diagnosis ,staging and management of cervical carcinoma

1. Invasive Cervical Carcinoma
Dr Aisha Nazeer.
Assistant professor OBS-GYN
QAMC/Civil Hospital.Bahawalpur

2. Learning Objectives
Understand the diasnosis,FIGO staging
and management of carcinoma cervix

3. Cervical carcinoma
• Fourth most common cancer among the
women in the world.
• Second most common cancer in Pakistan
(first ca breast)
• In pakistan;5601 new cases reported in
2018 and 3861 deaths.
• Almost 10 women die with cervical
cancer every day in Pakistan.

4. Epidemiology and Risk Factors
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Preventable disease because it has a long pre-invasive
state, cervical cytology screening programs are currently
available, and the treatment of pre-invasive lesions is
effective.
It is estimated that 30% cervical cancer cases will occur in
women who have never had a Pap test. In developing
countries, this percentage approaches 60%.
The worldwide incidence of invasive disease is decreasing,
and cervical cancer is being diagnosed earlier, leading to
better survival rates (1,3).
The mean age for cervical cancer is 47 years, and the
distribution of cases is bimodal, with peaks at 35 to 39
years and 60 to 64 years of age.

5. Risk Factors
• Young age at first intercourse (<16years), multiple
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sexual partners, cigarette smoking, race, high parity, and
lower socioeconomic status.
Oral contraceptives may increase the incidence.
Many of these risk factors are linked to sexual activity
and exposure to STD.
Infection with human papillomavirus (HPV) has now
been determined to be the causal agent.
The role of human immunodeficiency virus (HIV) in Ca
Cx is thought to be mediated through immune
suppression.

6. Mechanism of HPV
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HPV infection has been detected in up to 99% of
women with squamous Ca Cx.
There are more than 100 different types of HPV, and
more than 30 of which can affect the lower genital
tract.
There are 14 high-risk HPV subtypes; two of the high-
risk subtypes, 16 and 18, are found in up to 62% of Ca
Cx.
The mechanism by which HPV affects cellular growth
and differentiation is through the interaction of viral E6
and E7 proteins with tumor suppressor genes p53 and
Rb respectively.

7. Cause
 Human papillomavirus (HPV)
 Types:
Oncogenic potential HPV types
Low 6,11,14,43,44
Intermediate 31,33,35,51,52
High 16,18,45,56

8. Pathophysiology
Exposure to risk
factor: eg Sexual
activity
Entry of HPV
Virus enters in the
basal layer of cervix
HPV infect the basal cells

9. Invasion to the
near by tissues
Cervical cancer

10. Evaluation
Symptoms – in early diseases
1.Abnormal vaginal bleeding is the most common
symptoms occurring in patients with Ca Cx.
• Intermenstrual bleeding
• post menopausal bleeding.
• Post coital, post examination bleeding.
2.Blood stained foul smelling vaginal discharge.
through evaluation of abnorma
l
3.In asymptomatic women Ca Cx is identified
cytological
screening test.

11. Symptoms
• In advanced disease;
• pain (malignant infiltration of spinal cord
• Incontinance (due to vesicovaginal
fistula)
• Anemia (from chronic vaginal bleeding)
• Renal failure (from ureteric blockade)
• Wait loss

12. Signs – Ca Cx
• PS & PV Examination
A. Cauliflower exophytic growth (80%) which is
friable, fixed, penetrable with probe, indurated
and it bleeds on touch.
B. Ulcerative growth (20%) which has indurated
base and bleeds on touch.
C. Flat indurated area.
• Per Rectal Exam
Enlarge bulky cervix is felt. Induration of sacral
ligaments can be appreciated. Rectal mucosa
may be free involve by ca growth.

13. Colposcopy findings of Invasive Ca Cx
• Colposcopic findings that suggest invasion are
1.abnormal blood vessels,
2.Irregular surface contour with loss of surface
epithelium and
3. Color tone change.
• Colposcopically directed biopsies may permit
the diagnosis of frank invasion and thus avoid
the need for diagnostic cone biopsy.

