Basic of Anatomy - ca cervix

1. Basics of Gynaecology Carcinoma Cervix
• Anatomy
• Blood supply
• Lymphatic drainage
• Clinical features
• Radiological anatomy
• Pathology
• Staging
PRESENTER: DR GOWTHAM MANIMARAN
MODERATOR : DR RITESH SHARMA

2. Anatomyof female genitaltract
• Externalgenitalia/Vulva
• Internalgenitalia

3. Mons
Pubis
External genital organs:
• Mons pubis
• Labia Majora
• Labia Minora
• Clitoris
• Vestibule
• Vestibular bulb
• The greater vestibular glands

4. • Bloodsupply
– Arteries
• Br.of internal pudendalartery(br of In.iliac artery)
– LabialA.,
– TransverseperinealA.,
– A to vestibularbulb,
– deep& dorsalarteries toclitoris
• Br.of FemoralA
– Superficial& deepexternalpudendalA
– Veins
• Internal ,external pudendalvein
• Vesical/vaginalvenousplexuses
• UltimatelyintoLongsaphenousvein

5. • Nervesupply
– Ant-suppart
• Ilioinguinal& genitalbr.of genitofemoralN(L1,L2)
– Post-inf part
• Pudendalbr.of post.cut. Nof thigh(S123)
– Inbetween
• Labial& perinealbr.of PudendalN(S234)
• Lymphatics
– Superf.Inguinalnodes
– Glandof Cloquet(deepinguinalnode)
– Int. Iliacnodes
– Rectallymphaticplexus

6. Vagina
ovries
Internal genital organs:
 Vagina
 Uterus
 Fallopian tubes
 Ovaries

7.  Vagina :
• Walls
– Ant : 7.5 cm
– Post : 9cm
– 2 lateral walls
• Fornices :
– Ant : shallow
– 2 lateral
– Post : deep

8. • BloodSupply
– Arteries( from internal iliac artery)
• Cervicovaginalbr.Ofuterine A
• VaginalA
• Middle rectalA
• Internalpudendal
• UterineandvaginalbranchesAnastomose -2azygosarteries/median longitudinal vessels
– Veinsdrain into:
• Vaginal veins(from lateral plexus)Internal iliacV
• Internal pudendal V
• Lymphaticsdrain into
• Upper1/3rd : internal iliacnodesandexternaliliacgroup
• Middle 1/3rd: internal iliacnodes
• Lower1/3rd (below hymen): superficial inguinalgp.
• Nervesupply
• Parasympathetic:S234
• Sympathetic: hypogastricplexus
• Lowerend : pudendal N(sensory)

9.  Uterus :
• Hollow, pyriform muscular organ in pelvis
• Position: Anteversion and Anteflexion
• Measurements:
7.5 cm long
5 cm wide
3 cm thick
• Parts:
Body
Isthmus
cervix

10. – Anterior
• Above int.os : uterovesical pouch
• Below int.os: separated from UB by
loose areolar tissue
– Posterior
• Pouch of Douglas with coils on intestine
– Lateral
• Broad ligament
• Mackenrodt’s ligament
• Uterine A &ureter
Relations of Uterus

11. Ligaments of uterus
• Uterosacral ligament
• Transverse cervical/
Mackenrodt's ligament
• Pubovesicocervical lig
• Round ligament
• Broad ligament
o Mesovarium
o Mesosalpinx
o Mesometrium
• Suspensory lig of ovary/ infundibulopelvic
ligament

13. • Blood supply
– Arteries:
• Uterine A
• Ovarian & Vaginal As.
– Veins drain into
• Internal iliac veins
• Nerves
– Sympathetic
• Motor : T5 & T6
• Sensory : T10 – L1
– Parasympathetic
•Pelvic N ( S2,3,4) : both motor & sensory :
ends in ganglia of Frankenhauser

14. Microstructure of Uterus

15. Fallopian tubes :
• 10-14 cm
• Lies within the superior border of broad
ligament
• 2 openings
– Medially into cornua
– Laterally into abdominal cavity

16. • BloodSupply
– Arteries
• UterineA
• OvarianA
– Veins
• Throughpampiniforn plexusinto ovarianveins
• Lymphatics
• Para-aorticnodes
• Nervesupply
– Uterine & ovariannerves

17. The Ovary
• Paired, situated on either side of uterus
• Close to lateral pelvic wall
• In ovarian fossa of Waldeyer
• Size: 4*3*2 cm
• Only intra-abdominal structure not covered by peritoneum

