5%-10%24Routes of spreadInto the vaginal mucosa,extending microscopi

15、cally down beyond visible or palpable disease;Into the myometrium of the low uterine segment and corpus, particularlly with lesions arising from the endocervix.Into the paracervical lymphatics and from there to the most common involved lymph nbodes ( the obturator; hypogastric,and external iliac nod

16、es).Direct extesion into adjacent structures or parametria, reaching to the obturator fascia and the wall of the true pelvis25How can we evaluate the patient?Stage: Pelvic examination, Rectovaginal examination, Intravenous pyelography(IVP) Ultrasonography or CTStaging is clinical, but can use IVP an

17、d CTCervical cancer is the only gynecologic malignancy that is not surgically staged26Clinical Staging for Cervical CarcinomaStage 0Carcinoma-in situ; Confined to the epithelium only27Clinical Staging for Cervical CarcinomaStage I Invasion is strictly confined to the cervixIa: Invasive cancer identi

18、fied only microscopically .Ia1: Minimal microscopically evident stromal invasion =3mm in depth and no wider than 7mm.Ia2: Microscopic invasion 50%PV: Vulva and vaginal: normal Cervix: erosion with contact bleeding,Uterus: N/S, mobile. Parametrium: clear Wants to preserve her reproductive function 44

19、Treatment strategy for CIN45Case discussion 48 yrs, G3/P1, midlife C/O: postcoital bleeding for 4 monthsMenstruation irregular with 30-60 days cycle and 5-20 days duration. Abnormal discharge with bad smell. LMP: 2 months agoPap smear: squamous cell cancer PV: Vulva : Normal, vaginal: right fornix involved by cervical growth. Cervix: growth with ulceration and contact bleeding.Uterus: N/S, mobile. Parametrium: nodular thickening to pelvic sidewall on rightB