14. Abnormal blood Vessels
• Figure

15. Pathophysiology
carcinoma is the most common variety of invasive cancer in
the cervix. (80% incidence).
large cell keratinizing, large cell nonkeratinizing, and
small cell types.
1.Squamous Cell Carcinoma:- Invasive squamous cell


differentiated squamous
The category of small cell
cell
carcinoma includes poorly
carcinoma and small cell

anaplastic carcinoma. It is more aggressive and carries poor
progonosis.
Verrucous carcinoma and papillary (transitional) carcinoma
are reared variants of squamous cell carcinoma.

16. 2. Adenocarcinoma
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In recent years, It has increasing trends, reported in 20
to 30 years of ages.
Newer reports show a proportion as high as 18.5% to
27% as compared to 5% in older reports.
Adenocarcinoma of the cervix is managed in the same a
manner to that used for squamous cell carcinoma.
About 80% of cervical adenocarcinomas are made up
predominantly of cells of the endocervical type with
mucin production.
The remaining tumors are populated by endometrioid
cells, clear cells, intestinal cells or a mixture of more than
one cell type.

17. Rare Varieties of Ca cervix
Adenosquamous Carcinoma•
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Sarcoma – Embryonal rhabdomyosarcoma,
Leiomyosarcomas and mixed mesodermal tumors
and cervical adenosarcoma.
Malignant Melanoma
Neuroendocrine Carcinoma
Note: They are the rarest varities

18. Investigations and importance of
Staging Procedures
• Examination under anesthesia; Per speculam and bimanual
examination. PR examination , Feel for lymph nodes.
• Biopsy is crucial to confirm malignancy and tumor type.
• MRI of abdomen and pelvis will assess local spread of
disease in the cervix and will detect enlarged lymph nodes
in pelvic area.
• Xray chest is vital to exclude lung metastasis.
• Cystoscopy and Proctoscopy to assess local spread to
bladder and rectum

19. FIGO-Staging
.
– Stage 1:- Carcinoma strictly confined to the cervix (extension to the
corpus should be disregarded).
Stage 1a:- Preclinical carcinomas of the cervix, that is, those
diagnosed only by microscopy.
Stage 1a1:- maximum horizontal dimension is 7mm and depth of
invasion is 3mm.
Stage 1a2:-horizontal dimension 7mm and of invasion between 3
and 5mm.
Stage 1b:- Lesions invasive > 5 mm.
Stage 1b1:- Lesion ≤ 4 cm.
Stage 1b2:- Lesions > 4 cm.
Stage II: Tumour extends beyonds the cervix and involves the vagina.
IIA: Tumour involves the vagina
IIB: Tumour infiltrates the parametrium

20. StageIII:Thecarcinoma hasextended on to the pelvic wall.the
tumorinvolvesthe lowerthirdof the vagina.
Stage llla:No extensionon to the pelvic wall,but
involvementof the lowerthirdof the vagina.
Stage IIIb:Extensionon to the pelvic wallorhydronephrosis.
Stage IV:spreadof growthto adjacent organsinvolving mucosa
of bladder orrectum and distant organs.
Stage IVa:the carcinoma has extended beyond the true pelvis
orhasclinicallyinvolved the mucosa of the bladder orrectum.
Stage IVb:Spread to distant organs.

22. • figure

23. Mode of Spread
•
Ca Cx spreads by
1. direct invasion; into the vagina, parametrium,body of
uterus,urinary bladder and rectum.
2. Lymphatic spread; into pelvic(iliac and obturator) and
paraaortic lymph nodes
3. Blood-borne spread; to lungs,liver,bones,kidneys and
brain
4. Intraperitioneal implantation; unknown incidence,poor
pronosis

24. Treatment
• Depends on
• stage of disease
• Requirement for future fertility
• Patient,s performance status
• Multidisciplinary team (MDT) of
doctors(surgeons,radiother
• apist,radiologists and pathologists) and
nurses will be involved in management.
• Fitness of pt is crucial before embarking on
treatment .

