CPC ON cervical cancer awareness session month of January is considered to be the month of cervical cancer awareness

1. CLINICO PATHOLOGICAL CONFERENCE (CPC)
ON CERVICAL CANCER.

3. ELIMINATE
THE
CERVICAL
CANCER

4. A SILENT KILLER
KILLS WOMEN IN PRIME OF THEIR LIFE
• Globally, cervical cancer continues to be one of the most
common cancers among females, being the fourth most
common after breast, colorectal, and lung cancer.
• The majority of new cases and deaths (approximately 85% and
90%, respectively) occur in low- and middle-income countries,
where it is the third most common cancer among women.

7. GLOBALLY 604000 NEW CASES
342000 DEATH (2020)
A PREVENTABLE DISEASE &
LARGEST KILLER
PAKISTAN IS ONE OF THE TOP
COUNTRIES WITH THE
HIGHEST NUMBER OF
CERVICAL CANCER DEATHS
IN THE WORLD

10. Call for cervical cancer
elimination
AUGUST 2020, 73rd world
Assembly passed a resolution.

17. •CASE
PRESENTATION

18. HISTORY
BY DR. AISHA SAAD

19. BIODATA
Name: Zainab w/o Abdullah
Age;38 years
Education: Up to primary
Address: Hyderabad
LMP: 10 July 2022
Para:5+0
Marital status: Married for 20 years
Occupation: Housewife
Date Of Admission:18 July 2022
Mode Of Admission: OPD

20. PRESENTING COMPLAINTS
Intermenstrual
bleeding for 6
months
Vaginal
discharge for
6 months.
Postcoital
bleeding for 3
months

21. HISTORY OF
PRESENTING
ILLNESS
• My patient was in her usual state of health 6
months back, with a regular cycle of 6/28 days
with average flow mild dysmenorrhea and no
dyspareunia, intermenstrual bleeding, and
post-coital bleeding.
• Now from the last 6 months, she noticed the
change in her cycle and developed
Intermenstrual bleeding that was
• Non-cyclic and 3 to 4 episodes in between 2
cycles each lasting for 1 to 2 days
• Moderate in amount, no passage of clots,
• Reddish brown in color but
• Associated with back pain, lethargy, easy
fatigability.

22. HISTORY OF
PRESENTING
ILLNESS
• She also had vaginal discharge in her
bleeding-free days from the last 6 months
• Heavy enough that she had to use 1 to 2
pads/day
• Yellowish color
• Foul smelling
• Not blood stained non-itchy
• Not associated with backache or lower
abdominal pain.
• She was treated for vaginal discharge but
the type of discharge was not documented.

23. HOPC
• Patient also noticed post-coital bleeding for 3
months, which was
• Mild in the form of spots that occurred after each
act of sexual intercourse
• With dull backache
• Resolving spontaneously without any medication
• Not associated with deep dyspareunia, fever or
urinary or bowel symptoms.
• No history of nausea or vomiting or any pressure
symptom.
• Patient did not smoke and she had no history of
multiple sexual partners of her or her husband and
she was married at the age of 18 years.
• Patient does not observe any significant weight
change or any mass in body.

24. HOPC • For these complaints she went to her local general
practitioner who gave her some oral medications
but her signs and symptoms did not resolve
completely.
• She was referred to gynae department PUMHS for
further evaluation and management.
• Here her certain investigations including blood
investigation, pap smear, ultrasound, and MRI were
done and a plan of management was discussed
with the patient.

25. GYNEACOLOGICAL HISTORY
CURRENT CYCLE
• Duration :6/28
• Irregular
• Flow:; Average
• Dysmenorrhea: +ve
• Dyspareunia : +ve
• Inter Menstrual Bleeding : +ve
• Post Coital Bleeding : +ve
PREVIOUS CYCLE
• Duration :6/28
• Regular
• Flow:; Average
• Dysmenorrhea: +ve
• Dyspareunia : -ve
• Inter Menstrual Bleeding : -ve
• Post Coital Bleeding : -ve

26. GYNECOLOGIC
HISTORY
• Contraception history: Couple used
oral and injectable contraceptives for 3
years and stopped the use 1year back.
• Sexual history;
• This is the first marriage of the couple
and the couple is currently sexually active
with monogamy relationship
• She never had any pap smear before.

27. OBSTETRICAL HISTORY
She is P5+⁰ (2boys + 3girls)
All spontaneous vaginal
deliveries, all her pregnancies
remained uneventful without any
antepartum intrapartum or
postpartum complication. All her
babies were healthy without any
birth defects and are breast feed
and vaccinated.

28. PAST HISTORY
Past Medical History
She has no history of diabetes Mellitus
hypertension asthma COPD or cardiac disease..
Past Surgical History
No significant past surgical history.

29. FAMILY HISTORY:
No history of diabetes
cardiac disease or
asthma in the family but
there is a history of
hypertension in her
mother and two sisters.
No history of colorectal
ovarian or breast cancer
in the family.

30. Drug and allergy History
No significant history of allergy from any drug or food
Immunization History
She had regular immunization under an EPI schedule in her childhood.
No history of HPV vaccination.

