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Published on : Feb 24, 2014
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Slide 1 - 10/99 1 Cervical Cancer & Pap Smears
Slide 2 - Epidemiology 16,000 cases / year Incidence  but mortality from cervical cancer  over the past 50 years Cervical CA is still the 7th most common cancer in females and the 8th most common cause of death 10/99 2
Slide 3 - Etiology Human Papiloma Virus (HPV) + an unidentified co-carcinogen 10/99 3
Slide 4 - Risk Factors 1. Multiple sexual partners (> 1) 2. Average age 35-45 years 3. Coitus before the age of 18 years. 4. Delivery of the first baby before the age of 20 years. 5. Multiparity with poor birth spacing between pregnancy. 6. Poor personal hygeine. 7. Poor socioeconomic status. 8. Women with preinvasive lesions. Prior STDs (HSV II, genital warts, vaginal infections) Cigarette Smoking, and drugs abuse including alcohol. Oral Contraceptive usage Immunodeficiency Women who do not come for regular health check up and Pap tests. 10/99 4
Slide 5 - Age of Onset Carcinoma In-Stiu (CIS) 30 years Cervical Intraepithelial Neoplasia (CIN) 35 years Invasive Cervical Cancer 45 years 10/99 5
Slide 6 - Histological Types Squamous Cell Carcinoma 80-95% Adenocarcinoma 5-20% Other: Clear cell, sarcomas 10/99 6
Slide 7 - Symptoms CIN: Asymptomatic Invasive Cancer No classic presentation May present with abnormal vaginal bleeding May present with postcoital bleeding 10/99 7
Slide 8 - Physical Exam CIN Cervix appears normal to general inspection Invasive Cancer Exophytic growth seen on cervix Growth: Cauliflower-like, friable, deeply ulcerated Advanced Cancer Pelvic Masses Palpable 10/99 8
Slide 9 - Metastasis Morbidity and Mortality associated with regional spread of the cancer Spreads to pelvic nodes, ureters, bladder, rectum. Dangerous when cancer blocks ureters resulting in uremia --> death Hematogenous spread- uncommon 10/99 9
Slide 10 - Pathogenesis Site where squamous epithelium of vagina meets columnar epithelium of endocervix known as squamocolumnar junction (SCJ) Before puberty: SCJ located just inside the cervical os At puberty, increasing levels of estrogen lead to squamous metaplasia of columnar epithelium to squamous epithelium Results in repositioning of the SCJ further towards the uterus 10/99 10
Slide 11 - Pathogenesis (2) Region between the old and new SCJs known as the transformation zone Transformation zone is the site of 95% of the cervical cancer development Since zone is located within the cervical os, unable to be viewed during routine pelvic exam Exposure of transformation zone to carcinogens begins process of intraepithelial neoplasia While exact role of carcinogens in this process remains poorly understood, it is clear that HPV and cigarette smoking can cause dysplasia at the transformation zone 10/99 11
Slide 12 - Human Papiloma Virus (HPV) Certain types of HPV are responsible for genital warts, others for dysplasia/cancer HPV Types 6 & 11 associated with development of genital warts Types 16,18,31,33,35,39,45,51,52,56,58 associated with development of dysplasia/cancer 10/99 12
Slide 13 - Pap Smears Strong sensitivity and specificity Accuracy of Smear Requires adequate sample presence of enough inflamation and dysplasia quick fixation of specimen to glass slide 10/99 13
Slide 14 - When to Get Pap Smears ACOG Recommendations 1st Pap Smear at age when patient becomes sexually active (or by age 18) Yearly pap smears thereafter Others contend that monogamous women with no history of abnormal pap smears can have them done every 3 years 10/99 14
Slide 15 - Performing Pap Smear Patient asked to lie on her back at edge of exam table with feet in stirrups Metal or plastic speculum is inserted into vagina to expand the wall of vagina to enable access to cervix Cells are collected using cotton swab, wooden spatula, or cervical brush and smeared onto glass slide Preservative sprayed to prevent cells from drying and artifacts from forming Slide evaluated by lab technician who looks for abnormalities in the 50,000 to 300,000 cells on slide 10/99 15
Slide 16 - Pap Smear Classification Systems The Class System (I to V) The CIN System (CIN I to III) characterizes the degree of cellular abnormalities The SIL System (Bethesda System) Lesions characterized as LGSIL or HGSIL Presence of HPV noted This scheme is most widely used system these days 10/99 16
