This document discusses cervical carcinoma, including its definition, epidemiology, risk factors, screening and prevention methods, diagnosis, staging, and treatment. It notes that cervical cancer is the 4th most common cancer in women worldwide, with over 80% of cases occurring in developing countries. Screening methods discussed include the Pap smear, HPV testing, and visual inspection with acetic acid. Treatment depends on the stage of cancer, and may include surgery such as hysterectomy or cone biopsy, radiation therapy, or chemoradiation for more advanced stages. The document provides details on the FIGO staging system and comparisons between the 2018 and 2009 versions.

1. Cervical carcinoma
By
Mohammad Emam
Prof. of Obstetrics and
Gynecology
Early Cancer Detection Unit ( oncology unit ).
Mansoura Faculty of Medicine
Egypt.
2020

2. Definition
• It is the malignant neoplasm of the cervix.
• May arise from :
• The surface epithelium of the cervix
)exocervical c 85%)
• From the epithelial lining of the
cervical canal (endocervical carcinoma 15 %).

3. Objectives
Epidemiology of cancer cervix.
Screening & Prevention.
-Diagnosis.
Spread
-Staging.
-Treatment:

4. Epidemiology of cancer cervix.

5. Cervical Cancer Worldwide
230,000 women die
of cervical cancer
every year
– 80 % occur in
developing
countries.
“WHO , Cervical Cancer Screening in Developing
Countries. Report of a WHO Consultation. 2001”

6. Incidence of Cancers in
Egyptian Women
0
5
10
15
20
25
Breast
Cancer
Cervical
Cancer
Ovarian
Cancer
Uterine
Cancer
Percent
Source: GLOBOCAN 2000.

7. Who is at risk?
Exo cx carcinoma :
Women who have had more than one partner
Women who’s partner (s) has had more than one
sexual partner.
Women with STI

8. Who is at risk?
Women with immune problems:
– Steroid medications
– Transplanted organs
– Chemotherapy
– HIV
Women who smoke
1st intercourse before Age 18
Endocervical c
( like Endometrial c…Obesity , Diabetes , hypertension , low parity , endometrial hyperplasia)

9. STI
All over the world; HPV 16,18
are present in most cases.
In Mansoura study ,it was
found only in 45% of cases.

10. Screening & Prevention
1. Prevention is better than cure.
2. Most Cancers Develop In The Unscreened
And The Under screened populations

11. Serious
Widespread
Diagnosable in early stages.
Treatable
Cancer cx. Screening programs are in
adulthood.
But ov. cancer programs are still in relative
infancy, why?
Cancer Cervix Is an Ideal DiseaseFor
Screening

12. Gold standard Screening
test For Cancer Cervix
☼ PAP smear test is
considered to be the
gold standard .
☼ Has limitations ?

13. •Collection
•Reading
•Reporting
Limitations Associated with
Pap Smear

14. Pap Smear Preparation

15. Ayres’ spatula & endocervical
brush

16. Premalignant cervical lesions
Pathological ( CIN)
Cytological (Bethesda system )

17. Cervical intraepithelial neoplasia (CIN)
Transformation of cervical epithelium witch may
regress or progress to invasive cancer over >10 years.
CIN 1……….lower 1/3
CIN 2………lower 2/3
CIN 3…………..All epithelium except superficial cells
CIS………………All epithelium replaced by
malignant cells.

18. Bethesda system depends on
cytological criteria
Normal.
-Atypical squamous cells of undetermined significance (ASCUS)
-LGSIL……………CIN 1
-HGSIL………..CIN2, CIN3, CIS

19. Precursor lesions for cervical cancer

20. Prognosis of Premalignant
cx lesions
Regress Persist CIN3 Cancer
CIN I 57% 32% 11% <1%
CIN2 43% 35% 22% 5%
CIN3 32% 56% 12%

21. PAP Smear Normal:

22. LSIL
Dysplastic nuclear changes, binucleation

23. HSIL
Enlarged nucleus, less cytoplasm (increased N:C ratio).
Irregular nuclear membrane

24. What are
Alternatives to
Pap Smear?

25. Alternatives to Pap smear
– Automated pap screening.
– Visual inspection with acetic acid
(VIA), with magnification (VIAM)
&iodine (VILI).
– HPV testing.
– Polar probe.
– cervicography