31. •Personal History
• No history of smoking or taking alcohol.
• She has Normal bowel and bladder habits,
• Now from last 3 months her appetite is decreased and her sleep is also disturbed.
•Socioeconomic History
• She lives in 3 bedroom house of her own with 9 family members and 1
earning member and all the basic necessities of life are coped with
difficulty.

32. EXAMINATION
BY DR. YUSRA ABRO

33. EXAMINATION
General Physical Examination
A young lady of average height and built lying comfortably on bed
,well oriented with time ,place and person ,with height 158cm and
weight of 65kg making her BMI 26.
Vitals
BP: 110/70mmHg
Pulse: 88b/m
Temp:98.F
R/R : 17b/m

34. Sub vitals;
Anemia +ve
Jaundice –ve
Cyanosis –ve
Clubbing –ve
Edema –ve
JVP not raised
Thyroid not enlarged
All accessible lymph nodes not
palpable.
Breast examination:
Normal with no palpable mass
CNS
Intact
CVS
S1+S2 audible with no added
sounds
Chest : bilateral normal vesicular
breathing with no added
sounds

35. ABDOMINAL EXAMINATION
• Inspection:
Normal scaphoid abdomen with centrally placed inverted umbilicus moving
symmetrically with respiration and no any visible scar mark prominent veins or striae
noticed.
hernial orifices are intact
• Palpation:
non tender with no visceromegaly
• Auscultation:
normal bowel sounds audible

36. PELVIC EXAMINATION:
• Inspection: vulva and vagina
• Labia majora and minora appear normal with normal distribution of
hairs and well estrogenized.
cough reflex negative.
• Per speculum: Vaginal discharge is noticed that is yellowish and foul
smelling.
Cervix looks unhealthy and taking pap smear.

37. PELVIC
EXAMINATION:
• Bimanual examination:
• Tone of pelvic floor muscles is normal.
Uterus is normal in size,
• Anteverted,
• Mobile,
• Non tender,
• Both adnexa are clear.
Cervix appear irregular, fragile and
bleeding on touch.

38. PELVIC
EXAMINATION:
•Per rectal examination:
•Inspection ;skin around the
anal canal is normal.
•No mass or tenderness.
•Normal tone of anal sphincter.
•Rectal mucosa normal and
freely mobile.

39. DIFFERENTIAL
DIAGNOSIS
Cervical ectropion
Chronic cervicitis
Cervical polyp
Cervical carcinoma
Cervical intraepithelial neoplasia

40. INVESTIGATIONS
BY DR. ZOHA SATTAR KHUHARO

41. INVESTIGATIONS:
• FBC (Full blood count)
• Blood group
• RBS (Random Blood Sugar)
• UCE
• LFT
• HBs Ag/Anti-HCV
• Urine R/E (Routine test)

42. FULL BLOOD COUNT:
• RBC count: 4.2 million/mm3
• Hb level: 9.1g/dl
• Hematocrit: 34%
• Mean corpuscular volume: 65fl
• Mean corpuscular hemoglobin: 28pg
• Mean corpuscular hemoglobin concentration: 30g/dl
• WBC count: 7100/mm3
• Platelet count: 2,50,000Cu/mm3

43. • Blood group O+ ve
• Random Blood sugar: 114mg/dl
• Urea : 28mg/dl
• Creatinine: 0.9mg/dl
• Na+ : 134meq/L
• K+ : 3.6meq/L
• Cl- : 99meq/L
• HCO3: 21meq/L

44. LIVER FUNCTION TEST
• Bilirubin: 0.5mg/dl
• Direct bilirubin: 0.21mg/dl
• Indirect bilirubin: 0.29mg/dl
• ALP: 150U/L
• GGT: 14U/L
• SGPT: 35U/L

45. LIVER FUNCTION TEST
• Hepatitis B,C, HIV: - ve
• PT: 14 sec
• APTT:28 sec

46. SPECIFIC:
PAP SMEAR:
ATYPICAL SQUAMOUS CELLS.

48. MRI PELVIS:
Abnormal signal intensity lesion is
involving anterior lip of cervix,
It is causing narrowing of internal OS
that results in mild dilatation of
endometrial cavity.

49. MANAGEMENT
BY DR. SANA SATTAR

50. MANAGEMENT
PLAN
She was agreed to TAH And BSO as definitive
treatment .Discuss all Cons and Pons of
operations
• We involved MDT including:
1) Anesthetist
2) Gynecologist
3) Histopathologist
4) Radiologist

51. • Pre-operative: The patient admitted
• > All health parameters optimized
• >Hb optimized
• > All basic labs done
• > Anesthesia fitness done
• > Cardiac and chest fitness done
• Assessed woman’s understanding of the procedure, and provided an
explanation, clarification, emotional support, and need.
• we made sure that anesthesia would eliminate any pain during surgery and
that medication would be administered postoperatively to minimize
discomfort.
• Informed written consent taken

52. • Bowel preparations
• blood crossed method
• WHO pre operative check list was fulfilled
• Next morning at 10 am patient shifted to OT for TAH BSO on 22 July 2023
under general anesthesia after catheterization.
• Abdomen open by Pfannenstiel incision layer by layer till peritoneum
reached.
• On operative findings are:
• Uterus bulky and normal size and both ovaries and tubes are normal and
there were no signs of malignancy or metastasis is seen so extra facial
hysterectomy done.

