宮頸癌的診斷和治療

1、 cervical cancer. cervical cancer. lthe most common malignancy in gynecological oncology lincidence: 7.8/100,000 lmortality: 2.7/100,000 ldiagnosis: biopsy lmain modality of treatment: surgery and radiation lgoal of treatment: cure, except stage 4b special case l38 yrs, g3/p1, nurse lc/o: postcoital

2、 bleeding for 2 months lmenstruation regular with 30 days cycle and 5 days duration. abnormal discharge with bad smell. lmp: 12 days ago lpap smear: squamous cell cancer lpv: vulva : normal, lvaginal: yellowish discharge with bloody stained, lcervix: growth with ulceration and contact bleeding. lute

3、rus: n/s, mobile. lparametrium: thickening not to pelvic sidewall on both side cervical cancercervical cancer. . lhow can we make a diagnosis? how can we make a diagnosis? lhow can we evaluate the patient?how can we evaluate the patient? lhow can we manage the patient? how can we manage the patient?

4、 lhow should we explain to the patient? how should we explain to the patient? lcan we prevent cervical cancer?can we prevent cervical cancer? how can we make a diagnosis?how can we make a diagnosis? symptomssymptoms labnormal vaginal bleeding abnormal vaginal bleeding postcoital bleedingpostcoital b

5、leeding* * contact bleeding contact bleeding labnormal vaginal dischargeabnormal vaginal discharge lasymptomaticasymptomatic, just abnormal , just abnormal pap smearpap smear symptoms lthe classic symptom is intermittent, painless metrorragia or spotting only postcoitally or after douching. lprobabl

6、y the first symptom of early cancer of the cervix is a thin, watery, blood-tinged vaginal discharge that frequently goes unrecognized by the patients. las the maligancy enlarges, the bleeding episodes become heavier and more frequent, and they last longer. symptoms llate symptom or indicators of mor

7、e advanced disease include the development of pain referred to the flank or leg. lmany patients c/o dysuria, hematuria or rectal bleeding or obstipation resulting from bladder or rectal invasion. ldistant metastasis and persistent edema of one or both lower extremities as a result of lymphatic and v

8、enous blockage by extensive pelvic wall disease are late manifestation of primary disease and frequent manifestations of recurrent disease. how can we make a diagnosis?how can we make a diagnosis? lsigns lvagina: mucous, fornix lcervix: erosion growth ulceration barrel-shaped luterus: size, mobility

9、 lparamet: thickening gross appearence lthree categories of gross lesions have traditionally been described. lthe 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-shap

10、ed lesion. llittle visible ulceration or exophytic mass like a stone-hard cervix that regresses slowly with radiation therapy. lulcerative tumor,usually erodes a portion of the cervix or replacing the cervix , erodes a portion of the upper vaginal vault with a large crate. how can we make a diagnosi

11、s?how can we make a diagnosis? clinical tests:clinical tests: lpap smearpap smear lcolposcopy and target biopsycolposcopy and target biopsy lendocervical curettage (ecc)endocervical curettage (ecc) lcone biopsycone biopsy lbiopsybiopsy pap smear lpap smear is the most common and effective screening

12、method. lexfoliated cervical cells are scraped from the cervix by spatula. the entire t zone must be sampled. incomplete sampling could produce a false-negative smear. lthe endocervical canal is also sampled with a swab or cytobrush. lcells are fixed immediately to avoid air-drying cytologic artifac

13、ts colposcopy and directed biopsy la pap smear is only a screening test. a definitive diagnosis requires inspection of a well-visualized cervix with a colposcope. lthe cervix is painted with 3% acetic acid solution to enhance surface alterations and vascular changes. lthe colposcope evaluation is co

14、nsidered adequate or satisfactory if the complete t zone and full extent of the lesions is visualized. lareas of abnormality(e.g., white epithelium, mosaicism, and punctation) are selectively punch biopsied. cone biopsy lindications for cone biopsy 1.the lesion cannot be fully visualized . 2.the ecc

15、 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 situ how can we make a diagnosis?how can we make a diagnosis? la pap smear is only a a pap smear is only a screening test! s

16、creening test! ldefinitive diagnosis of definitive diagnosis of cervical cancer cervical cancer requires a biopsy!requires a biopsy! how can we evaluate the patient? histologic type:histologic type: lsqumous cell carcinoma ( scc) 80%squmous cell carcinoma ( scc) 80% ladenocacinoma 10%-15%adenocacino

17、ma 10%-15% lothers 5%-10%others 5%-10% routes of spread linto the vaginal mucosa,extending microscopically down beyond visible or palpable disease; linto the myometrium of the low uterine segment and corpus, particularlly with lesions arising from the endocervix. linto the paracervical lymphatics an

18、d from there to the most common involved lymph nbodes ( the obturator; hypogastric,and external iliac nodes). ldirect extesion into adjacent structures or parametria, reaching to the obturator fascia and the wall of the true pelvis how can we evaluate the patient? lstage:stage: pelvic examination, p

19、elvic examination, rectovaginal examination, rectovaginal examination, intravenous pyelography(ivp) intravenous pyelography(ivp) ultrasonography or ctultrasonography or ct lstaging is clinical, but can use ivp and ctstaging is clinical, but can use ivp and ct lcervical cancer is the only gynecologic

20、 cervical cancer is the only gynecologic malignancy that is not surgically stagedmalignancy that is not surgically staged clinical staging for cervical carcinoma lstage 0 carcinoma-in situ; confined to the epithelium only clinical staging for cervical carcinoma lstage i invasion is strictly confined

21、 to the cervix ia: invasive cancer identified only microscopically . ia1: minimal microscopically evident stromal invasion =3mm in depth and no wider than 7mm. ia2: microscopic invasion 50% lpv: vulva and vaginal: normal cervix: erosion with contact bleeding,uterus: n/s, mobile. parametrium: clear l

22、wants to preserve her reproductive function treatment strategy for cin leep (ectocervix), co2 laser therapy, cryotherapy no suspicion of invasion cone biopsy, cold knife cone, laser cone, leep cone (ecto and endocervix) suspicion of invasion biopsy endocervical currettage repeat pap smear suspicion

23、of cin/sil pap smear result abnormal case discussion l48 yrs, g3/p1, midlife lc/o: postcoital bleeding for 4 months lmenstruation irregular with 30-60 days cycle and 5-20 days duration. abnormal discharge with bad smell. lmp: 2 months ago lpap smear: squamous cell cancer lpv: vulva : normal, vaginal

24、: right fornix involved by cervical growth. cervix: growth with ulceration and contact bleeding.uterus: n/s, mobile. parametrium: nodular thickening to pelvic sidewall on right lbiopsy:scc. ivp:nonfunctional kidney treatment strategy for invasive cervical cancer cone biopsy or simply hysterectomy microinvasive invasion (less than 3mm) r