26. HPV testing
Detect High Risk HPV.
Sample from cervix-
similar to PAP.
Special transport
medium
Processed in the lab
Objective tests
Not suitable for Egypt))
Expensive

27. VILI: test-positive
– Well-defined area.
– Canary yellow .
– Transformation zone
VILI negative
– Mahogany brown

28. Via Is An Ideal Alternative to Pap smear
Keep a bottle
of vinegar in
your office.

29. inexpensive&1. Simple & quick
2. Immediate results
3. Not need cytopathologist .
4. One step diagnosis and ttt.
5. Sensitive
6. Specific??????
Advantages of VIA over PAP

30. WHO 2013 & VIA
 VIA ….should be an integral
step of inspection of cervix –
uteri on routine pelvic
examination in low resource
countries.
 As recommended by WHO project for the developing
countries 2013 (field studies in India & South Africa).

31. `
Colposcopy
How to do VIA?

32. Reporting Visual
Inspection Findings
Acetic Acid Test-
Negative
Aceto-white area(s) not
present
Acetic Acid Test-
Positive
Aceto-white area(s) :
1)Density of whiteness
2)Time needed for whiteness to appear
3) Time needed for whiteness to disappear
4)Sharpness of demarcation
5) Surface contour

33. NORMAL CERVIX
ACETO-WHITE
VIA images

34. Positive VIA

37. Treatment Of premalignant lesions
Local destructive therapy :
1. cryocautery
2. LEEP diathermy (Loop Electrosurgical Excision .
3.
4. Laser.
Hysterectomy.

38. Diagnosis of
invasive

39. Diagnosis: 1- History.
•
•
•
•
•
•
•
•
Many women are a symptomatic .
Presented with abnormal routine cx smear
Complain of abnormal vaginal bleeding
I M bleeding
post coital bleeding
perimenopausal bleeding
postmenopausal bleeding
blood stain vaginal discharge

40. Diagnosis : 1) History
-Increased vaginal discharge
-Pelvic pain
-Pain during sex ( Dyspareunia)
-Foul smelling discharge

41. 2- Examination:
• PV exam using cuscu’s speculem
• Nothing is found in early stage .
• Mass ,ulcerating fungating
• P/V& P/R is very helpful.

42. 3 ) Investigations
Bed side
Laboratory
Imaging
Instrumental
Miscellaneous

43. Spread

44. Patterns of spread
cervical stroma, vagina, and• Direct invasion
parametrium.
• Lymphatic spread pelvic and then par aortic
lymph nodes
• Hematogenous spread such as lungs, liver, and
bone

45. Lymphatic Spread
– Primary Group
●
●
●
●
●
● Parametrial nodes
Paracervical/ureteral nodes
Obturator nodes
Hypogastric nodes
External iliac nodes
Sacral nodes
– Secondary Group
●
i
●
● Common Iliac nodes
Inguinal nodes (deep and s
Periaortic nodes

46. STAGING
S

47. Rationale Of staging
• Staging is clinical
• FIGO staging
• Based on EUA, cystoscopy +/-
sigmoidoscopy
• Does NOT include MRI

48. CervicalCancer
• Stage I: The carcinoma is confined strictly to the cervix
• Stage II: The tumor extends to the upper part of the vagina. It may
extend beyond the cervix into nearby tissues toward the
pelvic wall with depth between 5-7mm. The tumor does not
invade the lower third of the vagina or the pelvic wall.
• Stage III: The tumor extends to the lower part of the vagina.
It may also have invaded the pelvic wall.
If the tumor blocks the flow of urine, one or both kidneys
may not be working well.
• Stage IV: The tumor extend beyond the true pelvic or has involved the
mucosa of the bladder or rectum or spread to other parts of
the body.
• Recurrent
cancer:
The cancer was treated, but has returned after a period of
time during which it could not be detected. The cancer may
show up again in the cervix or in other parts of the body.
Staging

