This document discusses cervical cancer, including its causes, risk factors, types, stages, diagnosis, and treatment. Some key points: - Cervical cancer is the second most common cancer in women globally and the leading cause of cancer deaths in women in Nepal. - Human papillomavirus (HPV) infection is the main cause, with HPV types 16 and 18 causing most cases. - Cervical cancer is staged using the FIGO system, with stage I being limited to the cervix and stage IV being widespread metastasis. - Treatment depends on the stage but may include surgery, radiation therapy, chemotherapy, or a combination. Screening programs can detect pre-cancerous lesions early and prevent

1. CERVICAL
CANCER
Renuka Tamrakar Mishra
MBBS, PhD.
Department of Obstetrics and Gynecology
CMCTH

2. To discuss various etiological factors of
cervical cancer
To discuss about the types and stages
To discuss about the diagnostic
modalities and management
OBJECTIVES

3. Most common gynecological cancer in
women – rank 2nd among all
malignancies for women
Develops in younger populations
In 2018 – 570 000 new cases identified
and 311 000 deaths globally
OVERVIEW

4. In Nepal every year 2,332 women are
diagnosed with Cx Ca and 1,367 women die
Cx Ca ranks as the first most frequent
cancer among women in Nepal
Higher incidence are found in developing
countries

5. In the developing countries 83% of all
the new cases of Ca Cx, 85 % of all the
deaths occur
Median age of diagnosis – 40-59 yrs
Women aged 20-39yrs – 2nd leading
cause of cancer deaths

6. Cx Ca is one of the easiest cancer to
prevent, with regular screening tests
and follow-up
Cervical screening helps to find cancer
at an early stage
Abnormal tissue or pre-cancerous cells
are found early, cervical cancer is easy
to prevent

7. WHO, two main strategies in reducing Ca
Cx
1. education (increasing awareness)
2. screening
Cx Ca is screened using various techniques
1. Pap Smear
2. Visual Inspection with Acetic acid (VIA)
3. VILI
4. LBC

8. 70-75% invasive cervical cancer develops in
flat surface cells that lines the cervix
(squamous cell carcinomas)
20-25% of cases develop in glandular
surface cells (adenocarcinomas)
3-5% - adenosquamous carcinomas

9. 1. Viral infections
Human Papillomavirus (HPV)
 etiologic infective agent
 75% by HPV 16 and 15% by HPV 18
 Vaccination against HPV 16 and 18 reduces
incidence by 92% and decreased persistent
infection by 100%
Herpes simples virus II ( HSV II )
Cytomegalovirus (CMV)
CAUSES

10. RISK FACTORS
Multiple sexual partner: more than 6
lifetime sex partners increases relative risk
of Ca Cx
Sexual intercourse at an early age: age <
16 yrs
Multi parity: 7 prior full term pregnancy
have 4 fold risk and 1 or 2 have 2 fold risk
compared to nulliparous

11. RISK FACTORS
Long term COC pill use: women who are +ve
for cervical HPV DNA and who are on COC’s
has 4 fold increase risk
Current COC users and within 9 yrs of use has
an increase risk of developing both squamous
cell carcinoma and adenocarcinoma of cervix
Cigarette smoking
Low socio economic groups

12. Asymptomatic
Vaginal bleeding (post coital, intermenstrual and
postmenopausal )
Watery or blood tinged vaginal discharge
Symptoms of advanced cancer: weight loss, loss of
appetite, fatigue, pelvic pain, back pain, single
swollen leg, heavy PV bleeding, hematuria and
bone fracture
SIGNS AND SYMPTOMS

13. General physical:
weight loss, enlarged lymph nodes
(supraclavicular, axillary and inguino-
femoral), edema of legs, ascites, pleural
effusion, hepatomegaly
Pelvic examination:
P/S: visible disease may take various forms
like ulcerative, exophylic, granular,
necrotic. Watery purulent or bloody
discharge.
EXAMINATIONS

14. Rectovaginal: for cervical consistency and
size, specially with endocervical carcinomas
 Spread to parametria are much more easily
detected
EXAMINATIONS