53. POST OPERATIVE DAY 1
General survey of the patient was
conscious and well oriented.

54. Patient was kept nil per oral till gut sounds were audible.
I/V fluids given 3liters/day.
I/V antibiotics and analgesic given.
Foleys catheter drain 2300ml of urine per day
Pelvic drain contained 90ml of mixed collected. Fluid’
Bowel sounds were audible after 8 hours.
Dressing is clean and dry.

55. POST OPERATIVE DAY 2 TO 5
. .
On general survey
patient was conscious
and well oriented.
Vitally stable,
Mobilized
Foley's catheter was
out on 2nd day.
Patient opened her
bowel on 2nd day post
operatively.

56. DAY 5
Patient
was vitally
stable.
Mobile. Orally
allowed.
Passing
stool and
urine.
No active
complaints
.
Wound
line
healing
Properly
with no
discharge..
Discharge
d and
called for
follow up
after 1
week.

57. Patient came after one week for further follow up and on examination she
was stable with healthy wound line.
Her stitches were removed and she was advised for follow up with the
histopathology report.
But the patient loss her follow up and went to Hyderabad with her
histopathology report’ where she was told that her report shows cervical
malignancy and findings of report were reconfirmed by AKUH laboratory.
Then she was referred to Oncologist for further management.

58. HISTO PATHOLOGY
• Simple endometrial hyperplasia without atypia & with chronic
nonspecific endometritis.
• Minimally invasive moderately differentiated nonkeratinizing
squamous cell carcinoma of cervix FIGO Stage 1A1
• Haemorrhagic cystic corpus luteum, one ovary.

59. HISTO PATHO BLOCKS WERE REVIEWED FOR
SECOND OPINION BY AKUH:
They reported:
• Cervix: Moderately differentiated Non keratinizing squamous cell
carcinoma HPV associated.
• Stromal invasion 0.1cm, and horizontal extent 0.9cm
• Endometrium: Autolysed endometrium
• Myometrium: Histologically unremarkable
• Ovary: corpus luteum.

60. HISTO PATHO BLOCKS WERE REVIEWED FOR
SECOND OPINION BY AKUH:
• LVI : identified
• Margins: ectocervical resection margin : 0.1cm, deep circumferential
margin : 1.2cm
• No comment was done on vaginal & adnexal involvement due to
limited specimen
• Lymph nodes : Not received
• FIGO stage 1A1

61. POST
SURGICAL MRI
PELVIS:
• Showing post surgical changes.
No abnormal intensity
enhancing lesion seen to
suggest recurrent/ residual
disease

62. Then patient underwent EBRT 45 Gy in 25 Fraction with weekly
Cisplatin from Hyderabad.
Then she was referred to NORIN HOSPITAL for brachytherapy.
At NORIN HOSPITAL she received intracavity HDR Brachytherapy total
of 18Gy in 3 Fractions from 21st January 2023 to 4th February 2023.
And she was on follow up since then.

63. 1ST FOLLOW UP AT NORIN HOSPITAL
1ST follow up done after
3months
MRI pelvis was done on
15-5-2023
That showed no
recurrent/ residual disease
noted in surgical bed.
Patient was also doing
well with no active
complaints

64. 2ND FOLLOW UP AT NORIN HOSPITAL
After 4 months of
1st follow up
patient complained
of;
Constant lower
abdominal and
back pain
Excessive watery
discharge with
occasional spotting.
On PV examination:
thickening of vault
was palpable with
mild PV bleeding.
Patient was then
again advised MR
pelvis with contrast.

65. CT SCAN
• That showed Ill defined heterogeneously
enhancing lesion seen in right side of pelvis at the
site of stump causing indentation of posterior wall
of bladder with loss of fat planes. Likely
representing recurrence of disease at surgical bed.
It measures 3.2 * 2.8cm.

68. She was then referred back to us for performing EUA and biopsy.
At our department her EUA was done that showed stenosed vagina with small growth
noticed on vault , bleeds on touch and irregular .
On Per rectal examination rectal mucosa was free and mobile with no evidence of
metastasis.
Biopsy was taken and samples were sent for histopathology.
The histopathology report of biopsy showed :
Moderately differentiated non keratinizing squamous cell carcinoma. Grade 2.

69. Now the
question is how
to proceed with
this case.
Chemotherapy Exenteration Radiation

70. ANATOMY & PATHOLOGY OF
CERVIX
BY DR. ZARISH HAQUE QURESHI

73. VASCULAR
SUPPLY OF
CERVIX

74. NERVE SUPPLY
OF CERVIX

75. LYMPHATIC
SUPPLY OF
CERVIX

76. HISTOPATHOLOGY OF
CERVIX
• Transformation zone of cervix: The area
where the endocervix and ectocervix meet is
called the squamocolumnar junction. The
squamocolumnar junction is sometimes referred
to as the transformation zone.
• Squamous metaplasia occurs continuously, it
is most active during fetal development,
menarche, pregnancy ,pregnancy.

