RCSI_PP_Staff-Template_Sept2023 1.pptx

[Audio] A picture containing sky, outdoor, building, tall Description automatically generated RCSI LEADING THE WORLD TO BETTER HEALTH Click to edit master title style CIN and Cervical Cancer Management Dr Ronan Daly RCSI O&G Clinical Tutor Rotunda Hospital Logo Description automatically generated Presenter Name Title, Department, RCSI.

[Audio] CIN: Describe the natural history of cervical dysplasia. Learning objectives Colposcopy: Describe the role of colposcopy Describe the process of colposcopy including treatments and outcomes Learning objectives: Cervical Cancer: Discuss cervical cancer in terms of its management and staging.

[Audio] Anatomy Ectocervix: projects into vagina, stratified squamous non-keratinised epithelium. Endocervix: connection between vagina and uterus, simple columnar glandular epithelium Transformation zone: squamocolumnar junction that marks the transition between the ectocervix and endocervix.

[Audio] Cervical Cancer Most cervical cancers originate in the transformation zone Most cervical cancers (up to 90%) are squamous cell carcinomas. These cancers develop from cells in the ectocervix and are most commonly caused by Human Papilloma Virus (HPV). Cervical adenocarcinomas develop in the glandular cells of the endocervix and are much rarer. Cervical Intraepithelial neoplasia develops in the transformation zone of the cervix The cervix is divided histologically into the endocervix and the ectocervix The endocervix is lined by columnar epithelium and the ectocervix is lined by squamous epithelium; the junction of these is called the squamocolumnar junction. Under the influence of oestrogen, part of the endocervix everts thereby exposing the columnar epithelium to vaginal environment. This change in pH results in the columnar epithelium transforming by a process of metaplasia to squamous epithelium.

[Audio] HPV & Cervical Cancer Squamous metaplasia HPV Dysplastic changes in transformation zone Cervical intraepithelial neoplasia Cervical cancer The physiological squamous metaplasia that occurs during puberty results in the transformation of columnar epithelium to squamous ectocervical cells in the transformation zone. Persistent high-risk HPV infection can lead to dysplasia and resultant intraepithelial neoplasia in the transformation zone, which can then progress to cervical cancer..

[Audio] Cervical Screening Screening results Where the cervix is suspicious for the presence of cancer, a screening test should not be taken, instead an urgent referral should be made to the colposcopy service. A detailed description of the cervix should be provided on the referral form..

[Audio] Colposcopy Outpatient procedure Patient is placed in the lithotomy position and a cuscos speculum is inserted to visualize the cervix. Cervix is examined closely using a type of biocular microscope called a colposcope. Colposcopy.

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[Audio] Application of acetic acid to cervix Acetic acid dehydrates cells Abnormal areas appear white (aceto-white) due to decreased glycogen and increased protein Application of iodine (Schiller’s test) Iodine is taken up by normal cells with a high glycogen content Abnormal cells do not take up iodine and remain white Colposcopy procedure.

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[Audio] A small punch biopsy may then taken, which is used to give a histological diagnosis. In certain circumstances, a “see and treat” option may be recommended, where a Large Loop Excision of the Transformation Zone (LLETZ) is performed under local anaesthetic. Follow up is crucial (usually 6 months post treatment). LLETZ – wire with a high frequency current running through it Provides both histology and treatment Aims to complete excise any area of abnormality Repeated LLETZ procedures associated with cervical incompetence, a single LLETZ does not affect fertility. Other potential treatment options at colposcopy include cryotherapy, laser vaporisation, cold coagulation. If a large specimen is required, a cone biopsy may be carried out under general anaesthesia in theatre. Decision between see and treat and punch biopsy is usually age-related (e.g. premenopausal may have fertility concerns with LLETZ, S&T usually done in postmenopausal women).

[Audio] Colposcopy - LLETZ procedure LLETZ – wire with a high frequency current running through it Provides both histology and treatment Aims to complete excise any area of abnormality Repeated LLETZ procedures associated with cervical incompetence, a single LLETZ does not affect fertility. Other potential treatment options at colposcopy include cryotherapy, laser vaporisation, cold coagulation. If a large specimen is required, a cone biopsy may be carried out under general anaesthesia in theatre..

