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Carcinoma Cervix
1. Cervical Cancer
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
2. Epidemiology and Risk Factors
• Preventable disease because it has a long pre-invasive
state, cervical cytology screening programs are currently
available, and the treatment of pre-invasive lesions is
effective.
• It is estimated that 30% cervical cancer cases will occur in
women who have never had a Pap test. In developing
countries, this percentage approaches 60%.
• The worldwide incidence of invasive disease is decreasing,
and cervical cancer is being diagnosed earlier, leading to
better survival rates (1,3).
• The mean age for cervical cancer in the United States is 47
years, and the distribution of cases is biomodal, with peaks
at 35 to 39 years and 60 to 64 years of age.
3. Risk Factors
• Young age at first intercourse (<16years), multiple
sexual partners, cigarette smoking, race, high parity, and
lower socioeconomic status.
• Oral contraceptives may increase the incidence.
• Many of these risk factors are linked to sexual activity
and exposure to STD.
• Infection with human papillomavirus (HPV) has now
been determined to be the causal agent.
• The role of human immunodeficiency virus (HIV) in Ca
Cx is thought to be mediated through immune
suppression.
4. Mechanism of HPV
• HPV infection has been detected in up to 99% of
women with squamous Ca Cx.
• There are more than 100 different types of HPV, and
more than 30 of which can affect the lower genital
tract.
• There are 14 high-risk HPV subtypes; two of the high-
risk subtypes, 16 and 18, are found in up to 62% of Ca
Cx.
• The mechanism by which HPV affects cellular growth
and differentiation is through the interaction of viral
E6 and E7 proteins with tumor suppressor genes p53
and Rb respectively.
5. Mechanism of HPV cont….
• Inhibition of P53 prevents cell cycle arrest and
cellular apoptosis, which normally occurs
when damaged DNA is present, whereas
inhibition of Rb disrupts transcription factor
E2F, resulting in unregulated cellular
proliferation.
• Both steps are essential for the malignant
transformation of cervical epithelial cells.
6. Evaluation
Symptoms –
1. Vaginal bleeding is the most common symptoms
occurring in patients with Ca Cx.
2. Irregular or a cyclic, intermenstrual bleeding or
post menopausal bleeding.
3. Post coital, post examination bleeding.
4. Blood stand foul smelling vaginal discharge.
5. Weight loss, or obstructive uropathy.
6. In asymptomatic women Ca Cx is identified
through evaluation of abnormal cytological
screening test.
9. Signs – Ca Cx
• PS & PV Examination –
A. Cauliflower exophytic growth (80%) which is
friable, fixed, penitrable with probe, indurated
and it bleeds on touch.
B. Ulcerative growth (20%) which has indurated
base and bleeds on touch.
C. Flat inddrated area.
PR –
Enlarge bulky cervix is felt. Induration of secral
ligaments can be appreciated. Rectal mucosa
may be free involve by ca growth.
10.
11.
12. Colposcopy findings of Invasive Ca Cx
• Colposcopic findings that suggest invasion are
i. abnormal blood vessels, ii. Irregular surface
contour with loss of surface epithelium, and
iii. Color tone change.
• Colposcopically directed biopsies may permit
the diagnosis of frank invasion and thus avoid
the need for diagnostic cone biopsy.
13. Colposcopy findings of Invasive Ca Cx cont…
• Abnormal Blood Vessels-
• Abnormal vessels may be looped, branched,
or reticular. Abnormal looped vessels are the
most common colposcopic finding and arise
from the punctated and mosaic vessels
present in cervical intraepithelial neoplasia
(CIN).
• Abnormal reticular vessels represent the
terminal capillaries of the cervical epithelium.
15. Colposcopy findings of Invasive Ca Cx cont…
• Irregular Surface Contour-
The surface epithelium ulcerates as the cells
lose intercellular cohesiveness secondary to
loos of desmosomes.
Irregular contour also may occur as a result of
papillary characteristics of the lesion.
16. Colposcopy findings of Invasive Ca Cx cont…
• Color Tone –
Color tone may change as a result of increasing vascularity,
surface epithelial necrosis, and in some cases, production of
keratin.
The color tone is yellow-orange rather than the expected pink
of intact squamous epithelium or the red of the endocervical
epithelium.