77. TRANSFORMATION ZONE OF
CERVIX
• It consists of endocervical stroma and
glands covered by squamous
epithelium
• It's position varies according to age
• 1. Childbearing age : Transformation
zone is located in ectocervix
• 2. Post menopausal: Transformation
zone is located in endocervix

78. PATHOGENESIS
• It is due to HPV and environmental
factors
• HPV 16 and 18 causes squamous cell
carcinoma by infecting only damaged
surface epithelium not intact one.
• HPV has viral proteins E6 and E 7 (
tumor suppressor gene)
• ( E6 inhibit p53 gene and E7 inhibit Rb
gene )
• Due to inhibition tumor suppressor
gene causes neoplastic growth

79. CERVICAL INTRAEPITHELIAL
NEOPLASIA
BY DR. BUSHRA

80. CERVICAL INTRA EPITHELIAL NEOPLASIA
• CIN is the neoplastic changes in the epithelium but does
not penetrate the basement membrane.
• Once basement membrane invaded it is called invasive
carcinoma.
• It is pre invasive disease of cervix.
• Prognosis varies with the degree of invasion.

81. CLASSIFICATION OF SQUAMOUS LESIONS ON THE BASIS OF
CERVICAL CYTOLOGY ACCORDING TO BETHESDA
Cytology Histology
Bethesda BAC/NHSCSP
2013
ASCUS,ASC-H Borderline
changes in
squamous cells
HPV
LSIL Low grade
dyskaryosis
CIN1
HSIL High grade
dyskaryosis
(moderate)
CIN2
HSIL High grade
dyskaryosis(sever
e)
CIN3
HSIL,SCC High grade
dyskaryosis/?
invasive SCC
SCC
ASCUS, atypical squamous cells of
undetermined significance;ASC-
H,atypical squamous cells can not
exclude HSIL;CIN,cervical intra
epithelial neoplasia;LSIL,low-grade
squamous intraepithelial
lesion;HSIL,high-grade squamous
intraepithelial
lesion;SCC,squamous cell
carcinoma.

82. CLASSIFICATION OF GLANDULAR LESIONS ON THE BASIS OF CERVICAL CYTOLOGY ACCORDING TO
BETHESDA AND BRITISH ASSOCIATION FOR CYTOPATHOLOGY/NHS CERVICAL SCREENING
PROGRAMMED NOMENCLATURE
• According Bethesda 2001.
• AGC(Atypical glandular cells) NOS (Not otherwise specified )
• Endocervical
• Endometrial
• Glandular
• AGC (Atypical glandular cells) favor neoplastic specified
• Endometrial.
• Glandular
• Endocervical AIS (Adenocarcinoma In SITU)
• Adenocarcinoma
• Endocervical
• Endometrial
• Extrauterine
• NOS
BA/NHSCSP 2013.
• Borderline changes in
endocervical cells
• Glandular neoplasia.
• Endocervical type
• Non cervical

84. PATHOLOGICAL CLASSIFICATION OF CERVICAL CANCER

85. RISK FACTORS &
INVESTIGATIONS
BY DR. RASIA SAJJAD

86. CERVICAL
CANCER RISK
FACTORS
• HPV :16,18
Others
• Low socioeconomic status.
• Tobacco smoking(Two-fold)
• Oral contraceptives(2.5-fold)
• Early sexual debut
• Multiple sexual partners(of women or of the
partner)
• Other sexually transmitted infections(e.g.
herpes simplex virus, chlamydia) and
bacterial vaginosis.
• Immunocompromised ,including HIV(5-fold)

87. CLINICAL PRESENTATION
• Irregular vaginal bleeding.(most common presentation)
• Post coital bleeding(Most specific)
• Profuse, purulent foul smelling vaginal
discharge(advanced disease)
• Pain(advanced disease)
• Pyometra

88. • If there is extra cervical advanced stage disease with spread into
surrounding tissue and organs, it can cause other symptoms include
• Hematuria
• Urinary incontinence
• Bone pain
• Lower limb edema
• Flank or loin pain
• Changes to bladder or bowel habits
• Loss of appetite, weight loss and fatigue.

89. EXAMINATION
General physical examination
• Anemia
• Supraclavicular lymph node Palpable
• Inguinal lymph node enlarged

90. Abdominal examination:
•Abdominal mass.
•Enlargement of liver or kidney.

91. • Per Speculum Examination
• May reveal lesions eg:
• Proliferative ,cauliflower like, vascular
friable growth which bleed on touch.
• Ulcerative lesion with flat indurated
areas
• Offensive vaginal discharge.

92. Bimanual Examination
If there is growth in the cervix ,it could be .
• Hard
• Friable
• Irregular
Restricted mobility in advanced stage tumor or involvement of parametrium
Uterus feel enlarged and soft consistency due to pyometra.
Per Rectal Examination: feel firm with palpable nodules
Performed to exclude posterior extension.