18. Cortex:
• Lined single layer of germinal
epithelium of Waldeyer
(cuboidal epi.)
• Tunica albuginea : stromal cells
thickened beneath germinal
epithelium
• Contain primordial follicles
• Corpus albicans/ atretic follicles
Medulla:
• Loose connective tissues, blood
vessels,nerves, muscles
• Hilus cells : homologous to
interstitial cells of testes

19. • Blood Supply
– Arterial : Ovarian A
– Veins :
• Through pampiniform plexus ovarian V
Lt. Renal Vein IVC
• Lymphatics
• Para-aortic nodes
Nerve supply :
• Sympathetic supply from T10 along ovarian A

20. Lymphatics of Female genital tract

22. Innervation Of Female
genital tract

23. Clinical Features of Gynaecologic malignancies
• Cervical CA:
1. MC during routine gynecologic(before symptoms appear) cytologic smears Pap
smear, colposcopy and biopsies, and HPV testing
2. Visible lesions present with an exophytic mass or a barrel-shaped cervix because of an
endocervical lesion
3. Metrorrhagia (intermenstrual bleeding), menorrhagia (heavier menstrual flow), or
postcoital bleedingsymptoms related to anemia
4. Advanced diseasebowel obstruction, renal failure, foulsmelling serosanguinous or
yellowish vaginal discharge, pelvic pain, flank and/or leg pain, rectal bleeding,
obstipation, dysuria, hematuria, or persistent edema of lower extremities because of
lymphatic/venous blockade by pelvic sidewall disease may occur.
5. Pain in the pelvis or hypogastrium may be caused by tumor necrosis or associated
pelvic inflammatory disease.
6. Pain in the lumbosacral area the possibility of PALN involvement with extension into
the lumbosacral roots or hydronephrosis should be considered.

24. • Endometrial CA:
1. The most common presentation for endometrial cancer is postmenopausal vaginal
bleeding, 80%-90%
• Ovarian CA:
1. Ovarian cancer has insidious growth and is asymptomatic in early-stage disease. Vague
gastrointestinal complaints of dyspepsia, nausea, early satiety, bloating, constipation, or
obstipation are common presenting symptoms, as are genitourinary symptoms including
frequency, urgency, or incontinence. Other ill-defined symptoms include fatigue, back
pain, pain with intercourse, and menstrual irregularities
2. Germ cell and stromal cell malignancies abdominal discomfort or symptoms of excessive
estrogen or androgen production.
3. Granulosa cell tumorsprecocious puberty.
4. Sertoli-Leydig cellvirilization.
• Fallopian Tube CA:
1. Two Triads (a)pelvic pain,pelvic mass, and leukorrhea and (b) vaginal bleeding, vaginal
discharge, and lower abdominal pain. (11%)
2. Hydrops Tubae Profluensis a sudden emptying of accumulated fluid in the distended
fallopian tube that causes profuse, watery, serosanguineous vaginal discharge.(9%)

25. • Vaginal CA:
Rare malignancy, constituting 1% to 2% of all gynecologic malignancies.
• Urethral CA:
1. Irritative or obstructive urethral symptoms. Bleeding (hematuria) or spotting is
the prevailing presenting sign in 50% to 60% of patients.
2. 30% to 50% of patients experience pain or irritative symptoms, difficulty
urinating, and frequent micturition.Urinary retention and overflow
incontinence may occur in advanced cases.
3. 10% to 20% patients, dyspareunia, perineal pain, and inguinal
lymphadenopathy. Urethrovaginal and vesicovaginal fistulas may develop in
advanced, neglected cases.
• Vulval CA:
1. Vulvar pruritus, bleeding, pain, discharge.

26. CT images

38. MRI of uterus and vagina
• On T2-weighted magnetic resonance imaging (MRI), the
uterus displays a zonal anatomy, with three distinct zones:
the endometrium, junctional zone and myometrium.
• The endometrium and uterine cavity appear as a high-signal
stripe; the thickness varies with the stage of the menstrual
cycle. In the early proliferative phase, it measures up to 5
mm, and widens to up to 1 cm in the mid-secretory phase.
• A band of low signal, the junctional zone, borders the
endometrium. It represents the inner myometrium and is of
constant thickness and signal throughout the menstrual
cycle; it usually measures 5 mm.
• The outer myometrium is of medium-signal intensity in the
proliferative phase, and of high-signal intensity in the mid-
secretory phase as a result of the increased vascularity and
prominence of the arcuate vessels.