This document presents a case study of carcinoma cervix. It begins with an overview of the epidemiology, pathogenesis, risk factors, symptoms, diagnosis, staging, treatment and prevention of cervical cancer. It then discusses the specific case of a 45-year-old woman who presented with irregular bleeding, post-coital bleeding, and foul-smelling discharge. Her examination revealed a cauliflower-like growth on the cervix. Tests showed stage 2B carcinoma cervix. She was given conservative treatment including antibiotics and blood transfusion to improve her general health before definitive treatment. The document concludes with an open discussion and review of the case.

1. Presented by
Dr.Ishtiaqul Haque Mortuza(Labib)
Resident
Department of Urology
CMCH
A case of carcinoma cervix

2. 1st
• Understanding Ca cervix
• Its diagnosis, Treatment & prevention
2nd
• History of a particular patient
• Management of that particular patient
3rd
• Open discussion
• Review
OBJECTIVES

3. Understanding the basics
of Ca cervix
Its Diagnosis, treatment &
prevention
Step One

4. • Cervical carcinoma is 12th most common and 5th most
deadly cancer in women.
• It affects 16 per 100000 (1 lac) women per year and kills
about 9 per 100000 (1 lac) per year
• Approximately 80% cervical cancer occur in developing
countries
• Worldwide in 2008 it was estimated that there were
473000 cases of cervical cancer and 25300 deaths per
year
Epidemiology

5. High prevalent area/countries of Ca cervix around the World

6. What is Carcinoma cervix?
It is the malignant neoplasm of the cervical
epithelium -- the squamous epithelium of ectocervix
(part of cervix that is next to vagina) and
columnar/glandular epithelium of endocervix.

7. The Squamo-Columnar junction(SCJ) is the meeting point of
the columnar epithelium that lines the endocervix, with
squamous epithelium that lines ectocervix.it is a dynamic
point. The process of carcinogenesis starts in the
transformation zone(TZ).It is an area where squamous
metaplasia takes place in the columnar cells.

8. The location of transformation zone varies among
women. In teenagers it is in the ectocervix and more
susceptible to infection than adult. In older women it
may be higher in the cervical canal

9. • It is the pre-malignant(pre-invasive) condition of cervical
epithelium that is graded upon the degree (from mild,
moderate to severe degree) of dysplasia, in which cervical
epithelium is replaced by varying degrees of atypical cells.
• It has two classifications-
1. WHO classification
2. Bethesda system
What is CIN?
Dysplasia CIN (WHO) Limit of histologic
change
Bethesda
Mild CIN-1 Basal 1/3 LSIL
Moderate CIN-2 Basal half to 2/3
HSIL
Severe(CIS) CIN-3 Whole thickness

10. Pathogenesis of CIN and Ca Cervix in Short
Squamocolumnar junction
Replacement of
columnar epithelium
Squamous
epidermadization
(in growth of
sq.cell under the
columnar cell)
Metaplasia of
sub-columnar
reserve cell
Immature unstable cell
Carcinogen
1.HPV
2.seminal flud histones
3.unknown factors
Physiologic
metaplasia
Host response+ -
Well differentiated
squamous epithelium
Atypical metaplasia
CIN CIS
Invasive carcinoma

11. Macroscopic & Microscopic view of pathological changes
in cervix
Macroscopic View Microscopic view

12. Electron Microscopic picture of malignant cell of
cervix

13. • Early sexual intercourse ( < 16 years)
• Early age of pregnancy
• Too many/frequent births
• Low socio-economic status
• Multiple sexual partners
• STDs
• Infections: HPV(16,18,31,33),HIV,Chlamydia.
• Immunosuppressed individuals
• OCP
• Smoking
• Husband whose previous wife died of cervical malignancy
Risk factors for CIN & Ca Cervix

14. • HPV plays central role in development of cervical carcinoma. HPV is
epitheliotropic and its DNA is found in 99.7% of all cervical carcinoma.
Once epithelium is acutely infected with HPV one of the 3 clinical
scenarios ensues:
1) Asymptomatic latent infection
2) Active infection but no genome integration
3) Neoplastic transformation following integration of
oncogenic HPV DNA into human genome.
Natural history of cervical carcinogenesis

15. Staging of Carcinoma Cervix (FIGO)
Stage 1A Stage 1B

16. Stage 2A Stage 2B

17. Stage 3A Stage 3B

18. Stage 4A Stage 4B

19. • Squamous cell Ca
• Adenocarcinoma
• Verrucous Ca
• Adenoma Malignum
• Adenoid cystic Ca
• Adenosquamous Ca
• Neuroendocrine Ca
• Direct extension to cervix from
endometrium,
rectum, bladder
Types of carcinoma cervix
Histological Type
• Exophytic--- arise from ectocervix,
cauliflower like growth,
friable, bleed to touch
• Ulcerative--- Initially superficial,
later deep with indurated
edge
• Infiltrative--- Arise from endocervix and
cervix become barrel shaped
Naked eye

