2. Introduction
Carcinoma of cervix is the commonest form of female
genital cancer in developing countries.
Though common, it is preventable and curable if
detected early.
In developed countries, the incidence of this disease
has fallen considerably owing to regular screening
procedures using the Pap smear and vaccination.
3. Introduction……
In the absence of an effective screening system in
Ethiopia, most cases seek clinical care very late and
thus the only modality of treatment left for these
patients is radiation and chemotherapy.
Approximately:
70% of invasive cervical ca are squamous cell
tumors
20–25% is adenocarcinomas and
2–5% is adenosquamous
4. Etiology
Sexual transmission of Human papilloma virus
(HPV) is the most common factor associated with
cervical Ca.
Over 66 types of HPVs have been isolated, and many are
associated with genital warts.
Though, there are more than 18 high oncogenic types
of HPV, those types commonly associated with
cervical carcinoma are 16, 18, 31, 33, 52, and 58.
But 70% of cases are caused by HPV-16 and -18.
6. Etiology……
Associated risk factors:
Sexual promiscuity
First coitus at early age, multiple child births
Infections with Herpes Simplex type II, HIV
Smoking
Family history
Immunosuppression
7. Screening and prevention
Case 1:
M.M., a 44 -year-old woman, asks you about vaccines
to prevent cervical cancer. She heard that a vaccine is
now available.
Should M.M. consider this vaccine for her daughter?
Would this substitute for Pap smear screening for her
daughter?
8. Screening
Screening is done commonly by Papanicolaou (PAP)
smear and prevention is through vaccination.
Uncomplicated HPV infection in the lower genital tract
can progress to cervical intraepithelial neoplasia
(CIN).
Premalignant condition of the uterine cervix
This lesion precedes invasive cervical carcinoma
and is classified as low-grade squamous
9. Screening
Carcinoma in situ demonstrates cytologic evidence
of neoplasia without invasion through the basement
membrane and can persist unchanged for 10–20
years, but most of these eventually progress to
invasive carcinoma.
The Pap smear is 90–95% accurate in detecting
early lesions such as CIN but is less sensitive in
detecting cancer when frankly invasive cancer
10. Screening
Inflammation, necrosis, and hemorrhage may
produce false-positive smears, and colposcopic-
directed biopsy is required when any lesion is
visible on the cervix, regardless of Pap smear
findings.
11. Prevention
Vaccination against pathologic HPV appears to be an
effective cervical cancer prevention strategy.
Vaccines are made with inactivated virus-like
particles that are non-infectious but highly
immunogenic.
Quadrivalent vaccine against HPV strains 16,18, 6
& 11(Gardasil)
Bivalent vaccine against HPV strains 16 &18
(Cervarix)
12. Prevention
Since it is difficult to show a vaccine prevent cancer, key
surrogate markers, such as CIN, are used to assess
efficacy in cervical Ca.
CINs are premalignant lesions that may develop into
cancers.
Hence, use of HPV vaccines, which decrease the
formation of precancerous lesions, will ultimately lead to a
reduction in the incidence of cervical ca.
Efficacy has not been established in women older than 26
years of age.
13. Prevention……
HPV screening (Pap smears) should continue for all
vaccinated women because the vaccine does not
prevent all serotypes of HPV and the duration of
vaccine-induced anti-HPV immunity is unknown.
15. Prevention…..
Gardasil is approved for prevention of genital warts
caused by HPV types 6 and 11.
Additionally, Gardasil is approved to prevent HPV-related
anal cancer in men; however, not routinely
recommended.
There are no data to support using these vaccines to
prevent other cancers associated with HPV (penile
cancers or head and neck cancers).
16. Guideline of vaccination
It is recommended to take vaccine before HPV
infection.
Usually it is started at age 11 or 12 but can be given
0.5 ml from 9-26 years in 3 doses.
For Gardasil at 0, 2 and 6 months
For Cervarix at 0, 1 and 6 months
17. Screening and prevention case
M.M. should consider HPV vaccination for her
daughter.
The vaccines are indicated in women 9 to 26 years of
age, but the vaccine is most effective if initiated before
sexual activity.
Whether or not M.M.’s daughter is vaccinated, she
should still receive Pap smear screening according
to current guidelines.