49. The tumor extends to the pelvic wall and/or involves lower third of the vagina and or causes hydronephrosis or non-functioning kidney**
Stage IIIA: Tumor involves lower third of the vagina, with no extension to the pelvic wall
Stage IIIB: Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
The carcinoma is strictly confined to the cervix
(extension to the corpus would be disregarded)
Stage IA: Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion ≤5 mm and largest extension ≤7 mm
Stage IA1: Measured stromal invasion of ≤3.0 mm in depth and extension of ≤7.0 mm.
Stage IA2: Measured stromal invasion of >3.0 mm and ≤5.0 mm with an extension of not >7.0 mm
Stage IB: Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA*
Stage IB1: Clinically visible lesion ≤4.0 cm in greatest dimension
Stage IB2: Clinically visible lesion >4.0 cm in greatest dimension
The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum.
A bullous edema, as such, does not permit a case to be allotted to Stage IV
Stage IVA: Spread of the growth to adjacent organs.
Stage IVB: Spread to distant organs.
Stage II
Stage I
FIGO staging system, 2009
Cevical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina
Stage IIA: Without parametrial invasion
Stage IIA1: Clinically visible lesion ≤4.0 cm in greatest dimension
Stage IIA2: Clinically visible lesion >4 cm in greatest dimension
Stage IIB: With obvious parametrial invasion
Stage III
Stage IV
*All macroscopically visible lesions—even with superficial invasion—are allotted to stage IB carcinomas. Invasion is limited to a measured stromal invasion with a maximal depth of 5.00 mm and a horizontal
extension of not >7.00 mm. Depth of invasion should not be >5.00 mm taken from the base of the epithelium of the original tissue—superficial or glandular. The depth of invasion should always be reported
in mm, even in those cases with “early (minimal) stromal invasion” (~1 mm). The involvement of vascular/lymphatic spaces should not change the stage allotment.
** On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to
another cause.

50. FIGO 2018 specification
Incorporates importance of modern imaging findings
Incorporates microscopic finding in early cervix
limited disease .
Abolishes importance of horizonal spread in
microscopic disease
Specific stage group has been assigned to lymphnode
positive patients

51. Stage Description 2018 Description 2009
I
Confined to cervix only, disregarding uterine corpus
involvement
Confined to cervix only, disregarding uterine
corpus involvement
IA
Invasive carcinoma, diagnosed only by microscopy,
with maximum depth of invasion <5 mm
Invasive carcinoma, diagnosed only by
microscopy. Maximum depth of stromal
invasion 5mm, maximum horizontal spread
7mm
IA1
Stromal invasion <3 mm in depth Stromal invasion ≤3 mm in depth, horizontal
spread ≤7mm
IA2
Stromal invasion ≥3 mm and <5 mm in depth Stromal invasion >3 ≤5 mm
in depth, horizontal
spread ≤7mm
IB
Stromal invasion ≥5 mm (greater than Stage IA)
but limited to the cervix uteri
Clinically visible lesion confined to cervix or
lesion > IA2 including superficial lesions
IB1
Stromal invasion ≥5 mm and tumor <2 cm in
greatest dimension
Clinically visible lesion, ≤ 4cm
in greatest dimension
IB2
Invasive carcinoma ≥2 cm and <4 cm in greatest
dimension
Clinically visible lesion, > 4cm
in greatest dimension
IB3 Invasive carcinoma ≥4 cm in greatest dimension
dodulmondal@gmail.com
NONE

52. Stage Description 2018 Description 2009
II Carcinoma invades beyond the uterus but
not extending onto the lower third of the
vagina or to the pelvic wall
Carcinoma invades beyond the uterus
but not extending onto the lower third
of the vagina or to the pelvic wall
IIA Tumor extending beyond uterus but not
involving lower third of vagina and without
parametrial invasion
Tumor extending beyond uterus but not
involving lower third of vagina and
without parametrial invasion
IIA1 Invasive carcinoma <4 cm in greatest
dimension
Clinically visible, ≤ 4cm
in greatest
dimension
IIA2 Invasive carcinoma ≥4 cm in
greatest dimension
Clinically visible tumor, >4cm
in greatest
dimension
IIB With parametrial involvement but not up
to the pelvic wall
With parametrial involvement but not up
to the pelvic wall
dodulmondal@gmail.com

