CARCINOMA CERVIX

1. Carcinoma Cervix

4. Early stage cervical cancer

5. Incidence
 Commonest cancer in women in India
 High incidence in developing countries
 In US – accounts for 2 % of cancer related deaths
 In Mexico accounts for 25 % of cancer related deaths
 Incidence and mortality declining in developed
countries with screening

6. Causation
RISK FACTORS
 Sex workers
 First coitus at early age
 Multiple sex partners
 Promiscuous male
 STDs
 Cigarette smoking
 Immunodeficiency
 Vit A & D deficiency

7. Natural History
CIN I
CIN II
CIN III
CIS INVASIVE CANCER
5 yrs
3 yrs
1 yrs
10 yrs

8. Types
 Squamous cell carcinoma
 Adenocarcinoma
 Small cell carcinoma

9. Spread
 Direct spread to cervical stroma, LUS, vagina or
paracervical tissues; bladder or rectum
 Lymphatic spread to internal & external iliac,
obturator, common iliac, prescaral and aortic nodes
 Distant spread to lung, extrapelvic nodes, lung &
bone

10. INCIDENCE OF PELVIC/PARAAORTIC NODES IN
CA CX
I B II A II B III
Pelvic Para-
aortic
Pelvic Para-
aortic
Pelvic Para-
aortic
Pelvic Para-
aortic
12-
25%
<5% 20-
35%
10-
15%
30-
45%
15-
20%
40-
50%
25-
35%

11. PATHOLOGY
A. EPITHELIAL TUMORS
1. Squamous Tumors
(a) CIN I, II, III
(b) Sq Cell Ca
2. Glandular Tumors
(a) CGIN
(b) Adenocarcinoma
3. Others
(a) Adenosquamous
(b) Small cell ca
B. MESENCHYMAL TUMORS
1. Leiomyosarcoma
2. Stromal sarcoma
3. Sarcoma botryoides
C. MIXED TUMORS
1. Adenosarcoma
2. Carcinosarcoma
D. MISCELLANEOUS TUMORS

12. Clinical Features
SYMPTOMS
 Asymptomatic in pre-
invasive and early stage
 Abnormal vaginal
bleeding
 Abnormal vaginal
discharge
 Pelvic pain
 Flank pain
 Hematuria/ incontinence

13. Clinical Features
SIGNS
(To be elicited on inspection & palpation by bimanual
& recto-vaginal exam)
 Cachexia and pallor
 Lymphadenopathy
 Cervical growth
 Bleeds on touch
 May extend to vagina &/or parametrium
 Exclude involvement of rectal mucosa & pyometra

14. Advanced cervical cancer

15. Investigative Work-up
 To confirm diagnosis
 To assess the extent of disease
 Pre-treatment investigations

16. Investigative Work-up
 Cervical biopsy (and rarely by colposcopy)
 Chest X-ray for all patients
 USG/IVP to evaluate renal status
 Cystoscopy/ proctoscopy if indicated by patient’s
symptoms
 Role of CT/MRI/PET for nodal status evaluation
doubtful
 Std lab tests including CBC, LFT & RFT

17. FIGO Staging
Stage 0 Carcinoma in situ
Stage I Ca confined to cervix
IA Invasive ca limited to a depth
of 5mm and width of 7mm
IA1 Invasion not > 3mm
IA2 Invasion > 3mm but < 5mm
IB Clinical lesions confined to cx or
preclinical lesions > IA
IB1 Lesions not > 4cm
IB2 Lesions > 4cm

18. FIGO Staging contd…
Stage II Ca extends beyond cx but not
upto LPW or lower 1/3 vagina
IIA No obvious para involvement
IIB Obvious para involvement
Stage III Ca extends upto LPW or lower
1/3 vagina or hydronephrosis
IIIA No extn to LPW but lower 1/3
vagina
IIIB Extn to LPW or hydronephrosis
Stage IV Extn beyond true pelvis or to
bladder/rectal mucosa

19. Treatment
FACTORS INFLUENCING TREATMENT
 Tumor stage
 Tumor size
 Evidence of nodal involvement
 Risk factors for surgery or radiotherapy
 Patient preference
 Physician preference

20. Treatment options
 Surgery
 Radiotherapy
 Concurrent chemoradiation

21. Options for surgery
 Conisation of cervix
 Simple hysterectomy
 Modified radical hysterectomy (Class II)
 Radical hysterectomy (Class III)
 Exenteration operations

22. Treatment
Role of surgery
 Pre-invasive lesions Superficial ablation
 For IA1 Conisation or extrafascial
hysterectomy
 For IA2 Class II Wertheim’s with BPLND
 For IB & IIA Class III Wertheim’s with BPLND
 In central recurrence Exenterative surgery

