Globally, over 600,000 new cases and 300,000 deaths were estimated for cervical cancer in 2020 . Third most common gynecological cancer in Palestine. Palestine has a higher age-standardized mortality rate than other countries in the region

1. CERVICAL NEOPLASIA
Musa Abu Sabha

3. Epidemiology
• Globally, over 600,000 new cases and 300,000 deaths were
estimated for cervical cancer in 2020 .
• Third most common gynecological cancer in Palestine.
• Palestine has a higher age-standardized mortality rate than
other countries in the region
Elshami, M. et al 2021

4. Some Basics !

5. Some Basics !

6. Premalignant Lesions
• Cervical neoplasia without penetration of BM.
– usually asymptomatic
– The progression from premalignant to invasive cancer has been
reported to be approximately 8–10 years
– Most lesions regress spontaneously. Others remain static, minority
progress into cancer.

7. RISK FACTORS
• Persistent HPV( 16.18. 31.33.35) infection
• HSV,HIV
• Smoking
• Immunocompromised women.
• Early age of intercourse
• Multiple sexual partners

10. Screening tests
• Screening tests for premalignant cervical lesions include:
– Cytology and HPV-DNA typing.
• Cytological screening uses the Pap test.
– The most common site for cervical dysplasia is the transformation
zone (T-zone) 95%

11. Pap Smear
• How is it performed?
– Two specimens are obtained with the Pap smear: an ectocervical
sample performed by scraping the T-zone with a spatula and an
endocervical sample obtained with a cytobrush in a nonpregnant
woman or a cotton-tip applicator in a pregnant woman.

12. Pap Smear
• What cytological screening methods can be used?
– With the conventional method, the specimens are smeared onto a
glass slide, which is placed in fixative and then microscopically
examined.
– With the thin-layer, liquid-based cytology, the specimens are rinsed
into a preserving solution and then deposited on a slide as a thin layer
of processed cells.

15. Pap Smear

16. Pap Smear

17. Interpretation : Bethesda system

20. Approach to an abnormal Pap smear

21. Approach to an abnormal Pap smear
• Accelerated repeat Pap: an option in case of ASC-US of any age,
and the preferred option with either ASC-US OR LSIL in patients
age 21-24. repeat Pap in 12 months
– If repeated pap is negative, repeat in another 12 month, if anything
else proceed to colposcopy or biopsies
• HPV DNA testing: preferred if ASC-US in patients>25 year. If
high-risk HPV DNA is identified, do colposcopy

22. Approach to an abnormal Pap smear
• Colposcopy : This is indicated for evaluation of LSIL in patients
age ≥25, and all patients with ASC-H and HSIL.
– Satisfactory or adequate colposcopy is diagnosed if the entire T-zone
is visualized and no lesions disappear into the endocervical canal.
– -Unsatisfactory or inadequate colposcopy is diagnosed if the entire T-
zone cannot be fully visualized

23. Approach to an abnormal Pap smear

24. Colposcopy

25. Approach to an abnormal Pap smear

27. Approach to an abnormal Pap smear

28. If the Pap smear is worse than the histology
• Cone biopsy
– Other indications for conization of the cervix include abnormal ECC
histology, a lesion seen entering the endocervical canal, and a biopsy
showing microinvasive carcinoma of the cervix.
– Deep cone biopsies can result in an incompetent cervix. Another risk
of cone biopsy is cervical stenosis.

30. Management according to histology
repeat Pap in 6 and
12 months;
colposcopy and
repeat Pap in
12 months; or HPV
DNA testing in 12
months. rarely used anymore

31. Invasive Cervical Cancer
• A 43-year-old woman complains of intermenstrual postcoital
bleeding for the past six months between regular menstrual
cycles that occur every 28 days. On pelvic examination a 3 cm
exophytic mass is seen from the anterior lip of the cervix. The
rest of the pelvic examination, including a rectovaginal
examination, is normal.

33. Invasive Cervical Cancer
– Cervical cancer is neoplastic prolifration that has penetrated
basement membrane
– Mostly ectocervix 80% and start from T zone
– Third most common gynecological tumor, mean age 45
– Risk factors mostly HPV

34. Clinical presentation
– Asymptomatic
– Postcoital bleeding(most common symptom)
– Intermenstrual bleeding
– Postmenopausal bleeding
– Grossly ulcers or nodules or paplules on ecto or barrel sign of endocervix(bulky anlarged, >6cm
* Advanced ? Stage 3-4
– Lower extremity pain ( spinal cord infiltration)
– Incontinence ( vesicovaginal fistula )
– Anemia ( Chronic bleeding )
– renal failure ( ureteric blockage ) --> common cause of death

35. Pathophysiology
– 70% are squamous cell carcinomas, the remainder adenocarcinomas .
– Cervical tumours are locally in pelvic area, also spread via lymphatics.
in late stages 🡪 via blood vessels.
– grow thro the cervix to reach the parametria, bladder, vagina and rectum.
– Mets? in pelvic (iliac and obturator) ,para-aortic nodes ,
in late stages🡪 liver and lungs

36. Diagnostic tests:
– Cervical biopsy: initial diagnostic test, most common diagnosis is
squamous cell carcinoma
– Metastatic workup: as pelvic examination , chest x-ray,
cystoscopy, sigmiodscopey, IVP

37. Staging of cervical carcinoma
– The only gynecological tumor that Staged clinically is cervical
cancer.
(other gynaecological tumors have reliance on surgery and
pathology to give the ultimate stage)
Stage1: limited to cervix, most common stage at diagnosis

40. Management
• Specific by stage:
– Stage Ia1: total simple hysterectomy, either vaginal or abdominal
– Stage Ia2: modified radical hysterectomy
– Stage IB or IIA: either radical hysterectomy with pelvic and paraaortic
lymphadenectomy (if premenopausal) and peritoneal washings
OR pelvic radiation (if postmenopausal
– Stage IIB, III, or IV: radiation therapy and chemotherapy for all ages

41. Follow up
• Should be followed up with Pap smear every three months for
two years after treatment, and then every six months for the
subsequent three years.
• Patients who have a local recurrence can be treated with
radiation therapy; if they had received radiation previously, they
might be considered candidates for a pelvic exenteration.
• Patients with distant metastases should be considered for
chemotherapy treatment. cisplatinum.

43. Cervical Neoplasia in Pregnancy

44. Management
• CIN :
– Pap smear and colposcopy every three months during the pregnancy
– At 6–8 weeks postpartum the patient should be reevaluated with
repeat colposcopy and Pap smear
– Any persistent lesions can be definitively treated postpartum

45. Management
• Microinvasion:
– should be evaluated with cone biopsy to ensure no frank invasion
– If the cone biopsy specimen shows microinvasive carcinoma during
pregnancy, these patients can
– be followed conservatively, delivered vaginally, reevaluated, and
treated two months postpartum

46. Management
• Invasive cancer:
– before 24 weeks of pregnancy, the patient should receive definitive
treatment (e.g., radical hysterectomy or radiation therapy).
– after 24 weeks of pregnancy, then conservative management up to
about 32–33 weeks can be done to allow for fetal maturity to be
achieved, at which time cesarean delivery is performed and definite
treatment begun

48. CERVICAL NEOPLASIA