93. INVESTIGATIONS
Baseline
Full blood
count
Blood group
RBS
Urine R/E
HBsAg
&Anti-HCV
Specific
Pap smear
Liquid based cytology.
Colposcopy
Punch biopsy
Abdominopelvic
Ultrasonography
Trans vaginal ultrasound
Trans rectal ultrasound
CT scan
MRI
Lymphangiography
OTHER
• LFT
• S .Urea ,Creatinine,
• S. Electrolytes
• Intravenous
pyelography
• Chest X-ray

94. VISUAL INSPECTION OF NEOPLASIA UNDER
ANESTHESIA
• Naked eye visual inspection of uterine cervix for early
detection of cervical precancerous lesions and early
invasive cancer is done by
1. VIA(Visual inspection after application of 5% acetic acid)
2. VILI(Visual inspection after application of lugol’s iodine)

96. VILI(-)NEGATIVE
A normal cervix with squamous epithelium
turns brown or black, columnar epithelium
doesn't change colour
Patchy ill defined colorless or partially
brown areas are seen.
Satellite thin yellow non iodine uptake areas
with angular or digitating margins are seen
far away from squamo columnar junction.

97. VILI(+)POSITIVE
• Dense thick, mustard yellow or saffron
yellow iodine non uptake areas seen in
transformation zone close to or
abutting the squamocolumnar junction
or close os.
• When entire cervix turns densely yellow.
• In invasive cancer it show yellow
coloured frank, nodular,
ulceroproliferative growth on cervix.

98. INVESTIGATIONS
BY DR. NANCY TALREJA

100. REPORTING OF PAP SMEAR:
The slide is stained with a special stain Papanicolaou stain then examined under microscope.
The features suggestive of dyskaryosis are
increased nuclear cytoplasmic ratio,
increased number of mitotic figures
hyperchromasia
nuclear pleomorphism
and loss of polarity.

101. Pitfalls of smear test:
• The result may not be true representative of actual disease
process because of following reasons.
• Technical error
• Deep seated lesions(because it is taken from surface
epithelium so deep seated lesions can easily be missed)
• Underestimation: It has false negative result may vary from 2-
25%.smear reporting only mild dyskaryosis proved to be CIN
2-3 or even invasive disease in 50% women on subsequent
biopsy.

102. LIQUID BASED
CYTOLOGY
It collects whole sample from sampling device in a liquid
medium that is sent to laboratory for processing.
Cells are transferred from the transport liquid to a slide as a
monolayer for examination.
This test reduces proportion of inadequate smears and
increases the detection of true dyskaryosis and improved
recall rates.
It is now standard test used for NHS cervical screening
programme.

103. • For cervical cytology false
positive rate vary from
7-27%(high specificity)
• False negative rates from
• 20-50%(low sensitivity)

104. COLPOSCOPY
• It comprises of low power
magnification and
illumination of the lower
genital tract after
application of acetic acid(3-
5%) and lugol’s iodine.

105. Objectives:
Assess the presence and severity of the abnormalities
detected on cytology.
Guide colposcopically directed biopsies from the area
with the most severe changes.
Exclude invasive changes

106. • Aid in out patient management and treatment of CIN.
• Assist follow up after treatment.
• The size and topography of the lesion should be ascertained
especially if lesion is extended into the cervical canal or onto
the vagina.

107. INDICATIONS OF COLPOSCOPY
Diagnostic:
1. Post menopausal bleeding.
2. Post coital bleeding
3. Cytological abnormality on pap smear.
4. Abnormal bleeding cervix.
5. Pre-operative assessment in early stages of CA cervix.
Therapeutic:
1. Cervical biopsy
2. Helps in follow up in conservative

108. CLINICO-COLPOSCOPIC INDEX
Variable 0 score 1 score 2 score
Index cytology Low grade _ High grade
Smoking status No _ Yes
Age <30 years >30 years _
Acetowhitening Slight Marked _
Surface area of lesion <1cm² >1cm² _
Intercapillary distance <350 micron(fine or no
mosaic/punctation)
>350 micron(coarse
mosaic/punctation)
_
Focal of lesion Unifocal or multi focal Annular _
Surface pattern Smooth Irregular _

109. MAXIMUM SCORE10
0-2 score Insignificant
3-5 score Mixed pattern histology with tendency of lesion CIN 1 or 2
6-10 score High grade lesion 3

110. •Punch Biopsy.
• In this small tissues are taken
from multiple sites, from area
involving normal as well as
abnormal area (from periphery)
and examined for disease.
• Centre of tumor has necrotic
tissue so if we take biopsy from
centre and send for
histopathological examination it
will show only necrotic tissues

111. RADIOLOGICAL IMAGING
BY DR. HIRA

112. ULTRASOUND IMAGING
Ultrasound :
• Cheaper, faster and widely available than other imaging techniques.
• It is radiation free,non invasive no contrast medium required.
• It may provide information on detecting tumour presence, evaluating
local tumor extent in good hands.
• Ultrasound or CT guided true cut biopsy in equivocal extra uterine lesion
is recommended to reduce false positive findings by imaging methods.

113. Transvaginal and trans rectal ultrasound:
Alternative to MRI in primary workup for cervical cancer evaluation.
Both offer excellent soft tissue contrast resolution, which is crucial for
tumour detection and evaluation of local extent of tumour including the
depth of tumour infiltration in bladder and rectal wall.
Can evaluate lymph node status in order to plan optimal treatment.