Slide 17 - Evaluating the Pap Smear First, the smear is evaluated for adequacy of sample Secondly the sample is categorized as “normal” or “other” Lastly, all sample categorized as “other” are further specified as infection, inflammation, or various stages of cancer 10/99 17
Slide 18 - What to Inform Patients Prior to Obtaining Pap Smear No douching or usage of vaginal medications, lubricants, or spermicides within 2-3 days of exam (these products may hide abnormal cells) Schedule Pap Smear between days 12-16 of menstrual cycle, if possible Abstain from intercourse 1-2 days prior to smear 10/99 18
Slide 19 - Pitfalls of Diagnosing Cervical Cancer 30% of cases of cervical cancer are missed due to errors interpreting results of pap smears Ways of Improving Pap Smears rescreen portions of slide deemed negative to reduce false-negatives new liquid smears may be have higher sensitivty and specificity usage of computerized devices to analyze smear (PAPNET, VIRAPAP) 10/99 19
Slide 20 - Improving Access to Pap Smears 50% of patients who die of cervical cancer have never had a Pap Smear Uninsured, minorities, older patients and those who live in rural areas have limited access to Pap Smears These groups must be targeted to further reduce rates of cervical cancer in the US 10/99 20
Slide 21 - Precursor Lesions Reason for thorough classification schemes for intraepithelial lesions is to determine the likelihood of such lesions progressing to overt cancer Usual progression from mild dysplasia to overt cancer takes 7-8 years Precursor lesions characterized as mild dysplasia have 65% chance of spontaneously regressing, 20% chance of remaining the same, 15% chance of worsening 10/99 21
Slide 22 - Precursor Lesions (2) Unfortunately, we are unable to predict with much accuracy, which lesions will regress and which will worsen over time For this reason, ACOG recommends any patient with a mildly abnormal smear undergo further evaluation with culposcopy and/or biopsy 10/99 22
Slide 23 - Culposcopy Culposcope: A stereomicroscope that enables investigators to examine areas of dysplasia and select best sites to biopsy device has green filter that helps identify presence of blood vessels (an ominous sign) Before culposcopy, cervix coated with acetic acid which enhances presence of dysplasia Key to culposcopy is complete visualization of transformation zone 10/99 23
Slide 24 - Cone Biopsy Reasons for Performing Cone Biopsy Investigator is unable to visualize the entire transformation zone Endocervical curretage shows dysplastic changes Results of Pap Smear are remarkably different than results from culposcopy Cone biopsy is a minor surgical procedure to further investigate the transformation zone Performed using a scalpel or laser 10/99 24
Slide 25 - Treatment of CIN Most effective treatment is excision of precursor lesions Ways to Remove Lesions Cryocautery- freezing, thawing, & refreezing lesion Culposcopic Laser Therapy- more accurate, capable of removing low and high grade lesions Excisional Biopsy- performed on low grade lesion Always schedule follow-up Pap Smears to assure lesions have not returned 10/99 25
Slide 26 - Managing Cervical Cancer All visible lesions should be biopsied Lesions must be properly staged to determine whether cancer has spread and help determine therapeutic approach Cervical Cancer spreads by lymphatics or direct invasion Lymphatic Spread: Cervical/paracervical nodes  regional nodes  deep pelvic nodes Direct spread: To bladder, vagina, parametria, rectum CT Scan helpful in assessing cancer that has spread 10/99 26
Slide 27 - Treatment of Invasive Cervical Cancer Option 1: Surgery Useful in patients with Stage I and II cancer Radical hysterectomy is procedure of choice for overt cancer When performing surgery, spare ovaries so they can continue to manufacture estrogen Potential pitfalls of surgery: hemorrhage, damage to nerves supplying bladder, formation of fistula 10/99 27
Slide 28 - Treatment of Cervical Cancer Option 2: Radiation Reserved for poor surgical candidates or patients with advanced disease Problems with radiation- infertility, radiation cystitis, fibrosis Usually ineffective in patients with recurrent cervical cancer 10/99 28
Slide 29 - Prognosis Patients with CIS and cancer limited to cervix- cure rate 90-100% Patients with advanced cervical cancer- cure rate is 25-50% 10/99 29
Slide 30 - Reasons for Such Good Prognosis for Cervical Cancer Presence of an easily identifiable precursor lesion Slow progression of cancer Access to cheap non-invasive diagnostic tools (Pap Smears and Culposcopy) Simple and effective treatments 10/99 30