15. Two pattern of local growth:
1. Exophytic: if arises from ectocervix
2. Endophytic : if arises from endocervical canal
Lymphatic spread: cervical lymphatics follows the
parametrial lymphnodes  obturator lymphnodes
 internal, external and common illiac
lymphnodes
 lymphatics passing through the cardinal ligament
drain in to ureteric nodes.
PATTERN OF SPREAD

16. Local tumor extension: Extension through
paramatria to pelvic side wall  causes
urethral blockage
Distant metastasis from hematogenous
dissemination – lungs , ovaries, liver and
bones

17. History of the patient
Pelvic examination: The vagina and adjacent
organs are examined visually and bimanually
Papanicolaou smear (Pap smear): done as a
screening for Ca Cx
55-80% sensitivity for detecting high grade lesion
on any given single test
If abnormal Pap smear – colposcopy
DIAGNOSIS

18. Colposcopy: a procedure in which a colposcope (
lighted, magnifying instrument) is used to check
the cevix and vagina for abnormal tissues.
Colposcopic findings: suggestive of invasion are:
1. Abnormal blood vessels
2. Irregular surface contour with loss of surface
epithelium
3. color tone change

19. Biopsy:
 Cervical punch biopsy or conization – most
accurate
- Large cone shape sample of cervical tissue is
removed and examined for cancer cells
 Endocervical curetting – lining of cervical
canal is scraped and examined for cancer cells

20.  Mosaic
 Punctation
 Acetowhite
 Leukoplakia
 Atypical vessels
COLPOSCOPY

21. COLD KNIFE CONIZATION

22. Squamous cell carcinoma
Adenocarcinoma
Mixed cervical cancers
Neuroendocrine carcinomas
Non-carcinoma malignancies – melanoma,
lymphoma ( rarely )
PATHOLOGIC TYPES

23. Most common – 85% of all Ca Cx
Arises from ectocervix
Decrease incidence of squamous cell carcinoma in
the past 30 yrs
Four subtypes:
i. Cauliflower-like
ii. Endogenic
iii. Ulcer
iv. Neck-tube
INVASIVE SQUAMOUS CELL CARCINOMA

24. 10-15% of cervical cancer
Arise from endocervical mucosa
- often occult and maybe advanced before
becoming clinically evident
Sub types:
- mucinous endocervical adenocarcinoma (most
common)
- endometrioid adenocarcinoma
- minimal deviation adenocarcinoma
ADENOCARCINOMA

25.  Adenocarcinoma:

26. Cervical cancer is staged by the International
Federation of Gynaecology and Obstetrics (FIGO)
staging system – based on clinical examination
rather than surgical findings
The TNM staging system for cervical cancer is
analogous to the FIGO system
STAGING OF CERVICAL CANCER.

27. FIGO STAGING
Stage 0 - full-thickness involvement of the
epithelium without invasion into the stroma
(carcinoma in situ )
Stage I - limited to the cervix
Stage IA - Invasive cancer identified only
microscopically, Invasion is limited to measured
stromal invasion with a maximum depth of 5 mm
and no wider than 7 mm

28. FIGO STAGING
Stage IA1: Measured
invasion of the stroma
< 3 mm in depth and < 7
mm diameter
Stage IA2: Measured
invasion of stroma > 3
mm but < 5 mm in depth
and < 7 mm in diameter

30. FIGO STAGING
Stage IB: Clinical
lesions confined to the
cervix or preclinical
lesions greater than
stage IA
Stage IB1: Clinical
lesions < 4 cm in size
Stage IB2: Clinical
lesions > 4 cm in size

32. FIGO STAGING
Stage II is carcinoma
that extends beyond the
cervix but has not
extended onto the
pelvic wall. The
carcinoma involves the
vagina, but not as far as
the lower third

33. FIGO STAGING
Stage IIA: no obvious
parametrial
involvement.
Involvement up to
upper 2/3rd of vagina.
Stage IIB: obvious
parametrial
involvement, but not
into the pelvic side
walls.