114. COMPUTED
TOMOGRAPHY
(CT)SCAN
In western countries all women
diagnosed with cervical cancer
undergo MRI and CT.
Complex/advanced cases are also
often offered PET-CT to determine
extent of disease.
PET-CT seems to enhance the accuracy
in diagnosing involved lymph nodes
and extra cervical disease.

118. MRI
MRI has high accuracy in (90%) in describing the
Size
Stage
extent of disease
And detailed assessment of lymph node,
It is obviously superior to CT and in this examination is
done under anesthesia combined with cystoscopy
redundant.

119. MRI aid in :
• initial staging
• primary treatment selection
• planning,response assessment
• and restaging of recurrence in patients
with cervical cancer.
MRI is essential to confirm patients
eligibility before planned fertility sparing
treatment of cervical cancer.

123. Stage IIB

128. (D)
(C)

129. (A)STAGE
VIA
(b)

133. FIGO STAGING OF
CARCINOMA OF CERVIX
(CLINICAL AND EUA
STAGING)
BY DR. NAILA HANIF LAKHO

134.  STAGE 1: TUMOR
CONFINED TO CERVIX
• Stage 1A
• microscopic invasive
carcinoma with depth of
invasion <5mm.
Stage1A1: stromal invasion
<3mm in depth.
Stage1A2: stromal invasion
3mm or more & <5mm.

135. STAGE 1B:
invasive carcinoma with deepest
invasion
5MM/ MORE
STAGE1B1:
INVASIVE CARCINOMA 5MM OR
MORE & <2CM.

136. • Stage1B2: invasive
carcinoma 2cm or
more & <4cm.
• Stage1B3: invasive
carcinoma 4cm /
more.

137.  STAGE 11:
INVASION BEYOND
UTERUS.
• Stage11 A : upper 2/3rd of
vagina without parametrial
involvement.
• Stage11 A1: invasive
carcinoma <4cm.
• Stage11 A2: invasive
carcinoma 4cm/ more.
• Stage11 B: parametrial
involvement.

138. STAGE 111:
lower 3rd of vagina & / extend to
pelvic sidewalls &/ causes
hydronephrosis / nonfunctioning
kidney & / involve pelvic /
paraaortic lymph nodes.
STAGE 111A : lower 3rd of
vagina.

139. • Stage111B:
Extension to pelvic
sidewalls &/
hydronephrosis & /
nonfunctioning
kidney.

140. STAGE 111C:
PELVIC / PARA-AORTIC
LYMPH NODE.
• Stage 111C 1: Pelvic
lymph nodes
metastasis only.
• Stage 111C 2:
Paraaortic lymph
nodes metastasis only.

141.  STAGE IV:
BEYOND TRUE PELVIS/
BLADDER/ RECTAL
MUCOSA.
• Stage1V A:
• Spread to adjacent
pelvic organ.

142. • Stage 1V B:
• Distant Organs
metastasis.

143. MANAGEMENT OF
CA CERVIX
BY Dr. Nimra Nehaj

144. SURGERY
RADIATION with CHEMOTHERAPY
a valuable adjunct
Management of
Cervical Cancer:

145. VARIABLE SURGERY RADIATION
1 SURVIVAL 85% 85%
2 SERIOUS
COMPLICATION
UROLOGICAL FISTULA 1-2% INTESTINAL & UROLOGICAL
STRICTURE & FISTULA
3 VAGINA Initially shortened
May lengthened with regular
intercourse
FIBROSED & STENOSED
4 OVARIES CAN BE CONSERVED DESTROYED
5 CHRONIC EFFECTS BLADDER ATONY 3% FIBROSIS BLADDER BOWEL 8%
6 APPLICABILITY PATIENT IN GOOD HEALTH ALL PATIENT
7 SURGICAL
MORTALITY
1% 1% (PE DURING INTRA CAVITY
THERAPY)

146. Management Cervical
Carcinoma: FIGOStage IA1
STAGE FERTILITY SPARING FAMILY COMPLETE
IAI with no LVSI CERVICAL CONIZATION EXTRAFACIAL
HYSTERECTOMY
IAI with LVSI RADICAL TRACHELECTOMY
with PELVIC
LYMPHADENECTOMY
EXTRAFACIAL
HYSTERECTOMY+ PELVIC
LYMPHADENECTOMY

147. CERVICAL CONIZATION:
Cold Knife Cone (CKC)
Laser conization
Loop electrosurgical
excision procedure
(LEEP), which is also
referred to as Loop
excision of the
transformation zone
(LLETZ)

148. COLD KNIFE CONE (CKC)

149. LOOP ELECTROSURGICAL EXCISION
PROCEDURE (LEEP)

150. RADICAL TRACHELECTOMY:

151. Management : FIGOStage IA2
STAGE FERTILITY SPARING FAMILY COMPLETE
IA2
Cervical Conization With
Pelvic Lymphadenectomy
Radical Trachelectomy
With Pelvic
Lymphadenectomy
Type B / Modified Radical
Hysterectomy +Pelvic
Lymphadenectomy
Extra Facial Hysterectomy
+ Pelvic
Lymphadenectomy
(low risk).

