This presentation describes epidemiology, risk factors, pathology, clinical examination, staging and management of cervical carcinoma. SCREENING is not included

2. PREVENTABLE DISEASE!
• Long pre invasive state
• Cervical cytology screening
• Treatment of pre-invasive lesions is
effective

4. CERVICAL CANCER
• Fourth most common cancer among women in the
world
• Second most common cancer among women in
India, incidence 3.5%(First is Ca Breast- Incidence
28%)

5. GLOBAL DISEASE BURDEN
India contributes to
one third of cases
and one third of
mortality due to
cancer cervix in
the world.

6. STAGE AND AGE AT PRESENTATION
• Mean age at presentation- 52
years
• Bimodal with peaks at 35 to 39
years and 60 to 64 years
• 70 to 83% present in Stage II-III
in India
FIGO STAGE 5-Year
Survival
Stage I 81-96%
Stage II 65-87%
Stage III 35-50%
Stage IVA 15-20%

7. PRE-INVASIVE LESIONS
• Invasive cervical cancers are usually preceded by a
long phase of preinvasive disease
• Characterized by varying degrees of epithelial
dyplastic changes within Transformation zone
• Hallmarks of CIN are nuclear atypia and aberrant
cytoplasmic differentiation
• Cell of origin is the basal cell of squamous metaplasia

8. CAUSE
• HPV is a necessary cause
• HPV can be identified in more than 99% of
cervical cancers
• HPV is associated with both squamous and
adenocarcinoma

10. RISK FACTORS
INCREASED RISK DECREASED RISK
Multiple sexual partners, Early sexual
activity, male sexual promiscuity (Increase
HPV infection)
OCP (?Adenocarcinoma)
HIV (More prone for HPV and
Persistance of HPV) – ART does not
decrease risk
Low socioeconomic strata
Multiparity
Unscreened population
Circumcised Male partner (Decrease
HPV)
Nuns (Decrease HPV)
IUCD use (?Improving cellular immune
response)

11. HPV
• DNA virus
• More than 200 HPV types have been identified
• Most common 12 carcinogenic varieties identified by IARC:
16,18,31,33,45,35,39,51,52,56,58 and 59
• In addition, 5 are possibly carcinogenic (36,53,66,68,72)
• HPV 16 is the most pathogenic (50% of cases)
• HPV 16,18 contribute to 70%
• HPV 18 (45 also) particularly plays a role in adenocarcinoma

12. HPV
Persistent
HPV
Low
grade
High
grade
Cancer
1 to 2
years 10 to 30 years
Transient HPV
Normalises Normalises

14. CARCINOGENESIS
• Genital HPV infection by sexual transmission
• 50% of infections cleared by 6 months, 25% of the remaining are
cleared by 1 year
• Persistent infection which leads to integration into host genome is
required for progression to cancer
• Virus encodes for 6 early proteins (E proteins 1 to 6) and 2 late
proteins L1 and L2 (Capsid proteins)
• Integrated virus remains dormant for years
• Triggered by co factors [smoking, OCP, other STD, Previous
pregnancy] Expression of viral oncogenes, E6 and E7 which lead to
suppression of tumour suppressor genes p53 and Rb respectively.

15. • Productive HPV infection leads to cytological
changes: CIN I
• >50% CIN I regress on their own
• 10 to 20% progress to CIN 3 and invasive
cancer by >10 years

16. PRE-INVASIVE LESIONS
Enlarged nuclei, increased mitosis, nuclear
stratification WITHOUT Stromal Invasion

17. CIN I
Represent productive HPV infection
50% cleared by 3 years
CIN II
Adolescent & Young women: 63% clear by 2
years
Regression lower in older women
However, overall 40% CIN 2 can regress
CIN III
Risk of progression high (30-50%)