20. Mode of spread
• By lymphatics
• By blood
• By direct
implantation

21. • Abnormal P/V bleeding in the form of :
1) Blood stained leucorrheal discharge
2) Scanty spotting
3) frequent leucorrhea which is usually serosanguinous,
purulent, odorous and non pruritic
4) Post coital bleeding.
• Pelvic pain often unilateral, radiates to hip/thigh
(advanced case)
• Involuntary loss of feces and urine through vagina(sign of
fistula)
• Generalized weakness, anemia, weight loss
Symptoms of carcinoma cervix

22. Diagnosis of Ca cervix
Diagnosis
Preclinical
Incidental on
histopathology
During
screening
procedures
Clinical
History
Clinical
examination
Investigation

23. • General investigations
CBC
S.creatinine
PPBS
Urine R/M/E
SGPT
ECG
• For confirming the diagnosis
Tissue biopsy & histopathology:
1) Colposcopy guided or
2) multiple punch biopsy from schiller’s unstained area (when
colposcopy not available)
• For detection of metastasis
USG of W/A
CXR
CT scan
IVU
MRI
PET scan
Investigations

24. • Primary surgery
• Primary radiotherapy
• Chemotherapy
• Combination therapy
Treatment Modalities for Ca cervix

25. Treatment protocol for CIN
Pap's smear
Normal Abnormal
Routine
screening
Colposcopy &
biopsy
CIN-1 CIN-2 CIN-3
Normal Abnormal
Conservative Rx
LEEP
Cryotherapy
Cone excision
Definitive Rx
Hysterectomy
Follow up
colposcopy
Routine
screening
Conservative Rx

26. Radical hysterectomy with
therapeutic
lymphadenectomy(+adjuvant
P/O radiotherapy with
concomitant chemotherapy
for high risk group)
• Stage
1A-2A
Primary radiation
(External beam +
Brachy therapy)
• Stage
2B-4A
Palliative Rx +
chemotherapy
(combination of
paclitaxel,
cisplatin &
ifosfamide)
• Stage
4B
Treatment of Ca cervix according to stage

27. Rx in special situation(Pregnancy with Ca cervix)
Early Pg with Ca cervix(stage 1-2A)
• Radical hysterectomy with therapeutic lymphadenectomy
with fetus left in situ unless pt. is unwilling to terminate
pregnancy
Gestational age closer to viability or
unwilling to lose the baby
• Continuation after counseling about the maternal risk
Pg with cervical dysplasia and CIS
• NVD can be allowed
Pg with carcinoma and stromal invasion
• LSCS
• Caesarian hysterectomy with therapeutic
lymphadenectomy(as soon as fetal maturity established)

28. 50
25
15
1st Year 2nd year 3rd year
Percentage of deaths after treatment

29. • In asymptomatic patients
3 month interval in 1st year
4 month interval in 2nd year
6 month interval in 3-5 year
• In symptomatic patients
Pt. should be evaluated with appropriate
examinations immediately when sign & symptoms occur.
positive cytology,
palpable tumor,
pain in lower limb,
unilateral lower limb edema,
vaginal bleeding/discharge,
ascites,
unexplained weight loss,
supraclavicular lymphadenopathy
Post treatment Follow-Up

30. • Methods of prevetion
1)Raising health awareness.
2)Identification of high risk group
3) Screening ( VIA test, Pap’s smear)
4) Vaccination ( Cervarix, Gardasil)
5) Using condoms
• Screening reduces the incidence & mortality of ca cervix
in developing countries
• Vaccination reduces the risk of cancerous & precancerous
change in cervix
• Condom is useful in treating potentially precancerous
changes in cervix
Prevention

31. • Complications of carcinoma cervix depends upon the site,
invasion, necrosis, infection & metastasis of the tumor.
• Complications are:
1. Pyometra
2. V V F
3. R V F
4. Ureteric pain
5. Pyelitis
6. Pyelonephritis
Complication

32. Stage 2 year survival (%) 5 year survival (%)
1A 99.5 98.7
1B 97.7 95.9
2A 85.6 68.8
2B 80.7 64.7
3A 58.8 40.4
3B 62.2 43.3
4A 35.6 19.5
4B 23.9 15.0
Prognosis

33. • Methods of screening
1. VIA (Visual Inspection with Acetic acid) test
2. Pap’s smear
3. HPV testing
4. Cervicography
• Schedule of screening
Start --- with onset of sexual act or at 18 yrs. age
Interval--- yearly up to 30 yrs. age then,
3 year interval after 30 yrs. age(if 3 consecutive
negative test occur)
Duration-- up to 65 yrs. Age(stop screening if she is in routine
schedule, if not at least 2 screening
should offer)
Screening methods and schedule
Others