53. Stage Description 2018 Description 2009
III Carcinoma involves lower third of vagina and/or
extends to pelvic wall and/or causes hydronephrosis
or nonfunctoning kidney and/or involves pelvic
and/or para-aortc lymph nodes
Carcinoma extending to lateral pelvic wall and/or
involving the lower third of vagina and/or causing
hydronephrosis or nonfunctioning kidney
IIIA The carcinoma involves the lower third of the
vagina, with no extension to the pelvic wall
The carcinoma involves the lower third of
the
vagina, with no extension to the pelvic wall
IIIB Extension to the pelvic wall and/or
hydronephrosis or nonfunctoning kidney
(unless known to be due to another cause)
Extension to the pelvic wall and/or
hydronephrosis or nonfunctoning kidney
(unless known to be due to another cause)
IIIC Pelvic and or para-aortic lymphadenopathy
irrespective of tumor size and extent. r or p used
to denote radiological or pathological
involvement NONE
IIIC1 Pelvic LN only
IIIC2 Para aortic (± Pelvic LN)
dodulmondal@gmail.com

54. Stage Description 2018 Description 2009
IV
The carcinoma has extended beyond the true
pelvis or has involved (biopsy proven) the
mucosa of the bladder or rectum. (A bullous
edema, as such, does not permit a case to be
alloted to Stage IV) or spread to distant
organs
The carcinoma has extended
beyond the true pelvis or has
involved (biopsy proven) the
mucosa of the bladder or
rectum. (A bullous
edema, as such, does not permit a case to
be alloted to Stage IV) or spread to
distant organs
IVA
Spread to adjacent pelvic organs
Invading bladder or rectal mucosa (biopsy
proven). Bullous edema alone disregarded
IVB
Spread to distant organs Distant organ metastasis
dodulmondal@gmail.com

55. Treatment of
invasive

56. SURGERY RADIOTHERAPY
TREATMENT DILEMMA
56

57. Factors For choice of treatment
• Patient
• Fitness of the patients
• Age of the patients
• Disease:
• Stage
• Type of lesion
• Gynecologist:
• Experience
• The resources available.

58. Therapy
Cervical conization
Simple hysterectomy
Radical hysterectomy
Radiation therapy with chemo sensitization

59. Treatment
Stage 1A1………………….Conization.
Stage 1A2…..Simple hysterectomy or cone..
1B-IIA…………….Radical hysterectomy or
Radiotherapy.
IIB-IV……………..Chemoradiation.

60. surgery & radiation
Bladder dysfunction
Vesico/uretero fistula
Bowel obstruction
Ovarian preservation
Vaginal preservation
Surgery Radiation
Sigmoiditis
Rectovaginal fistula
Bowel obstruction
Vesico/uretero fistula
Ovarian failure

61. Werthemeim’s hystrectomy
• Total abdominal hystrectomy including:
• the parametrium.
• Pelvic lymphadenectomy
• 3 cm vaginal cuff
• The original operation conserved the ovaries
,since squamouss cell carcinoma does not
spread dirctly to the ovaries.
• Oophorectomy should be performed in cases of
adenocarcinoma as there is 5-10% of ovarian
metastosis

62. complications
• Low blood counts
• Uteric pain due to
pyelitis and
pyelonephritis
• Vesicovaginal fistula
• Menorrhagia
• Post-menopausal PV
bleed
Disease related Related to surgery
• Infection & sepsis
• Hemorrhage
• Severe pain
• Shock

63. Complications (cont..)
Related to radiation
•
• Anorexia
• Fatigue.
• Nausea .
• Vomiting
• Skin changes, which range from
redness (like a sunburn) to
• blistering and peeling where
the radiation enters the body
Low blood counts
Related to chemotherapy
• Immune suppression
• Myeolosupression
• mucositis
• Nausea
• Vomiting
• Diarrhea
• Alopecia
• Loss of appetite
• Increased chance of infection
• Easy bruising or bleeding
• Fatigue

64. Uremia.
Vesicovaginal fistula
-Rectovaginal fistula
Cachexia
The commonest Complications

65. prognosis
• Depends on clinical stage
• Pathologocal type Adenocarcinoma and
adenosquamous carcinoma have a
somewhat lower 5-year survival rate
than squamous carcinoma, stage for
stage

66. Mobile: 002/01223475579
Email. mae335@hotmail.com