18. PATHOLOGY
• Squamous cell carcinoma
• Adenocarcinoma
• Adeno squamous carcinoma
• Adenoid cystic carcinoma
• Adenoid basal carcinoma
• Glassy cell carcinoma
• Neuroendocrine tumours
• Undifferentiated
• Lymphoma , Metastasis
Squamous cell carcinoma, NOS
•Keratinizing
•Non-Keratinizing
•Papillary
•Basaloid
•Warty
•Verrucous
•Squamotransitional
•Lymphoepithelioma-like
•Endocervical adenocarcinoma in situ, usual type
•Endocervical adenocarcinoma, usual type
•Mucinous Carcinoma
NOS type
Gastric type(including minimal deviation type)
Intestinal type
Signet ring cell type
•Villoglandular carcinoma
•Endometrioid carcinoma
•Clear cell carcinoma
•Serous carcinoma
•Mesonephric carcinoma
•Adenocarcinoma admixed with neuroendocrine carcinoma

19. TIME TRENDS AMONG HISTOLOGICAL
TYPES
0%
20%
40%
60%
80%
100%
1970 1995 2015
SCC
Adeno
Others
•Age adjusted incidence of SCC decreased by 40% since 1970
•Age adjusted incidence of adenocarcinoma increased by 29%

20. HPV IN SQUAMOUS VS
ADENOCARCINOMA
• HPV 16 : 60%
• HPV 18: 13%
• HPV 58: 5%; 33-5%; 45- 4%
Squamous
• HPV 16: 36%
• HPV 18: 37%
• HPV 45: 5%; 31- 2%; 33- 2%
Adeno

21. MODE OF SPREAD
• Direct spread (early =vagina, parametrium, body of uterus,
late = urinary bladder, rectum)
• Lymphatic spread (parametrial, obturator, hypogastric nodes)
• Vascular spread – distant metastasis – lungs, liver, bones,
kidneys, brain
Primary group Secondary group
H = Hypogastric Common illiac
O = Obturator Para aortic
P = Presacral and
parametrial
inguinal
E = External illiac

22. PRESENTING SYMPTOMS
EARLY CERVICAL CANCER
• Often asymptomatic
• Irregular/heavy vaginal bleeding
• Post coital bleed
• White discharge (foul smelling)/serosanguinous

23. ADVANCED DISEASE
• Menometrorrhagia & White discharge
• Postcoital bleed
• Pain
• Urinary/bowel symptoms
• Sciatica/lowerlimb edema
(Triad of Sciatica, Lowerlimb edema and HUN is
ominous)

24. SIGNS
• P/S & P/VExamination–
A.Cauliflower exophytic growth (80%) which is friable,
fixed, penitrable with probe, indurated and it bleeds
ontouch.
B.Ulcerative growth (20%) which has indurated base and
bleeds on touch.
C. Flat induratedarea.
PR–
•Enlarge bulky cervix is felt. Induration of secral
ligaments can be appreciated. Rectal mucosa may be
free involve by cagrowth.

27. STAGE DESCRIPTION
I The carcinoma is strictly confined to the cervix (extension to uterine corpus should be
disregarded)
IA Invasive carcinoma that can be diagnosed only by microscopy, with maximum depth of invasion
<5mm
IA1 Measured stromal invasion <3mm in depth
IA2 Measured stromal invasion ≥3mm in depth and <5mm depth
IB Invasive carcinoma with measured deepest invasion ≥5mm(greater than Stage IA), lesion limited
to the cervix uteri
IB1 Invasive carcinoma of ≥5mm depth of stromal invasion, and <2cm in greatest dimension
IB2 Invasive carcinoma of ≥ 2cm and < 4cm in greatest dimension
IB3 Invasive carcinoma of ≥ 4 cm in greatest dimension
II The carcinoma invaded beyond the uterus, but has not extended onto the lower third of the
vagina or to the pelvic wall
IIA Involvement limited to upper two-thirds of vagina without parametrial involvement
IIA1 Invasive carcinoma of < 4cm in greatest dimension
IIA2 Invasive carcinoma of ≥ 4 cm in greatest dimension
IIB With parametrial involvement but not upto the pelvic wall