35. FIGO STAGING
Stage III:
Carcinoma that has extended
into the pelvic side walls.
On rectal examination there is
not cancer free space
between the tumor and the
pelvic side wall.
The tumor involves the lower
third of the vagina.
All cases with a
hydronephrosis or
nonfunctioning kidney
should be included, unless
they are known to be due to
other causes

36. FIGO STAGING
Stage IIIA: No
extension onto the pelvic
sidewall but
involvement of the
lower third of the
vagina
Stage IIIB: Extension
onto the pelvic sidewall
or hydronephrosis or
nonfunctioning kidney

38. FIGO STAGING
Stage IV: is
carcinoma that has
extended beyond the
true pelvis or has
clinically involved
the mucosa of the
bladder and/or
rectum.
Stage IVA: Spread
of the tumor onto
adjacent pelvic
organs.

39. Stage IVB: Spread
to distant organs

42. Full blood count, platelet count, liver function tests,
renal profile
Biopsies, cystoscopy, sigmoidoscopy, chest and
skeletal radiographs, and liver function tests
For patients with advanced disease, an abdominal
and pelvic CT scan is helpful in planning
management
PRE-OPERATIVE INVESTIGATIONS

43. Stage IA1 and IA2
(microinvasive cervical carcinoma)
More conservative approach
Conization or simple hysterectomy or simple
trachelectomy
Radical hysterectomy and bilateral pelvic
lymphadenectomy in high risk Ia2
Fertility preserving surgery
TREATMENT

44. TREATMENT
Stage Ib-IIa: radical surgery or
chemoradiotherapy
Stage IIb: combination of external beam
chemoradiation ( teletherapy) and intracavity
brachytherapy

45. TREATMENT
Stage IIIa and IIIb: chemoradiation therapy,
usually external beam followed by intracavity
brachytherapy
Stage IVa: pelvic chemoradiotherapy
Stage IVb: some pelvic radiation therapy to
control bleeding from vagina and
chemotherapy for distant metastasis
 palliative support

46. Stage IA1 CaCx
does patient
Wish to preserve
Fertility?
NO YES
Hysterectomy observation with
cone biopsy
Observation Observation

47. Stage IA2 CaCx
Does patient prefers to
Preserve fertility?
YES NO
- Radical trachelectomy+ - Radical
Pelvic lymph node dissection hysterectomy+
pelvic lymph node
dissection OR
Brachytherapy +
pelvic radiotherapy

48. Stage IB / IIA ( < 4cm)
Is there suspicion of bowel
Or bladder involvement ? YES Cystoscopy/proctoscopy
with biopsy
NO
Treatment choice: Radiotherapy pelvic radiotherapy+
brachytherapy
surgery
Radical hysterectomy + bilateral pelvic lymph node dissection+ para aortic
node sample
 If +ve for pelvic nodes or +ve for parametria: pelvic radio therapy +
Cisplatin-containing chemotherapy

49. Stage IB2/IIA (> 4cm)
Is there suspicion of bladder or
Bowel involvement: YES Cystoscopy/proctoscopy with
biopsy
NO
Therapy decision:
- Primary radical - Neoadjuvant - Primary
Hysterectomy chemotherapy chemoradiation.
Radical hysterectomy pelvic radotherapy pelvic radiotherapy
Pelvic node dissection Cisplatin containing Cisplatin containing
Para aortic node chemotherapy + chemotherapy+
adjuvant hysterectomy brachytherapy.

50. To evaluate response to treatment.
General physical examination.
Pelvic examination /radiologic scanning – to see
progressive shrinkage of mass.
Pap smear: 3 monthly for 2 yrs.
- 6 monthly for 3 yrs.
- annually.
X-ray chest annually.
FOLLOW UP

51. • Prognosis depends on the stage of the cancer
• Stage: 5 Yr-survival
IA  100%
IB  88%
IIA  68%
IIB  44%
III  18-39 %
IV  18-34%
PROGNOSIS

52. According to FIGO, survival improves when
radiotherapy is combined with cisplatin-based
chemotherapy
As the cancer metastasizes to other parts of the
body, prognosis drops dramatically because
treatment of local lesions is generally more
effective than whole body treatments such as
chemotherapy

53. Recurrent cervical cancer detected at its earliest
stages might be successfully treated with surgery,
radiation, chemotherapy, or a combination of the
three
Thirty-five percent of patients with invasive
cervical cancer have persistent or recurrent disease
after treatment

54. THANK YOU