25. Treatment Options
• Surgery –
– Conization
– Simple hysterectomy
– Radical Trachelectomy
– Radical Hysterectomy (werthiems)
– Shauta’s
– Plevic exenteration (Anterior / posterier)
• Radiotherapy-
– External (teletherapy) and internal brachytherapy
• Chemotherapy –
• Palliative Therapy -

26. Management(Specific by stage)
PRE CLINICAL LEISONS; STAGE 1A
1a1; local excision with good clear margin is all
that is required, so fertility is preserved.
Total simple hysterectomy(if family complete)
CLINICAL INVASIVE CERVICAL CARCINOMA: STAGES 1B_-_1V
1b1;
• Radical hysterectomy and bilateral pelvic node
dissection(Wertheim s hysterectomy) is standard of care. It
includes removal of cervix, upper third of vagina, uterus and
parametrial tissue.Pelvic lymph node removal includes
obturator,external and internal iliac nodes.
• Radical trachelectomy for young patients who have not
completed families
;

27. Management(specific by stage)
In pts with early stage 1b,
• who are overweight for radical surgery or
• who are unfit anesthetically, pelvic radiotherapy
is treatment of choice.it has similar sussess rate to
surgery.
• When disease is beyind cervix (stage11-1V),
Radiotherapy with or without chemotherpy
becomes optional treatment

28. SURGERIES FOR CARCINOMA CERVIX
Cone biopsy
Radical
Trachelectomy
Radical
Hysterectomy
Exenteration

30. Pathology Gross

31. SURGERY complications
Radical hysterectomy n pelvic node dissection is standard
surgical option for stage 1b.
It is associated with high morbidity.
• Complications of anesthsia.
• Post operative chest,wound and urinary tract infection.
• Hemorrhage.
• Thromboembolism.
• Obturator nerve damage
• Bladder atony (needs intermittent self catheterization)
• Sexual dysfunction due to vaginal shortening.
• Lymphoedema due to removal of lymph nodes.
• Management includes leg elevation,good skin
care,massage and occasionally compression stockings.

32. RADIOTHERAPY
Aim is to deliver a lethal dose of radiation to the tumor and
Minimize damage to surrounding tissues.
External beam radiotherapy; (teletherpy)
• source is from a machine called linear accelerator at a
distance from patient.
• 45Gy given in fractions over 4 weeks.
Internal radiotherapy; (brachytherapy)
• Patient undergoes EUA,and radiation source(selenium
rods) inserted into uterus. These rods are then attached to
radiotherapy source. So high dose of radiation is delivered
to tumor and harmful effects on bladder n rectum
minimized as effects are targetted only 5mm from rods.

33. 2 IMPORTANT REFERENCE POINTS IN
BRACHYTHERAPY OF CANCER CERVIX
Point A Point B
LOCATION 2cm above and 2 cm
lateral to external os
2 cm above and
5cm lateral to
external os
STRUCTURE Para cervical/
parametrial lymph
node
Obturator LN

34. TELETHERAPY + BRACHYTHERAPY
45-50 Gy 35-40 Gy
Cobalt - 60 Cesium, Iridium

35. RADIOTHERAY complications
Early; (due to initial inflammatory effects)
• lethargy.
• Skin erythema like sunburn.
• Urinary and bowel urgency.
• 5% experience serious side effects like bowel
perforation
Long term; (initial inflammotory process is replaced by
fibrosis)
• Radiotherpy induced menopuse
• Vaginal stenosis
• Bladder damage leading to cystitis and hematuria.
• Bowel damage leading to malabsorption and mucous
diarrhea.

36. CHEMOTHERAPY
CISPLATIN is given in conjunction with radiotherapy.
• It enhances the effects of radiotherapy .
• Might also address micrometastasis that are outside radiotherapy field.
PALLIATIVE TREATMENT
• When curative treatment is not possible , palliation of symptoms
becomes important. So early involvement of palliative care team is
essential.
• Radiotherapy can be used with palliative intent;for example ,a one-off
treatment can be used for symptomatic bone metastasis.s

37. Progonosis
Comparision of FIGO staging and
5 year survical rates
Stage 5 year survival rate(%)
1 83
11 65
111 36
1V 10

38. Case scenerio
A 32 yr old, is diagnosed with 3 cm stage 1b1 squamous cell
carcinoma of cervix on biopsy.she is devastated because she
and her partner would like to start a family. What fertility
sparing treatment would you like to recommend?
a. Cold knife cone biopsy.
b. LLETZ
c. Radical hysterectomy with bilateral lymph node
dissection.
d. Radical radiotherapy with cisplatin chemotherapy.
e. Radical trachelectomy with bilateral pelvic
lymphadenectomy.s

39. THANK YOU