23. What is radical hysterectomy
 Also known as Wertheim’s hysterectomy or Meigs’
hysterectomy or Class III hysterectomy
 Involves removal of
 Uterus with cervix
 Cuff of vagina
 Total parametrium
 Bilateral pelvic lymph nodes
 Major complications
 Ureteric injury
 Vascular injury
 Bladder dysfunction
 Lymphocyst formation

24. What are Exenteration operations
 Anterior exenteration
 Posterior exenteration
 Total exenteration

25. How do we give radiotherapy
 Usually as concurrent chemoradiation
 Total dose to Pt A is 7000-8000 cGy & 5500 cGy to Pt B
 Initially external beam therapy
 Through two or four portals
 180-200 cGy/25 #/4500-5000cGy
 Aim – to sterilize peripheral disease and reduce the size of the
cervical growth
 Then brachytherapy
 Through uterine tandems and ovoids
 Fletcher-Suit afterloading technique
 LDR or HDR in 1-5 sittings
 Approx 3000 cGy to Pt A

26. Treatment
Role of radiotherapy
 As primary therapy
 In IB & IIA disease - alternative to surgery
 In IIB, III & IVA - only choice for therapy
 In locoregional recurrence after surgery
 Adjuvant to surgery
 When nodal metastasis +
 Positive cut margins
 Parametrial involvement

27. Treatment
Role of Chemotherapy
 Chemotherapy used concurrently with RT has been
found to improve survival. Usually cis-platinum on a
weekly basis till RT is completed.
 Chemotherapy is also used for palliation in recurrent
or advanced cases beyond the scope of curative
intent

28. Follow-up
 3-monthly for two years; then, 6-monthly for
next three years
 By symptoms such as vaginal bleeding, pelvic
masses, renal lumps, chest symptoms
 Findings suggestive of recurrence
 Pap smear, colposcopy and imaging
 Annual X-rays

29. Possible questions
 LAQ
 Discuss the diagnosis and management of pre-
invasive lesions of the cervix
 Discuss the management of Stage IIA cervical
cancer
 How do we stage cervical cancer? Discuss the role
of radiotherapy in the management of cervical
cancer

30. Possible questions
 SAQs
 Colposcopy
 CIN III
 Pap Smear
 Staging of cervical cancer
 Diagnosis of cervical cancer
 Down-staging of cervical cancer
 LEEP

31. Possible questions
 MCQs
 Ca cervix involving upper 2/3 of the vagina is
classed as
 IIA
 IIB
 IIIA
 IIIB
 For ca cervix IIIB, treatment of choice is
 Chemotherapy
 Surgery
 Surgery + radiotherapy
 Chemoradiation

32. Possible questions
 MCQs
 The commonest malignancy in women in India is
 Ca endometrium
 Oral ca
 Ca cervix
 Ca ovary
 Ca cervix commonly starts at
 Portio vaginalis
 Squamocolumnar junction
 Erosions of the cervix
 Endocervical canal

33. Possible questions
 MCQs
 Earliest symptom of cervical cancer is
 Pelvic pain
 Pelvic lump due to pyometra
 Post-coital bleeding
 Foul-smelling vaginal discharge
 Commonest cause of death in cervical cancer is
 Infection
 Uremia
 Cachexia
 Distant metastasis

34. Possible questions
 MCQs
 How will you evaluate an HSIL report on pap
smear?
 Multiple punch biopsies
 Cold knife conisation
 Colposcopically directed biopsy
 Follow-up with Pap smears at 6-monthly intervals
 Which of the following is Schiller test positive?
 Erosion cervix
 Ectropion
 CIN III
 All of the above

35. Possible questions
 MCQs
 Staging of ca cervix is assigned by
 Physical examination
 Exploratory laparotomy
 Biopsy
 All of the above
 Treatment of choice for CIN III of cervix is
 Chemotherapy
 Radiotherapy
 Surgery
 Chemoradiation

36. Possible questions
 MCQs
 All of the following about ca cervix are correct
EXCEPT
 Coital bleeding is an early sign
 HPV is a known causative factor
 Disease is fairly common in celibate nuns
 Screening programme is quite effective in prevention

37. Possible questions
 MCQs
 A patient with unilateral renal shutdown and
hydronephrosis will be staged as:
 Stage IIA
 Stage IIIB
 Stage IVA
 Stage IVB

38. Possible questions
 MCQs
 The best method for diagnosis of an ulcero-
proliferative lesion of the cervix suspected of ca
cervix is
 Cervical smear
 Cervical punch biopsy
 Colposcopy
 CT scan or MRI

39. Possible questions
 MCQs
 In Stage 1A1 Ca cervix, invasion is limited to
 1 mm
 3 mm
 5 mm
 7 mm

40. Thank you