• Adenocarcinoma –
Adenocarcinoma of the cervix does not have a specific
colposcopic appearance.
Adenocarcinomas tend to develop within the endocervix,
endocervical curettage is required as part of the colposcopic
examination.
17.
18.
19. Histologic Appearance of Invasion
• Depth of invasion is a significant predictor for
the development of pelvic lymph node
metastasis and tumor recurrence.
• Although lesions that have invaded 3 mm or
less rarely metastasize, patients in whom
lesions invade between 3 to 5 mm have
positive pelvic lymph nodes in 3% to 8% of
cases.
23. FIGO-Staging
• Preinvasive Carcinoma-
– Stage 0:- Carcinoma in situ, intraepithelial carcinoma (Cases of stage 0
should be included in any therapeutic statistic).
• Invasive Carcinoma-
– Stage 1:- Carcinoma strictly confined to the cervix (extension to the
corpus should be disregarded).
– Stage 1a:- Preclinical carcinomas of the cervix, that is, those
diagnosed only by microscopy.
– Stage 1a1:- Lesion with ≤ 3 mm invasion.
– Stage 1a2:- Lesions detected microscopically that can be measured. The upper
limit of the measurement should show a depth of invasion of > 3-56 mm taken
from the base of the epithelium, either surface or glandular, from which it
originates, and a second dimension, the horizontal spread, must not exceed 7 mm.
larger lesions should be staged as 1b.
– Stage 1b:- Lesions invasive > 5 mm.
– Stage 1b1:- Lesion ≤ 4 cm.
– Stage 1b2:- Lesions > 4 cm.
24. Figo-Staging cont…
• Stage 2:- The carcinoma extends beyond the cervix but has not extended
onto the wall.
The carcinoma involves the vagina, but not the lower one third.
– Stage 2a:- No obvious parametrial involvement.
– Stage 2b:- obvious parametrial involvement.
• Stage 3:- The Carcinoma has extended onto the pelvic wall. On rectal
examination, there is no cancer-free space between the tumor and the
pelvic wall. The tumor involves the lower one third of the vagina. All cases
with hydronephrosis or nonfunctioning kidney.
– Stage 3a:- No extension to the pelvic wall.
– Stage 3b:- Extension onto the pelvic wall and/or hydronephrosis or nonfunctioning
kidney.
• Stage 4:- The carcinoma has extended beyond the true pelvis or has clinically
involved the mucosa of the bladder or rectum. A bullous edema, as such, does not
permit a case to be allotted to stage IV.
– Stage 4a:- Spread to the growth to adjacent organs
– Stage 4b:- Spread to distant organs.
34. Pathology
• Squamous Cell Carcinoma:- Invasive squamous cell
carcinoma is the most common variety of invasive cancer in
the cervix. (80% incidence).
large cell keratinizing, large cell nonkeratinizing, and
small cell types.
The category of small cell carcinoma includes poorly
differentiated squamous cell carcinoma and small cell
anaplastic carcinoma. It is more aggressive and carries poor
progonosis.
Verrucous carcinoma and papillary (transitional) carcinoma
are reared variants of squamous cell carcinoma.
36. Adenocarcinoma
• In recent years, It has increasing trends, reported in 20
to 30 years of ages.
• Newer reports show a proportion as high as 18.5% to
27% as compared to 5% in older reports.
• Adenocarcinoma of the cervix is managed in the same a
manner to that used for squamous cell carcinoma.
• About 80% of cervical adenocarcinomas are made up
predominantly of cells of the endocervical type with
mucin production.
• The remaining tumors are populated by endometrioid
cells, clear cells, intestinal cells or a mixture of more than
one cell type.
42. Other Varities of Ca Malignancy
• Adenosquamous Carcinoma
• Sarcoma – Embryonal rhabdomyosarcoma,
Leiomyosarcomas and mixed mesodermal tumors
and cervical adenosarcoma.
• Malignant Melanoma
• Neuroendocrine Carcinoma
Note: They are the rarest varities
43. Patterns of Spread Ca Cx
• Ca Cx spreads by
1. direct invasion into the cervical stroma, corpus, vagina, and
parametrium;
2. Lymphatic metastasis;
3. Blood-borne metastasis;
4. Intraperitioneal implantation.