[Audio] Cervical intraepithelial neoplasia CIN is a precancerous lesion, diagnosed by histopathological examination of a tissue biopsy, usually colposcopically-directed, and will display the following features: Loss of cellular differentiation Disordered cellular maturation involving squamous epithelium The basement membrane is not involved Grading: CIN 1 involves lower 1/3rd of epithelium. CIN2 involves lower 2/3rd of epithelium CIN 3 involves whole thickness of epithelium. Cervical intraepithelial neoplasia (CIN) 30% of CIN 3 will progress to cervical cancer within 10 years.

[Audio] As progressing from CIN 1 to 3: increasing nuclear : cytoplasmic ratio, large hyperchromatic nuclei, increasing mitosis.

[Audio] Aetiology · In 99.7% of cases, HPV causes precursor lesions that develop into cancer · Oncogenic subtypes are 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, and 58 Risk factors · Smoking · HIV infection/ immunosuppression · COCP use · Peaks in age of incidence in 30’s and in mid 60’s Spread · Direct/ local: inferiorly to vagina, anteriorly into bladder, laterally into parametrium, posteriorly into bowel · Lymphatic: parametrial nodes to iliac nodes (internal, external and common) and the obturator nodes, and later to presacral and para-aortic nodes · Haematogenous: lungs and liver at later stage Cervical Cancer Cervical Cancer.

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[Audio] Clinical presentation History: Abnormal uterine bleeding (AUB): Postcoital bleeding (PCB) Intermenstrual bleeding (IMB) Postmenopausal bleeding (PMB) Persistent blood-stained discharge Later presentation: Anorexia Weight loss Pain - secondary to ureteric obstruction after spread into pelvic side wall Anuria and renal failure (bilateral ureteric obstruction) Palable supraclavicular nodes Deep venous thrombosis could present as a swollen leg Cervical Cancer Staging Cervical Cancer Presentation.

[Audio] Examination: Any patient with AUB requires pelvic examination: a bimanual vaginal examination and speculum examination +/- Cervical biopsy Checking for palpable supraclavicular lymph nodes, renal angle tenderness. Cervical carcinoma may palpate and be visualised as solid or hard, rough, irregular, exophytic, friable. May be immobile in advanced disease. PR examination may reveal a hard mass anteriorly Cervical biopsy can be performed if Ca suspected on speculum examination Can be referred to colposcopy either.

[Audio] Investigations: Clinical history and examination Cervical biopsy Radiology: MRI pelvis (assesses size, invasion, lymph nodes) CT TAP +/- PET CT Examination under anaesthesia Cystoscopy + biopsy if bladder involvement suspected Sigmoidoscopy + biopsy if rectal involvement suspected Staging is based on correlation of physical examination, radiology and pathology after discussion in a MDT forum Cervical Cancer Staging Remember, 70% of cervical cancers will be diagnosed in the developing world, so advanced imaging modalities are not available in that setting.

[Audio] Stage Description 5-year Survival Rate I Carcinoma confined to the cervix 95-98% II Carcinoma invades beyond the uterus, but not to pelvic side wall or lower 1/3 of vagina 60% III Carcinoma involves lower 1/3 of the vagina +/- extends to the PSW +/- causes hydronephrosis or a non-functioning kidney +/- involves pelvic or para-aortic lymph nodes 40% IV Cancer has extended beyond the true pelvis or has involved (biopsy-proven) the mucosa of the bladder or rectum 15-20% Cervical Cancer Staging.

[Audio] Stage Description Stage I (Carcinoma confined to cervix) IA Microscopic invasion, maximum depth <5mm IB Invasive carcinoma confined to uterine cervix, maximum depth >5mm Stage II (Carcinoma invades beyond the uterus, but not to pelvic side wall or lower 1/3 of vagina) IIA Carcinoma limited to upper 2/3 of the vagina with no parametrial involvement IIB Parametrial involvement but not up to the PSW.

