Cervical Tumor 宫颈肿瘤 Xin LU Obstetrics and Gynecology Hospital Fudan University

Contents  CIN  HPV  Histology  Pathology  Diagnosis  Treatment  Cervical Cancer  General information  Pathology  Spread pattern  FIGO staging  Clinical signs  Diagnosis and differential diagnosis  Principle for treatment  Prevention

Key words Human Papillomavirus (HPV) Human Papillomavirus (HPV) Radical Hysterectomy (RH) Radical Hysterectomy (RH) Radiotherapy (RT) Radiotherapy (RT) Chemotherapy (CT) Chemotherapy (CT) Neoadjuvant chemotherapy Neoadjuvant chemotherapy (NACT) (NACT) Concurrent chemo-radiotherapy Concurrent chemo-radiotherapy (CCCR) (CCCR) Radical Trachelectomy Radical Trachelectomy人乳头瘤状病毒广泛全子宫切除术放射治疗化学治疗新辅助化疗同步放化疗宫颈根治术

Female Reproductive Anatomy

Transformation Zone

Cervical Cancer 子宫颈癌  World report:  Account for 1/3 female malignancies  New cases:  Death:   85% developing country  The 4th most common cause of death from malignancy in women.

流行病学 新发病例数 死亡病例数

Cervical cancer progression HPV infection HPV infection CINs 10-15yrs CINs 10-15yrs Carcinoma in situ Carcinoma in situ Cervical cancer Cervical cancer

Cervical tumorigenesis Progression Progression  Host immunity  Environmental factors  Genetics:  oncogene E6, E7 tumor suppresor gnen p53, Rb tumor suppresor gnen p53, Rb Regression Regression

High Risk Factors  HR-HPV  Use of oral contraceptives  Smoking  Multiple sexual partners  History of herpes infection  History of STD

Human Papillomavirus, HPV 人乳头瘤状病毒 1972 ： Harald zur Hausen 1995 ： High-risk HPV by International Agency for Research on Cancer ， IARC 90% cervical cancer with HPV infection

HPV High risk HPV （ HR-HPV ） oncogenic HPV HPV 16,18,31,33,35,39,45,51,52,56,58,59,68,73,82 HSIL, Cervical cancer Low risk HPV （ LR-HPV ） non-carcinogenic HPV HPV 6,11,42,43,44,54,61,70,72,81 LSIL

Precursors CIN: 宫颈上皮内瘤样病变 CIN I ： mild dysplasia ， 1/3 CIN I ： mild dysplasia ， 1/3 CIN II ： moderate dysplasia ， 1/3-2/3 CIN II ： moderate dysplasia ， 1/3-2/3 CIN III ： severe dysplasia CIN III ： severe dysplasia CIS(carcinoma in situ) 原位癌 CIS(carcinoma in situ) 原位癌

CIN

Histological Types Squamous carcinoma 80-85% Adenocaricinoma 15-20% Endometrial carcinoma Clear cell carcinoma Adenosquamous 3-5% Undifferentiated carcinoma From ： 2003 年 WHO 女性生殖器官肿瘤 From ： 2003 年 WHO 女性生殖器官肿瘤\

Spread pattern Local tumor extension Local tumor extension  most common Lymphatic Lymphatic  pelvic and para-aortic Hematogenous dissemination Hematogenous dissemination  uncommon

FIGO stage

Symptoms Asymptomatic Asymptomatic Abnormal pap smear Abnormal pap smear Watery, blood-tinged vaginal discharge Watery, blood-tinged vaginal discharge Post-coital bleeding Post-coital bleeding Pelvic pain Pelvic pain

 History  Physical examination  Cytology (pap smear, TCT, HPV)  Biopsy (colposcopy)  Conization  Imaging Diagnosis

Platform of diagnosis for cervical diseases  Pap smear TBS classification  TCT  HPV  Colposcopy--biopsy  LEEP

Colposcopy 阴道镜

Conization 宫颈锥切

 Cervicitis  Cervical polyps  Benign cervical tumor:myoma Differential Diagnosis

宫颈糜烂分度 轻 度 轻 度 中 度 中 度 重 度 重 度 宫颈糜烂分型 单纯型 颗粒型 乳突型

Cervical polyps 宫颈息肉

Principle for cervical cancer treatment Evidence based medicine Evidence based medicine  FIGO ( International Federation of Gynecology and Obstetrics)  NCCN (National Comprehensive Cancer Network) Individualized therapy ； Individualized therapy ；

TREATMENT Precursor- CINs Precursor- CINs Micro-invasive cancer Micro-invasive cancer Invasive cancer Invasive cancer

CINs CIN I: follow up 3—6months CIN I: follow up 3—6months CIN II: CIN II:  local therapy  conization CIN III: CIN III:  conization  hysterectomy

Stage Ia1: hysterectomy Stage Ia1: hysterectomy Stage Ia2: modified hysterectomy Stage Ia2: modified hysterectomy Stage Ia with positive margin (Ia or CIS): radical hysterectomy Stage Ia with positive margin (Ia or CIS): radical hysterectomy Micro-invasive cervical cancer

Surgical treatment Ib-IIa Surgical treatment Ib-IIa Radiotherapy Radiotherapy Chemotherapy Chemotherapy Combined therapy Combined therapy Treatment for invasive cervical cancer

Cervical cacner （Ⅰ b - Ⅱ a) RH+PLND+/- PAD 1. 标准的手术方式：广泛全子宫切除 + 盆腔淋巴清扫术 ; 2. 盆腔淋巴结清扫术 腹股沟深淋巴结 腹股沟深淋巴结 髂淋巴结 髂淋巴结 闭孔淋巴结 闭孔淋巴结 3. 腹主动脉旁淋巴结取样的指征： 可疑的腹主动脉旁及髂总淋巴结 可疑的腹主动脉旁及髂总淋巴结 大块附件病灶及增大的盆腔淋巴结 大块附件病灶及增大的盆腔淋巴结 浸润肌层全层的低分化肿瘤 浸润肌层全层的低分化肿瘤

Post-surgical treatment (high risk factors) poor differentiated poor differentiated deep myometrial invasion LVSI LN positive positive margin

Advanced stage （Ⅱ b ，Ⅲ，Ⅳ ) Radiotherapy (RT) Radiotherapy (RT) NACT + Radiotherapy NACT + Radiotherapy Concurrent chemo-radiotherapy ； Concurrent chemo-radiotherapy ； Combined RT and CT Combined RT and CT

Trachelectomy Fertility sparing Fertility sparing Ib <4cm Ib <4cm Evaluation of infertility factor Evaluation of infertility factor Procedure of trachelectomy Procedure of trachelectomy Complications Complications Outcome Outcome

Primary prevention 1. Health care 2. Sexual behavior 3. Dual protection 4. HPV vaccines 4. Cancer screening 5. Treat precursors Prevention Secondary prevention 1.Early screening 2. Early treatment

Take home message HPV (HR) HPV (HR) CINs CINs FIGO stage FIGO stage Surgery: Radical hysterectomy and PLND Surgery: Radical hysterectomy and PLND Post-operation treatment: high risk factors Post-operation treatment: high risk factors RT and CT RT and CT Fertility sparing trachelectomy Fertility sparing trachelectomy HPV Vaccine HPV Vaccine

OB/GYN Hospital of Fudan University THANKS