Carcinoma of the Cervix

1. CANCER OF UTERINE
CERVIX
By Dr. Kanumba
Dept of OBGY
SFUCHAS
10th /January/2013

2. PREAMBLE
• Cancer of Cervix is the commonest
malignant disease in women in
resource-poor countries, including
Tanzania.(50% of female cancers)
• The commonest Gynecological
cancer (50% of all gynecological
cancers)
• Third most common cancer
worldwide.

3. • 82% of all new cancer patients are
seen at an advanced stage of the
disease.
• Age 35-60 yrs
• Types: Squamous cell carcinoma 90%
• Adenocarcinoma 10%
• Developing from Low Grade SIL (25-
50%), High Grade SIL (98-100%).

4. • The diagnosis of Cancer of Cervix and its
precursors (SIL) can be made with minimally
invasive procedures by:
-Investigating all suspicious symptoms
without delay (Contact bleeding)
- Speculum examination to every Gyn
case
-Taking targeted biopsies of cervix for
histology following VIA (Visual
Inspection on Acetic Acid) or VILI
(Visual Inspection on Lugols Iodine)
- Colposcopy

5. OVERVIEW ANATOMY

7. Pathology

8. PREDISPOSING FACTORS
1. Herpes Virus II
2. Human Papiloma virus Type 16 & 18 (70%)
3. Immunodeficiency
4. Early onset of Sexual relations <15 yrs
5. Promiscuity, Prostitution
6. Multiparity
7. Drug abuse, Alcoholism
8. Smoking
9. Poverty
10. COC reduces the relative risk of HPV
infection
11. Consistent condom use reduces the risk of
HPV

9. Cervical Transformation Zone
Pathogenesis: Sexual Exposure
HPV Infection
Squamous Ep Columnar Ep
Squamous Ca Adeno Ca
High Risk Types (16,18)
Low Risk-6,11
Smoking, Hormone, Age, parity, Altered
immune response etc.

10. Clinical Features
1. Irregular bleeding from the genital
tract.
2. Postcoital bleeding. An early
symptom that should be investigated
without delay.
3. Postmenopausal bleeding
4. Foul smelling watery/pusy vaginal
discharge. A late symptom.

11. Clinical features………
5. Pelvic pain
6. Cachexia
7. Cervix modified to erythematous,
necrosis, ulceration, fungating mass
easy bleeding on touch.
8. Cervix indurate
9. Vaginal mass of various description

12. Invasive Cancer
• Raised lesion
• Rolled edges
• Raised white
epithelium
• Abnormal vessels
• Important to biopsy
this

13. STAGING CANCER OF CERVIX
• Stage O- Carcinoma in Situ. Intraepithelial
carcinoma.
• Stage I – Confined to the Cervix
• IA- Depth of the lesion 3- 5 mm from the base
of the epithelium. <7mm wide.
• IB – Depth of the lesion > 5 mm and exceed
7mm in width. Macroscopic.
• Stage II- Extension beyond the Cervix
• IIA- Extension to the Upper 1/3 of the vagina
• II B- Extension to parametrium but not to the
pelvic walls.

14. STAGING …….
• Stage IIIA – Extension to the lower 2/3
of the vagina
• IIIB – Extension to the parametrium to
the pelvic walls and/or Hydronephrosis
due to the tumour
• Stage IVA- Outside the true pelvis,
Involving the Bladder, Rectum
• IVB- Extending to distant organs
(Distant metastasis

15. MICROINVASIVE CARCINOMA
• It is a stage between the SIL III and clinical
invasive carcinoma of the Cervix.
• An incidental microscopic finding on
histological examination of cervical tissue
obtained from excisional techniques of SIL
treatment.
• Characterized by the spread of malignant
cells in two directions to ≤ 5mm depth and ≤7
mm width
• It is Stage IA of the Carcinoma of Cervix

16. Stages CA Cervix

17. DIAGNOSIS
• PAP Smear
• Biopsy of the Cervical tissue
–Punch Biopsy
–Cone Biopsy
–Amputation of the cervix

18. PAP SMEAR

19. PUNCH BIOPSY

20. Cone Biopsy

21. CLINICAL STAGING OF CANCER OF
CERVIX
EXAMINATION UNDER ANAESTHESIA (EUA)
• Inspection of the vaginal walls and Cervix
• Palpation of the Cervix for consistency
• Bimanual pelvic examination
• Palpation of the pelvis with fingers in the
vagina and rectum for the spread to the
pelvic walls
• Cystoscopy
• Rectosigmoidoscopy
• Take biopsy for histology

22. Complementary investigations
for clinical staging
• Chest Xray
• Abdominal Ultrasound
• MRI - Parametrium, The connective tissue of the
pelvic floor extending from the fibrous subserous coat of the supracervical portion of the
uterus laterally between the layers of the broad ligament.
• Lymphnodes, Kidneys
• Evaluation of the Renal
function

23. DIFFERENTIAL DIAGNOSIS
• Ectopia
• Cervicitis –TB, Trichomoniasis,
Chlamidia etc.
• Primary Syphilitic chancre
• Mucous Cervical Polyp
• Granulomas of various types
( Amoeba, Schistosomiasis)

24. MANAGEMENT
• Treatment of cancer of Cervix
should be carried out in
Specialized centers of Excellency
with multidisciplinary expertise,
appropriate facilities and
technologies
• Surgery – Simple Total Abdominal
Hysterectomy (TAH) or Radical
Hysterectomy

25. Management……..
• Radiotherapy- Intracavitary and External
beam
• Chemotherapy:- IV Drugs
• Palliative Treatment- the care for patients
with advanced or terminal disease is now a
specialty on itself.
- Analgesics
- Anaemia Treatment
- Dialysis
- Nutrition

27. Screening Programmes
Primary screening
• All women >18 yrs of age.
• All women having sexual relationships
• Secondary screening (1st Negative
result)
Follow-up Screening
• Every 2 years after the primary
screening
• Every 5 years if >60 yrs of age or had
Hysterectomy done

28. Prevention
• The vaccine, which protects against
cervical cancer, precancerous genital
lesions, and genital warts due to human
papillomavirus (HPV) types 6, 11, 16, and
18, has been approved for use in females
of 9-27 years of age.
• As it does not protect women who are
infected before vaccination, it is important
to vaccinate females before potential
exposure to the virus

29. Vaccines & Cervical Cancer
Gardasil –manufactured by Merck & Co. in
USA
• the first vaccine developed to prevent genital
lesions and genital warts due to human
papillomavirus (HPV) types 6, 11 (warts), 16 and
18 (cervical cancer).
• Vaccine is approved for use in females 9-27
years of age
• HPV types 16 and 18, cause approximately 70
percent of cervical cancers and against HPV
types 6 and 11, cause approximately 90 percent
of genital warts.

30. Hope for the Future
• A trial vaccine was developed
• The vaccine is currently undergoing
phase 2 clinical trial.
• The results are very promising.
• However it may take another 20 years
to reach us when our mothers are
gone.

31. Take Home Messages
• Avoid sex during teen age years.
• Stick to one partner.
• Use condom if you cannot stick to one
partner/avoid sex.
• GET A PAP SMEAR DONE IF YOU HAVE
NOT.
• Get one done every 2 years from then on.
• Service is afordable.
• Tell others about Cervical Cancer.

32. Sharing your knowledge is a
way to achieve immortality...!