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Cáncer invasor de cuello uterino: diagnóstico y tratamiento — Transcript

by 26 Vargas Ticona Mariana · 1,935 words · 321 segments · language en · Watch on YouTube

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0:02Good morning, everyone. The topic we
0:06are going to address today is invasive
0:09cervical cancer, how to diagnose it,
0:11staging, and treatment. As an
0:16introduction to this topic, cervical
0:19cancer is one of the most common
0:21cancers, being the fourth most common
0:24after breast, colorectal, and lung
0:26cancer. Globocan, which is the global
0:31cancer staging database, estimated that
0:34in 2020 there were approximately
0:36604,000 new cases of cervical cancer
0:39worldwide with 342,000 deaths annually.
0:46Eighty percent of women followed over
0:48time will acquire at least one
0:50high-risk human papillomavirus
0:53infection, which shows how easily it is
0:55transmitted. Regarding the human
1:00papillomavirus, genotypes 16 and 18
1:03account for 71%of cases between the two
1:05. On the other hand, the other
1:10so-called high-risk pool, which
1:12incorporates another 12 genotypes,
1:15includes 31, 33, 45, 52, and 58, which
1:18represent the other 19%of cervical
1:20cancers. The number of cases in 2020 in
1:26Bolivia, taken from the IARC, shows
1:29that cervical cancer continues to be
1:31the leading cause of morbidity and
1:33mortality. Approximately 1,985 cases
1:36were detected in 2020, which is
1:38equivalent to 21.9%, followed by
1:41cancers of the breast, uterine body,
1:43bladder, and stomach. As an
1:48introduction to the topic, focusing now
1:51on what cancer is, although cervical
1:53cancers originate from cells with
1:55precancerous changes, only some women
1:58with precancerous cervical changes will
2:00develop cancer. In most women,
2:04precancerous cells will disappear
2:06without any treatment. However, in some
2:10women, precancers turn into true or
2:13invasive cancers, and treating cervical
2:16precancers can prevent almost all these
2:18cancers. There are two types of
2:24cervical cancer, right? Cervical
2:27cancers and precancers are classified
2:29according to how they appear to an
2:31observer under a microscope in the
2:33laboratory. The two most common types
2:36of cervical cancer are squamous cell
2:39carcinoma, which is the most common,
2:41and adenocarcinoma, which is less
2:43common. The majority, nine out of 10 of
2:48these cases, are squamous cell
2:49carcinomas. These cancers develop from
2:53cells in the exocervix. Carcinomas of
2:57these cells most frequently originate
2:59in the transformation zone, which is
3:02the junction of the two squamocolumnar
3:04junctions, both the old or original one
3:07and the new physiological one, where
3:09the exocervix meets the endocervix.
3:12Most other cervical cancers are
3:14adenocarcinomas, which originate from
3:17glandular cells. Cervical
3:19adenocarcinoma originates in the
3:21mucus-producing gland cells of the
3:23endocervix. Cervical cancer, which has
3:28features of both squamous cell
3:30carcinomas and adenocarcinomas, is less
3:32common, and these are also called
3:35adenosquamous carcinomas or mixed
3:37carcinomas, which are very rare. The
3:42clinical presentation of cervical
3:44cancer, right? Early-stage cervical
3:47cancer may not cause noticeable signs
3:50or symptoms; in other words, it is
3:52asymptomatic. The possible signs and
3:56symptoms of cervical cancer are as
3:57follows. When there is vaginal bleeding
4:00, when there is unusual or abnormal
4:03vaginal discharge, there may be pelvic
4:06pain, dyspareunia, and postcoital
4:08bleeding, which is known as
4:10sinusorrhagia. How is cervical cancer
4:16diagnosed? So, as we have mentioned
4:19before, there are several diagnostic
4:22methods for cervical cancer, including
4:24personal and family history, physical
4:27examination, pelvic examination, and a
4:30cervical cytological study, which is
4:32the Pap smear. It can be complemented
4:37with the HPV test, which is a molecular
4:39test, or endocervical curettage in case
4:42of suspected adenocarcinoma or
4:43glandular atypia. Colposcopy and biopsy
4:47, which is mandatory, right? In all
4:50these cases. This is an image of how
4:55invasive cervical cancer can be
4:57diagnosed. A biopsy can be performed
5:00directly on the cervix using biopsy
5:04forceps or a punch, or a cone biopsy
5:07can be performed to send to pathology
5:11to guide us on what we are facing.