28. STAGE DESCRIPTION
III The carcinoma involves the lower third of vagina and/or extends to the pelvic wall
and/or causes hydronephrosis or nonfunctioning kidney and/or involves pelvic
and/or para-aortic lymph nodes
IIIA The carcinoma involves the lower third of vagina, with no extention to the pelvic wall
IIIB Extension to pelvic wall and/or hydronephrosis or nonfunctioning kidney(unless
known to be due to another cause)
IIIC Involvement of pelvic and/or para-aortic lymph nodes, irrespective of tumour size
and extent (with r{imaging} and p[pathology] notations)
IIIC1 Pelvic lymph node metastasis only
IIIC2 Para-aortic lymph node metastasis
IV The carcinoma has extended beyond the true pelvis or involved (biopsy proven) the
mucosa of bladder or rectum. ( A bullous edema, as such, does not permit a case to
be alloted to Stage IV
IVA Spread to adjacent pelvic organs
IVB Spread to distant organs

29. MANAGEMENT
•Surgery
•RT/Chemo RT
Stage I
to IIa
•Chemo RTStage IIb
to IVa
In early stage, both surgery and RT have similar survival (Landoni 1997)

30. WHEN TO CHOOSE SURGERY OVER RT
IN EARLY STAGE
• Young age
Vaginal length, moisture preserved: For sexual
function
Ovaries can be preserved
• Associated gynaec pathology(fibroids)/ ovarian
cysts
• RT contraindication
 Prior Pelvic RT
 Inflammatory bowel disease
 Collagen vascular disease

31. COMPLICATIONS OF SURGERY
• Intraoperative
Bleeding, injury to bladder, ureter, etc.
• Immediate postoperative
Pulmonary, Wound infection, DVT, PE, ileus
• Late complications
Bladder atony, Lymphedema, Lymph cyst
Fistulas(ureteric/vesical)

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

33. CLASSIFICATION OF RADICAL HYSTERECTOMY –
PIVER-RUDLEDGE AND SMITH CLASSIFICATION
• TYPE I
• TYPE II
• TYPE III
• TYPE IV
• TYPE V

34. Radical Hysterectomy – Piver-Rutledge
Classification
• Type I (Extrafacial hysterectomy): simple hysterectomy to remove the
entire cervical tissue
• Type II (Modified RH)- Wertheims Radical Hysterectomy- to remove more
paracervical tissue, still preserving blood supply to distal ureters and
bladder.
• Type III (RH): Meigs’ Radical Hysterectomy(1944)- wide excision of
parametrial and paravaginal tissue
• Type IV(Extended RH): complete removal of the periureteral tissue and a
more extensive resection of the paravaginal tissue
• Type V(Partial exenteration): radical removal of disease involving the distal
ureter and/or bladder

36. • Radicality defined in 3 D plane (Dorsal/Ventral
and lateral paracervix)
• Additional procedures incorporated (Nerve
sparing RH, Paracervical lymphadenopathy)
• To standardise terminology and to tailor
precise surgery according to patient
characteristics

37. STAGE WISE SURGICAL MANAGEMENT
Fertility
Preservation
Stage No Preservation
Conisation Stage IA1, LVSI
negative
Type I
Radical
trachelectomy +
BPLND
Stage IA1 & LVSI
positive, IA2, IB1,
IIA1(<2cm)
Type II + BPLND
Not offered Stage IB2, IB3,
IIA1(<2cm), IIA2
Type III + BPLND

38. RADIOTHERAPY IN CARCINOMA
CERVIX
• Can be given in all stages
• Total dose needed is 85 to 90 Gy
• Limitation:
• Bladder tolerance: 75 Gy
• Rectal tolerance: 70 Gy

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

40. 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

41. IMRT
Computer generated algorithms
Accurately distinguish between target
treatment volumes and normal tissue

42. CAUSE OF DEATH
• MOST COMMON CAUSE
OF DEATH IN CA CERVIX =
RENAL FAILURE - Uraemia
• II nd Most common =
HEMORRHAGE

43. WHO TARGETS FOR 2030
90% 70% 30%
HPV
Vaccination
of girls by 15
years
Women
between 35
and 45 years
to be
screened by
a HPV test
Reduction in
mortality
from
cervical
cancer