Although Gardasil has been approval to prevent HPV-
related anal cancer and genital warts, vaccination of
males to prevent spread of HPV and to prevent other
HPV-related cancers and diseases is more
18. Clinical presentation
Case 2: H.B. is a 66-year woman presented to the
emergency department with complaints of vaginal
bleeding and passing of large clots with abdominal
pain.
On examination she was found to have a large
cervical mass, which was biopsied and confirmed as
invasive, well-differentiated carcinoma.
She noticed increased vaginal bleeding, abdominal
19. Clinical presentation
She also complained of poor appetite, dyspareunia, and
constipation. She denied fever and chills. She was noted
to be severely anemic with a HCT of 23% and received 3
units of packed RBCs. CT scan showed an 8.6 x 6.0 cm
cervical mass with no evidence of hydronephrosis or
lymphadenopathy.
The patient underwent a pelvic examination for clinical
staging.
The final diagnosis received was stage IIB cervical ca.
20. Clinical presentation…..
Patients with cervical cancer generally are
asymptomatic, and the disease is detected on
routine pelvic examination such as antenatal care,
family planning etc.
Others present with abnormal bleeding or post-coital
spotting or post menopausal bleeding.
Yellowish vaginal discharge, lumbosacral back pain,
lower-extremity edema, and urinary symptoms may
21. Clinical presentation…..
In early cases there will be erosion of cervix or
changes of chronic cervicitis but in advanced
cases ulcerative or fungating cervical lesion is
observed on speculum examination.
22. Diagnosis
Investigations include:
Cervical biopsy
CBC
Renal function test
Serum uric acid
Chest radiograph
CT Scan and/or MRI
Examination under anesthesia for clinical staging
23. Staging
The staging of cervical carcinoma is clinical and
generally completed with a pelvic examination under
anesthesia with cystoscopy and proctoscopy.
Stage 0 is carcinoma in situ
Stage I (Early Stage) is disease confined to the cervix.
Stage IAI (depth of stromal invasive less than 3mm
with horizontal expansion of 7mm)
Stage IA2 (depth of invasion 3-5mm with 7mm
horizontal spread)
24. Staging…..
Stage II disease invades beyond the cervix but not to
the pelvic wall or lower third of the vagina
Stage III disease extends to the pelvic wall or lower
third of the vagina or causes hydronephrosis, and
Stage IV is present when the tumor invades the
mucosa of bladder or rectum or extends beyond the
true pelvis.
25. Staging
For treatment purpose, It is classified as:
Early stage disease
Stage IA1 and stage IA2
Overt disease
Stage IB and IIA
Advanced disease
Stage IIB to IV
26. Treatment
The treatment modalities for cervical cancer are:
Surgery, the main stay treatment
Radiotherapy: as treatment or palliation to arrest
vaginal bleeding or alleviate pain.
A combination of surgery and radiotherapy
Adequate nutrition
Correction of anemia
For advanced terminal cases: provide emotional and
psychological support.
27. Treatment
Carcinoma in situ (stage 0) can be managed
successfully by cone biopsy/abdominal hysterectomy.
For stage I disease, results appear equivalent for
either radical hysterectomy or radiation therapy.
For Stage IA1:
Simple conization of the cervix may be enough if the
patient desires fertility and provided surgical margins
are free of cancer or
Extra-fascial hysterectomy if childbearing has been
completed.
If there is lympho-vascular invasion, more
aggressive treatment is appropriate.
28. Treatment
Stage IA2:
Requires extensive surgery (modified radical
hysterectomy with pelvic lymphadenoctomy)
Stage IB and IIA- Overt disease
Radical hysterectomy with pelvic and para-aortic
lymphadenoctomy.
Advanced disease (Stage IIB to IV)
Patients with stages II–IV are primarily managed with
external beam irradiation and intra-cavitary treatment or
combined therapy.
Treatment is radiotherapy ± chemotherapy.
Eg. give cisplatin 1mg/kg/wk during radiation therapy.
30. Treatment…..
Palliative treatment:
End-stage cervical cancer patients may present with
pain from bony metastasis, respiratory distress from lung
metastasis and renal failure secondary to tumor growth.
Palliative chemotherapy: A combination of cisplatin
and paclitaxel has a better response rate
Pain management: Follow the WHO ladder approach.
Respiratory distress: Oxygen support and withhold
toxic medicines.