Manajemen Kanker Servix

Edi Hidayat
Subbagian Hematologi Onkologi Medik, Bagian Ilmu Penyakit Dalam FK UNSRI / RSMH Palembang

Anatomi

Indonesia
Pembunuh wanita no 1 Angka kejadian kanker di Indonesia: terdapat 100 kasus baru tiap 100.000 populasi, dan kanker serviks mencakup 20 % Ada sekitar 8000 kasus baru kanker serviks per tahun 432 kasus baru per tahun di RSHS (data statistik Obgyn RSHS 2011)

Three Types
Squamous cell Carcinomas Cancer of flat epithelial cell 80% to 90% Adenocarcinomas Cancer arising from glandular epithelium 10% - 20% Mixed carcinoma Features both types
Source: American Cancer Society

Etiologi
HPV tipe high risk tipe 16,18,31, 33, 39, 45, 51, 52, 56 dan 58 Coitarche di usia sangat muda (16 tahun), multiparitas dengan jarak persalinan terlalu dekat, sosial ekonomi rendah, higiene seksual jelek dan merokok

Patologi
Eksofitik. Mulai dari SCJ kearah lumen vagina Endofitik. Mulai dari SCJ tumbuh kedalam stroma serviks Ulseratif. Mulai dari SCJ dan cenderung merusak struktur jaringan pelvis dengan melibatkan fornices vagina untuk menjadi ulkus yang luas.

Ket : Skuamo kolumnar junction (SCJ)

Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society 2003
- Screening begin approximately three years after a women having vaginal intercourse. - Screening should be done every year with regular Pap tests - At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more if she has certain risk factors, such as HIV infection or a weakened immune system. -Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening. - Screening after a total hysterectomy (with removal of the cervix) is not necessary
American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

PAP SMEAR
Single Pap false negative rate is 20%. 50% of women with cervical cancer have never had a Pap smear. 25% of cases and 41% of deaths occur in women 65 years of age or older.

Clinical Presentation
CIN/CIS/ACIS asymptomatic Irregular vaginal bleeding Vaginal discharge Pelvic pain Leg edema Bowel/bladder symptoms

Physical Findings
Exophytic, cauliflower like mass Cervical ulcer, friable or necrotic Firm barrel-shaped cervix Hydronephrosis Anemia Weight loss

Diagnosis
Cervical Cytology (Pap Test) Cells are removed from the cervix and examined under the microscope. Can detect epithelial cell abnormalities Atypical squamous cells Squamous intraepithelial lesions Squamous cell carcinoma (likely to be invasive) Additional testing Colposcopy Cervix is viewed through a colposcope and the surface of the cervix can be seen close and clear. Cervical Biopsies Colposcopic biopsy removal of small section of the abnormal area of the surface. Endocervical curettage removing some tissue lining from the endocervical canal. Cone biopsy cone-shaped piece of tissue is removed from the cervix

FIGO staging system, 2009

Stage I
The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)
Stage IA: Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion 5 mm and largest extension 7 mm Stage IA1: Measured stromal invasion of 3.0 mm in depth and extension of 7.0 mm. Stage IA2: Measured stromal invasion of >3.0 mm and 5.0 mm with an extension of not >7.0 mm Stage IB: Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA* Stage IB1: Clinically visible lesion 4.0 cm in greatest dimension Stage IB2: Clinically visible lesion >4.0 cm in greatest dimension

Stage II
Cevical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina
Stage IIA: Without parametrial invasion Stage IIA1: Clinically visible lesion 4.0 cm in greatest dimension Stage IIA2: Clinically visible lesion >4 cm in greatest dimension Stage IIB: With obvious parametrial invasion

Stage III
The tumor extends to the pelvic wall and/or involves lower third of the vagina and or causes hydronephrosis or non-functioning kidney**
Stage IIIA: Tumor involves lower third of the vagina, with no extension to the pelvic wall Stage IIIB: Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney

Stage IV
The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to Stage IV Stage IVA: Spread of the growth to adjacent organs. Stage IVB: Spread to distant organs.
*All

macroscopically visible lesionseven with superficial invasionare allotted to stage IB carcinomas. Invasion is limited to a measured stromal invasion with a maximal depth of 5.00 mm and a horizontal extension of not >7.00 mm. Depth of invasion should not be >5.00 mm taken from the base of the epithelium of the original tissuesuperficial or glandular. The depth of invasion should always be reported in mm, even in those cases with early (minimal) stromal invasion (~1 mm). The involvement of vascular/lymphatic spaces shou ld not change the stage allotment. ** On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to another cause.

Stage 1
A
B

Stage 2

Stage 3

Stage 4
A B

PENATALAKSANAAN
Early stage: Karsinoma serviks mikroinvasive : Histerektomi totalis, trakhelektomi Stadium IA1: Total Abdominal Histerektomi (TAH)/Total Vaginal Histerektomi (TVH), trakhelektomi radikal Stadium IA2 : Histerektomi radikal tipe 2 dan limfadenektomi pelvis

Stadium IB1 IIA1 < 4cm : Histerektomi Radikal + Limfadenektomi Pelvis Stadium IB2 IIA2 > 4cm: Kemoradiasi primer Kemoterapi neo adjuvan + Histerektomi Radikal Pelvis Histerektomi Radikal + Limfadenektomi Pelvis Advanced Stage Stadium IIB, IIIA-B, IV A: Kemoradiasi: Radiosensitizer + radiasi eksterna + brakhiterapi. Khemoterapi : cisplatinum, pachitaxel, docetaxel, fluorourasil, gemcitabine Stadium IV B: Paliatif: observasi, radioterapi paliatif, kemoterapi paliatif, pembedahan paliatif

KEMOTERAPI

FAKTOR PROGNOSIS
Status dari kelenjar getah bening Ukuran tumor primer Kedalaman invasi stroma ada atau tidak adanya invasi ruang getah bening-vaskuler Ada atau tidak adanya keterlibatan parametrium Histologis tipe sel Status dari margin vagina

TERIMA KASIH