5:15Diagnosis can also be performed through
5:18auxiliary methods; among these, the
5:20tests and procedures to evaluate the
5:22extent of the disease are as follows. A
5:26computed tomography scan, a PET scan or
5:29positron emission tomography,
5:32cystoscopy, laparoscopy, chest X-ray,
5:35ultrasound, and magnetic resonance
5:38imaging can be performed. All these
5:42auxiliary methods are very useful for
5:45seeing cervical invasion, right? Here,
5:50in the image above, we have three
5:52images of a contrast-enhanced computed
5:55tomography scan where a cervical tumor
5:57can be seen, and in the image below,
6:00cervical involvement can also be seen
6:02via magnetic resonance imaging. This is
6:08very important; the Pap smear and the
6:10HPV test, which is called co-testing,
6:12also serve as a screening method, as we
6:14mentioned in previous classes. Since
6:18its introduction, the Pap smear of the
6:21cervix has been the cornerstone for the
6:24detection of cervical cancer. However,
6:27molecular techniques for identifying
6:30HPV DNA are very sensitive and specific
6:32. We have said that the sensitivity and
6:34specificity are greater than 95%. The
6:38current options for screening tests are
6:41as follows. You can perform the PAP
6:44alone; the COTEST, which is the PAP and
6:46the HPV test; or the HPV test, which is
6:49indicated when the result is likely to
6:51allow patients to be classified into
6:53low-risk and high-risk groups, when
6:55high-grade dysplasia or a more serious
6:57lesion is found. Essentially, the HPV
7:02test tells you more or less which
7:04genotype we are facing or identifying
7:06to better follow up with patients.
7:11Regarding prognostic factors, the
7:13prognosis of each patient with cervical
7:15cancer depends largely on the degree of
7:18dissemination of the disease at the
7:20time of diagnosis. More than 90%of
7:24cervical cancer cases can be quickly
7:26detected by either the Pap smear or the
7:29HPV molecular test. PAP and HPV tests
7:33are not performed on nearly 33%of the
7:36women who meet the requirements to have
7:38them, which leads to a high mortality
7:41rate, right? Higher than expected.
7:46Getting into the stages of cervical
7:48cancer, the carcinoma spreads by local
7:51invasion to regional lymph nodes or
7:53through the bloodstream. This tumor
7:57dissemination, in general, depends on
7:59the extent and invasion of the local
8:01lesion. Although cervical cancer
8:03usually progresses in an orderly manner
8:05, sometimes a small tumor with distant
8:07metastasis can be observed. For this
8:10reason, patients must be thoroughly
8:12evaluated to detect metastatic disease.
8:17Currently, the staging system designed
8:19by the International Federation of
8:22Gynecology and Obstetrics and the
8:24American Joint Committee on Cancer is
8:26used, and the FIGO system is the one
8:29most frequently used. This is the FIGO
8:332018 classification, which divides
8:35cancer into four stages. From stage one
8:39to stage four, and each one is further
8:41divided into other parts, right? For
8:44example, stage one comprises carcinoma
8:47limited only to the cervix;
8:49dissemination to the uterine body
8:51should not be taken into account. This
8:54is divided into 1A, which is invasive
8:57carcinoma that can only be diagnosed by
9:00microscopic study with a maximum depth
9:02of invasion less than or equal to 5 mm.
9:06Currently, the extent is no longer
9:08taken into account, only the depth.
9:10Previously, the extent was taken into
9:11account up to 7 mm. Stage 1a is divided
9:15into 1a1 and 1a2. Stage 1A1 is when the
9:19depth of stromal invasion is less than
9:21or equal to 3 mm. And 1A2 is when the
9:24depth of stromal invasion is greater
9:26than 3 mm and less than or equal to 5
9:29mm. Stage 1B is already an invasive
9:34carcinoma. Unlike the previous ones,
9:37which are microinvasive, this is now
9:40invasive with a maximum depth of
9:42invasion greater than 5 mm beyond stage
9:441A. The lesion is still limited to the
9:47uterine cervix and the size is measured
9:48by the maximum tumor diameter. We have
9:52the subdivision of stage 1B, which is
9:541B1, 1B2, and 1B3. 1B1 represents when
9:58the invasive carcinoma has a depth of
10:00stromal invasion greater than 5 mm and
10:03is less than or equal to 2 cm in its
10:05greatest dimension. Stage 1B2 is when
10:09the invasive carcinoma is greater than
10:112 cm and less than or equal to 4 cm in
10:14its greatest dimension. Stage 1B3 is
10:17when the invasive carcinoma is greater
10:20than 4 cm in its greatest dimension.