152. POST TREATMENT FOLLOW UP
Cytology
• 3 monthly 2 years
• 6 monthly 3 years
If all reports are negative
return them to national screening schedule

153. Cervical carcinoma:
Stage IB1, IB2, IIA1:
• Surgery & Radiation Both Can Be Used With
Comparable Outcome
• Surgical treatment is the preferred modality

154. FIGO STAGE IB1:
FIGO STAGE IB1 IS CONSIDERED LOW RISK WITH THE
FOLLOWING CRITERIA:
CERVICAL STROMAL INVASION LESS THAN 50% AND NO
SUSPICIOUS LYMPH NODES ON IMAGING.

155. FIGO STAGE IB1:
• Family Complete:
• Radical hysterectomy +
bilateral salpingectomy
+ pelvis
lymphadenectomy
• Fertility Sparing:
• Radical trachelectomy
with pelvic
lymphadenectomy

156. FIGO STAGE IB1:
• Pelvic Nerve Sparing
Surgical Procedure Is
Recommended
• So far radical curability is
maintained.
• Intra-pelvic Nerve Injury To
Autonomic Nerves (
Hypogastric, Splanchnic
Nerves, Pelvic Plexus)
• Lead To Urination, Defecation,
And Sexual Function (Post-
operative QOL)

157. FIGO STAGE IB2 AND IIA1:
SURGERY IS PREFERRED
• To determine the postoperative stage precisely (histopathologic
findings),
• Enabling individualization of postoperative treatment;
• To treat cancers, resistant to radiotherapy
• Conserve ovarian function.
• SURGERY: TYPE C RADICAL HYSTERECTOMY with PELVIC
LYMPHADENECTOMY

160. Radiation therapy for early-stage disease
(FIGO Stages IA, IB1, IB2, and IIA1)
In cases with contraindications for surgery or anesthesia,
RADIOTHERAPY provides equally good results in terms of local control
and survival.
Treatment decisions, are based on clinical, anatomic, and social
factors.
ICRT ( INTRACAVITARY RADIATION) 60-65 GY ( Microinvasive/ <1cm)
ICRT along with EBRT (EXTERNAL BEAM RADIATION)
DEFINITIVE RADIOTHERAPY or CCRT

161. RADIATION THERAPY FOR FIGO
STAGES IB3 AND IIA2
•Concurrent chemo radiotherapy (CCRT)
• is the standard of care for Stage IB3 and IIA2
disease.
CCRT includes
• External radiation
• Intracavity brachytherapy

162. ADJUVANT RADIOTHERAPY
• Following radical hysterectomy,
PORT with or without chemotherapy is indicated for
patients with adverse pathologic factors.

163. FIGO Stages IB3 and IIA2
POOR PROGNOSTIC FACTORS:
High-risk factor..
Need PORT with chemotherapy
1. Positive surgical margins
2. Positive Lymph Nodes
3. Positive Parametrium

164. FIGO STAGES IB3 AND IIA2
POOR PROGNOSTIC FACTORS:
• Intermediate risk factors..
• PORT without chemotherapy
• Largest Tumor Size > 4cm
• LVSI
• Deep Stromal Invasion ( Outer One-Third Of Cervical Stroma)

165. PORT
• PORT consists of whole pelvic EBRT.
• cover the tumor bed and draining lymph node areas.
• A dose of 45–50 Gy is usually prescribed.
• Intensity-modulated radiation therapy (IMRT),
an advanced refined technique of irradiation (postoperative setting to
reduce the toxicity).

166. CHEMOTHERAPY (NACT)
• (1) downstaging of the tumor to improve the radical
curability and safety of surgery
• (2) inhibition of micro metastasis and distant metastasis.
• Where radiotherapy facilities are scarce
• There is no consensus as to whether it improves prognosis
compared with the standard treatment

167. Radiation therapy for FIGO Stages IIB–IVA
• CCRT is considered the standard treatment for
patients with locally advanced cervical cancer
A once-weekly infusion of CISPLATIN (40 mg/m2 weekly with
appropriate hydration) for 5–6 cycles during external beam
therapy
For patients who are unable to receive platinum
chemotherapy,
5-fluorouracil based regimens are an acceptable
alternative.

168. FIGO STAGE IVB/DISTANT METASTASES
• Rare, 2% of cases.
• A management plan should consider that the median
duration of survival with distant metastatic disease is
approximately 7 months.
• Concurrent chemoradiation may have a better response than
systemic chemotherapy with overall and disease-free survivals
of 69% and 57%, respectively, reported in patients with
positive para-aortic and supraclavicular lymph nodes.

169. FIGO STAGE IVB/DISTANT METASTASES
• NO Role of prophylactic extended field radiotherapy in locally advanced
cervical cancer
• When para-aortic nodes are involved = EFRT+CCRT.
• IMRT may be used.
• CISPLATIN standard chemotherapy.
• CISPLATIN + TAXANES, TOPOTECAN, 5 FLOUROUROCIL, GEMCITABINE, OR
VINORELBINE.

170. POST-TREATMENT FOLLOW-UP
• Closer clinical follow-up in the first 2–3 years
• Routine follow-up
• every 3–4 months …. first 2–3 years,
• 6 months until 5 years,
• then annually for life.