34. Step Two
History of a particular patient
Management of that patient

35. • Name: Mrs.Shonai
• Age: 45 yrs
• Address: Mudrapur, Dhunot thana, Bogra
• Marital status: Married for 32 yrs
• Date of admission:
• Date of examination:
Demographic Details

36. • Intermenstrual bleeding for 1 year
• Post coital bleeding for 6 month
• Per vaginal leucorrhea discharge for 6
month
Chief complaints

37. • According to patients statement she had normal
menstrual cycle 1 year back. After that she is having
heavy irregular P/V bleeding which has become
excessive for last 3 month. She is also suffering from
post coital bleeding for 6 months. And for the last 6
months she is having blood stained leucorrheal
discharge which is sometime foul smelling. She also
gave history of weight loss since last 6 month. There
is no history of rectal pain and backache. Her bowel
and bladder habit are normal.
History of presenting illness

38. • No history of HTN, DM, Asthma, IHD
• All other family members are well according to
the patients statement.
History of past illness
Family history

39. • Patient having low socio-economic status. Lives in
kacha house, drinks water from arsenic free tube
well and uses sanitary latrine.
• Age of menarche: patient couldn’t mention
• MP/MC: 4/30 days
• MF: Average
• For the last 1 year cyclical pattern of menstruation is
absent
• Contraceptive: H/O using injectable contraceptives for
Socio-economic history
Menstrual history

40. • Married for 32 years
• Husband’s previous wife
died in cervical cancer
• Para: 3+1
• ALC: 5 years(dead)
• Appearance: ill looking
• Body built: Avg.
• Nutritional status: malnourished
• Co-operation: co-operative
• Decubitus: on choice
• Anemia: absent
• Jaundice: absent
• Edema: absent
• State of hydration: not dehydrated
• Lymph node: not palpable
• Pulse: 88 bpm
• BP: 110/70 mm Hg
• Temperature: 99⁰ F
• Respiratory rate: 16/min
Obstetrical history General examination

41. • NAD
• Inspection
healthy looking vulva and vagina
• Speculum examination
Cauliflower like growth arising from ectocervix & bleeds on
touch
• Bimannual exmination
Cervix is friable and bleeds on touch
Both the fornix are involved and growth is extended to
both parametrium but not to the pelvic side wall
Per abdominal examination
Per vaginal examination

42. • Rectal mucosa is free
• A case of carcinoma cervix (stage 2B)
• Myomatous polyp
Digital rectal examination(DRE)
Clinical/Provisional diagnosis
Differential diagnosis

43. • Mrs.Shonai,45 years married, non-diabetic, normotensive
women of low socio-economic condition hailing from
Mudrapur,Dhunot,Bogra to SZMCH with the complaints of
inter menstrual bleeding for 1 year which is heavy and
irregular, and become excessive for last 3 month. She also
complains of post coital bleeding for 6 month and blood
stained leucorrheal discharge for 6 month which is often
foul smelling. She had regular menstrual cycle with
regular menstrual flow. She gave H/O using injectable
contraceptives for years. She is married for 32 years,
para 3+1 and previous wife of her husband died in
carcinoma cervix.
• O/G/E she is ill looking with avg. body built and she is
neither anemic nor icteric. There is no palpable lymph
node. Her pulse 88 bpm, BP 110/70 mm Hg, temperature
99⁰ F, respiratory rate 16.
Salient feature

44. • Per abdominal examination revealed no
abnormality on inspection, palpation, percussion
and auscultation.
• Per vaginal examination revealed healthy looking
vulva and vagina on inspection. Per speculum
examination revealed a cauliflower like growth
arising from ectocervix that bleeds to touch.
Bimanual examination revealed friable cervix with
involvement both fornix and parametrium with
out pelvic side wall.

45. • CBC
TC: WBC-7000 cu-mm
DC: N-68%
L-26%
M-02%
E-04%
B-0%
Hb% - 11.5%
ESR- 60 mm in 1st hr
• S.creatinine 1.0 mg/dl
• Urine R/M/E
Physical Exm: straw coloured
Chemical Exm: acidic, albumin
trace amount, no reducing
substance
Microscopic Exm: pus cell 1-2
Epith.cell 1-2
RBC 2-3
• Biopsy taken from the lesion and
sent for histopathological
examination.
• Biopsy report: Infiltrating SCC,
moderately differentiated
• CXR(P/A view)- normal chest
skiagram
• USG of L/A- irregular
heterogenous mass(4.7x4.4)cm
in cervix
• IVU
Investigations
For General condition For confirming Dx
For detection of metastasis

46. • Diet : Normal
• Tab.Ciprofloxacin (500mg)
• Tab.Metronidazole (400mg)
• Cap.Traxyl (500mg)
• Cap.Omeprazole(20mg)
• Anemia correction (2 unit blood tansfused)
• Improvement of general health condition
Treatment
Conservative treatment

48. Step Three
Open discussion &
Review