[Audio] Stage Description Stage III (Carcinoma involves lower 1/3 of the vagina, PSW, pelvic/para-aortic lymph nodes or causes renal issues) IIIA Involvement of lower 1/3 of the vagina IIIB Involvement of pelvic sidewall and or renal system obstruction IIIC Involvement of para-aortic or pelvic lymph nodes Stage IV (Cancer has extended beyond the true pelvis or has involved (biopsy-proven) the mucosa of the bladder or rectum) IVA Spread to adjacent organs IVB Spread to distant organs.

[Audio] Stage Description 5-year Survival Rate I Carcinoma confined to the cervix 95-98% II Carcinoma invades beyond the uterus, but not to pelvic side wall or lower 1/3 of vagina 60% III Carcinoma involves lower 1/3 of the vagina +/- extends to the PSW +/- causes hydronephrosis or a non-functioning kidney +/- involves pelvic or para-aortic lymph nodes 40% IV Cancer has extended beyond the true pelvis or has involved (biopsy-proven) the mucosa of the bladder or rectum 15-20%.

[Audio] Early stage cervical cancers may be treated surgically: IA can be treated with a cone biopsy IB can be treated with a radical hysterectomy and lymph node evaluation (or radical trachelectomy if fertility a priority). IIA usually requires a radical hysterectomy with pelvic and para-aortic lymph node dissection. Limited role for surgery in later stage cervical cancers : IIB - IV Primary treatment is chemoradiation with brachytherapy. MDT discussion between gynae-oncologists, radiologists, oncologists plan treatments. Cervical Cancer Management Cervical Cancer Management.

[Audio] Treatment type Description Cone biopsy (Fertility sparing) Also known as conisation This is a surgery performed under general anaesthetic to remove a cone shaped piece of tissue from the cervix. Simple hysterectomy Uterus, fallopian tubes and cervix are removed (Vagina, lymph nodes and ovaries left in situ) Radical trachelectomy (Fertility sparing) Surgery to remove en bloc the cervix, parametrium, upper 1/3 of the vagina. Uterus left in situ and anastomosed with remaining vagina and abdominal cerclage placed to hold future pregnancy. Suitable for younger women who wish to preserve their fertility. Should not be performed if LNs positive. Radical hysterectomy Also known as Wertheim’s hysterectomy Total abdominal hysterectomy and excision of parametrium, upper 1/3 of vagina, pelvic lymph nodes Conservation of ovaries may be considered in younger women. Higher morbidity than simple hysterectomy Should not be performed if LNs positive..

[Audio] CCRT & Targeted Therapy Vaginal Brachytherapy & External beam Cisplatin Bevacizumab Immunothearapy Cervical Cancer Management Cervical Cancer Management Definitive platinum-based chemoradiotherapy and brachytherapy Treatment If LNs unequivocally positive on imaging Treatment is with curative intent External Beam Radiotherapy (Teletherapy) To treat lymph nodes Repeated treatments over 6 weeks Required for stages IIB and beyond Brachytherapy Local vaginal radiotherapy Treats central cervical disease Vaginal source of radiation is left in situ x 12-18hours Radical radiotherapy Combination of external beam radiotherapy and brachytherapy.

[Audio] Cervical Cancer Management Localised recurrence: - Pelvic Exenteration Distant disease: - Chemotherapy +/- immunotherapy Cervical Cancer Recurrence.

[Audio] RCSI LEADING THE WORLD TO BETTER HEALTH Cervical Screening CIN is a pre-cursor lesion to cervical cancer and is a histological diagnosis at colposcopy. Cervical cancer is primarily caused by HPV infection, emphasising the importance of HPV vaccination and cervical screening. The role of surgical management in cervical cancer is limited to the early stages of the disease. Main Learning Points Logo Description automatically generated.

[Audio] Click to edit master title style 27 March 2024 Acknowledgements: Dr Niamh Daly Ms Claire Thompson Thank you Ronan Daly O&G RCSI Clinical Tutor Rotunda Hospital Click to edit master title style Presenter Name Title, Department, RCSI.