171. Recurrent disease
LOCALLY IN PELVIS
PARA-AORTIC LYMPH NODES
 Within 3 Years
 Poor Prognosis
 Uremia Most Common Cause Of Death.
Depend upon performance status, extension of status, and site of
recurrence

172. Local recurrence
Most common site= pelvis
Confirmation of recurrence with a pathologic specimen
obtained by biopsy is essential prior to proceeding
with either therapy.
A PET/CT scan is the most sensitive noninvasive test to
determine any sites of distant disease, before

173. GOOD PROGNOSTIC FACTORS
• Isolated central pelvic recurrence
• No pelvic side wall involvement
• A long disease free interval
• Largest diameter of recurrent tumor <3 cm.

174. Local recurrence
TREATMENT OPTIONS:
when follows primary surgery
RADICAL CHEMORADIATION
PELVIC EXENTERATION

175. Local recurrence
Radical Irradiation +/_Concurrent Chemotherapy
5 Year Disease Free Survival Rates 45-74%
Pelvic Exenteration (Selected patients) =
No Evidence Of Intraperitoneal Or Extra pelvic Spread
+ Clear Tumor Free Space Between Recurrent Disease
And Pelvic Side Wall.

176. PARA-AORTIC NODAL RECURRENCE
• The second most common site of recurrence.
• Isolated para-aortic nodal recurrence,
curative-intensive radiation therapy, or
chemoradiation
can achieve long-term survival in approximately
30% of cases.

177. COMPREHENSIVE PALLIATIVE CARE
Common symptoms and signs of advanced cervical cancer include:
• PAIN
• URETERIC OBSTRUCTION causing renal failure
• Hemorrhage
• Malodors vaginal discharge
• Lymphedema
• Fistula

178. PALLIATIVE RADIOTHERAPY
Short duration radiotherapy
No standard dose fractions schedule
A dose of 20 Gy in five fractions over 1 week or
30 Gy in 10 fractions over 2 weeks
In patients with severe vaginal bleeding, a short course of EBRT may
be tried and,
If it fails, ICRT can effectively control intractable bleeding.
Control of bleeding is usually achieved after 12–48 hours of radiotherapy
for Short-duration.

179. PALLIATIVE RADIOTHERAPY
• In patients with pain arising from enlarged para-aortic or supra-clavicular nodes,
skeletal metastases, and symptoms associated with cerebral metastases,
• Palliative radiotherapy should be given
• larger fractions over shorter periods.
• Commonly used schedules in large single fractions,
20 Gy in five fractions,
30 Gy in 10 fractions.

180. PREVENTION
BY DR MENAHIL AWAN

182. PRIMARY PREVENTION
• Get vaccinated
• Safe sex
• Reducing number of sexual partners
/polygamy.
• Avoiding Early marriages
• Regular screening
• Avoiding tobacco, smoking , pan /gutka
• Using barrier method (condoms) during sex

183. HUMAN
PAPPILOMA VIRUS
• Every sexually active woman is at
risk of acquiring an oncogenic
infection
• 50-80% of women ---- HPV
infection in their lifetime.
• 50% of those will be an oncogenic
type HPV
• The RISK starts from sexual debut
and continues throughout life.

184. • With more than 200 HPV
subtypes.
• Classified according to their
oncogenic potential as follows:
• low‐risk subtypes HPV‐6,
HPV‐11. (anogenital warts)
• high‐risk subtypes (invasive
cancers) HPV‐16, HPV‐18 (65-
75%),31, 33, 35, 39, 45, 51, 52,
56, 58,59.

185. HPV VACCINE
• All vaccines are
recombinant vaccine
composed of virus like
particles that are not
infectious because they
don't contain viral DNA
Bivalent 16,
18(Cervarix)
Quadrivalent
16, 18, 6, 11
(Gardasil)
Nonavalent
6, 11, 16, 18,
31, 33, 45,
52, 58
• 9-14 yrs: 0, 6
months
• >15 yrs 0,1,6
months
• 9-14 yrs: 0, 6
months • >15 yrs
0, 2, 6 months
• 9-14 yrs: 0, 6
months • >15
yrs 0, 2, 6
months

186. SINGLE DOSE
CAMPAIGN
• HPV vaccine is cheaper ,
easily available, used in
developing countries
• One dose is enough to
lower the incidence of
cervical cancer

187. SECONDARY PREVENTION
It is done by screening
Aim of screening : To detect cervicalcancer
precancerous lesion
RCOG
START… 25 YEAR
3 YEARS TILL 50
5 YEARS TILL 65
STOP AT 65 IF….
SOGP
3-5 YEARS OF
MARRIAGE
3-5 YEAR
STOP 65 IF..
AT LEAST ONE TILL
WHO
30 YEARS
5-10 YEARS
STOP AFTER 50 IF…
yearly (USA)
2-3 yearly (Iceland)
5 yearly (Finland)

189. APPROACHES
SCREEN & TREAT
SCREEN, TRIAGE & TREAT
PARTIAL GENOTYPING
VIA
CYTOLOGY
COLPOSCOPY

198. THANK YOU