10:25Now entering stage 2, it is also
10:27divided into 2A and 2B. 2A, well, stage
10:312 is a cervical carcinoma with invasion
10:34outside the uterus, but which does not
10:36extend to the lower third of the vagina
10:39or the pelvic wall, meaning it only
10:41involves the upper 2/3 of the vagina.
10:45Next, we will break down stage 2, which
10:47is divided into 2A, which is
10:49involvement limited to the upper 2/3 of
10:51the vagina without parametrial
10:53involvement. Stage 2A can in turn be
10:58divided into 2A1 and 2A2. 2A1 is when
11:02the invasive carcinoma is less than or
11:04equal to 4 cm in its greatest dimension
11:06, and 2A2 is when the invasive
11:08carcinoma is greater than 4 cm in its
11:10greatest dimension. And 2B is when it
11:13invades the parametria, but does not
11:15extend to the pelvic wall. It also
11:18still involves the upper 2/3 of the
11:19vagina. Stage 3 is a carcinoma that
11:23infiltrates the lower third of the
11:25vagina. It has spread to the pelvic
11:28wall, can cause hydronephrosis,
11:30produces kidney failure, or infiltrates
11:32the pelvic and para-aortic lymph nodes.
11:36Stage 3 is divided in turn into 3A, 3B,
11:38and 3C. We are going to break down each
11:40of these. 3A, carcinoma that
11:43infiltrates the lower third of the
11:45vagina without spread to the pelvic
11:47wall. 3B is a spread to the pelvic wall
11:52. It can cause hydronephrosis or kidney
11:55failure, unless another cause is known,
11:57right? And adjacent. And stage 3C is
12:00pelvic or para-aortic lymph node
12:03involvement, including micrometastases,
12:06regardless of tumor size and extent,
12:08right? We have two, the 3C1, metastasis
12:13only in pelvic lymph nodes. And when it
12:16is already a stage 3C2, there is
12:18metastasis in para-aortic lymph nodes.
12:21No, there is no need for you to
12:23memorize the bottom part. And stage
12:27four, the carcinoma has spread outside
12:30the true pelvis or there is
12:31biopsy-verified involvement of the
12:33bladder or rectal mucosa. Bullous edema
12:36alone is not sufficient to assign stage
12:39four. In other words, stage four is
12:42when there is local or distant
12:44metastasis. And it is divided into A
12:48and B. We speak of A when the spread is
12:50to adjacent pelvic organs, either
12:52invading the bladder in front or the
12:54rectum behind. And stage 4B is already
12:59spread to distant organs, for example,
13:01liver, lung, brain, bones. And the
13:07treatment is what we would have to do,
13:09right? We must prevent progression to
13:12cervical cancer and offer the
13:14appropriate treatment for each patient.
13:19For advanced stages, the treatment for
13:22stage 1A1, a micro-invasive carcinoma
13:25without lymphovascular invasion,
13:27involves cervical conization with
13:29negative margins, a 3 mm border; the
13:31cone can be repeated if necessary, or
13:34an extrafascial hysterectomy or
13:36modified radical hysterectomy with
13:38lymph node dissection can be performed.
13:44The treatment for stages 1B1, 1B2, and
13:462A is external radiation therapy plus
13:49chemotherapy plus brachytherapy, or a
13:51radical hysterectomy plus pelvic and
13:53aortic lymph node dissection and/or
13:56external radiation, chemotherapy,
13:58brachytherapy, and adjuvant
14:00hysterectomy can be performed. This
14:03treatment is performed by oncologists.
14:07And the treatment for stage 2B onwards,
14:103, and 4, is treatment with external
14:13radiation therapy, chemotherapy, and
14:15brachytherapy sessions. The treatment
14:20for stage 4B cervical cancer is
14:22external radiation therapy,
14:24chemotherapy, and sometimes and often
14:27palliative care. This is a current
14:31classification, the types of
14:33hysterectomy according to the Querleu
14:35and Morrow classification, which is
14:37divided into five, right? In the past,
14:40people spoke of Piver radical
14:42hysterectomies, which would more or
14:45less correspond to type 3 of Querleu,
14:48right? Considerations regarding
14:54cervical cancer. We must keep in mind
14:57that it can often be mistreated without
15:00oncological criteria. Often, after
15:04treatment, it can progress, it can
15:05recur, and it can metastasize, right?
15:08So, we must have that in clear
15:11consideration, and that would be all.
15:14Thank you very much.

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