1. Cervical carcinoma arises from the cervix which has lymphatic drainage to the hypogastric, obturator, external iliac, and common iliac lymph nodes. 2. Risk factors include early age of first intercourse, multiple sexual partners, HPV infection, smoking, and poor socioeconomic status. 3. Screening involves Pap smear testing which is transitioning to liquid based cytology and HPV testing. Colposcopy and biopsy are used for diagnosis. 4. Treatment ranges from local destruction for pre-invasive lesions to radical surgery or chemoradiation for invasive cancer, depending on the stage.

1. CERVICAL CARCINOMA

7. ANATOMY
Parts of Uterus
1.Body/Corpus
2.Isthmus
3.cervix-a)supra-vaginal
part b)vaginal part
Ligaments
1.Broad ligament
2.Round ligament
3.Uterosacral ligament

8. LYMPHATICS
LYMPH NODES AROUND UTERINE
CERVIX
1.Uppermost-Hypogastric LN
2.Obturator LN & External illiac LN
3.Inferior & superior gluteal, Common
illiac,Presacral and Subaortic LN
4.Anterior branch-Internal illiac LN
5.Posterior branch-superificial rectal
LN
COMMON ROUTES OF LYMPHATIC
SPREAD
Obturator LN or Hypogastric LN or
External illiac LN
Common illiac LN or para-aortic LN

9. ANATOMIC SITES OF FIRST
METASTASIS

10. HISTOLOGY
• Squamocolumner
junction
• Transformation
zone

11. RISK
FACTORS
Early coitus
Multiple sexual partners
Early childbirth
Multi-parity with poor birth spacing
Partner with penile cancer
Poor personal hygeine
Poor socioeconomic status
Smoking,alcohol,drugs
Immunosuppression(eg.transplant
recipients)
Infections-
STDs,HIV,HSV2,Condylomata
HPV(16,18,31,33,45…)
Pre-invasive lesions

13. HPV-an essential criteria for CA Cervix

15. HPV infection & proliferation

16. Molecular biology of HPV
infection

19. HPV vaccination
•GARDASIL-Quadrivalent(VLPs for HPV
6,11,16,18)
•CERVERIX-Bivalent(VLPs for HPV16,18)
Efficacy 100% for seronegative or
seropositive but with negative HPV
DNA
•ACS GUIDELINES
Reccomended for girls @ 11 to 12
years(9-18years)
Cervical Screening programme to
remain unaffected

20. PRE-INVASIVE LESIONS of CERVIX

21. COMPARISON B/W VARIOUS CLASSIFICATION
SYSTEMS

23. Pre-invasive to invasive
% of CIN REACH INVASIVE STAGE IN YEAR
4% 1 Y
11% 3 Y
22% 5 Y
30% 10 Y

24. screening
ACS NCCN ACOG
Start Within 3 years of 1st sexual
activity, no later than 21
year
Age 21 year
Upto 30
Y
Conventional Pap-annually
Liquid Pap-2yearly
Every 2 years
>30Y Every 2-3 years after 3
consecutive normal pap
smears
Every 2-3 years after 3
consecutive normal pap
smears
Or every 3 years when
cytology + HPV Test
Every 3 years after 3 consecutive
normal pap smears
Stop Age 70 years after 3
consecutive normal Paps &
no abnormal results within
10 years
Age 70 years after 3
consecutive normal Paps & no
abnormal results within 10
years
Age 65-70 years after 3
consecutive normal Paps & no
abnormal results within 10 years
Post
hystere
ctomy
none none None.except H/O CIN2-CIN3
HPV
DNA
>30 years,every 3 years with
cytology

25. DIAGNOSIS
• Clinical features
 Mostly asymptomatic
 Post coital bleeding
 Post menopausal bleeding
 On Inspection- cervicitis/erosion - bleeds on touch
• investigations
 Pap smear test
 Liquid based cytology
 DNA study
 Colposcopy
 Cone biopsy

26. CONVENTIONAL PAP GIVING WAY TO
LIQUID PAP

27. HYBRID CAPTURE TEST FOR HPV DNA

28. COLPOSCOPY & BIOPSY

29. 29
Conization
•Removes a cone-
shaped piece of
tissue
•Often allows for
diagnosis and
treatment
•Performed with
local anesthesia in
the office or under
general anesthesia in
the operating room

30. CONE BIOPSY

31. TREATMENT
LOCAL DESTRUCTION LOCAL EXCISION RADICAL TREATMENT
Ceauterisation
Cryo-surgery
Laser ablation
Conisation
LLETZ
LEEP
NETZ
Trachelectomy
Hysterectomy with
removal of vaginal cuff

32. Local excision methods

33. RADICAL SURGICAL TREATMENT

34. INVASIVE CERVICLE CANCER

35. PATHOLOGY
•Invasive squamous carcinoma
Small cell
Large cell
Keratinising
Non-keratinising
Rare varients
Papillary
Verrucous
sarcomatoid

36. Adenocarcinoma
•Adenocarcinoma in situ
•Invasive adenocarcinoma
Mucinous
Minimal deviation adenocarcinoma
Glassy cell adenocarcinoma
Adenoid basal adenocarcinoma
Adenoid cystic adenocarcinoma
Serous

37. Other types
• Neuroendocrine tumors-Anaplastic small cell tumors
• Rare neoplasms
 Metastasis-from colon , breast
 Sarcomas - Embryonal Rhabdomyosarcoma,
Leiomyosarcoma,Adenosarcoma
 Lymphoma
 melanoma

38. 38
CLINICAL FEATURES
1. BLEEDING --- postmenopausal, metrorrhagia, menorrhagia, post coital bleeding.
2. PAIN in the pelvis or hypogastrium
3. URINARY Symptoms
4. RECTAL Symptoms
5. DISTANT SITE SPECIFIC METASTATIC MANIFESTATIONS
a. LYMPHATIC SPREAD --- to supraclavicular LN, para-aortic lymphadenopathy (non
specific abdominal symptoms)
b. HEMATOGENOUS SPREAD---- to lungs (cough, respiratory distress, in 21% of patients
in metastatic setting)
---- bone pain

39. INTERNAL EXAMINATION (EXAMINATION UNDER ANAESTHESIA –
ADVISED)
1. INSPECTION ---
Cauliflower like growth --- exophytic nature
Bleeding from the growth
Serosanguineous vaginal discharge
2. PALPATION ----
1) uterus ---- size, shape, position
2) cervix ---- bulky
3) growth might obliterate the vaginal fornices
4) friable growth, ulcerated , which bleeds to touch ---- blood present
on finger tips
5) parametrium – nodular thickening extending upto the lateral pelvic
wall (by per –rectal examination)
39
CLINICAL FEATURES -EXAMINATION - DIAGNOSIS

40. 40

41. 41
STAGING --- FIGO STAGING
1) FIGO staging was based on
anatomical compartmental spread of
cervical cancer.
2) No inclusion of lymph nodal status
3) LVI not included because
pathologists do not agree on status
on presence of LVI
4) MRI, CT and PET Scan – not included
in formal staging.

42. FIGO STAGING OF CA CERVIX

43. Staging & survival

44. IMAGING STUDIES
CT scan
 Detects para-aortic metastasis(Sp-100%)
MRI scan
 Assessment of extracervical tumor extension
 Assessment of local tumor control
 Early prediction of tumor regression
 Can differentiate reccurant tumors from fibrosis
FDG PET scan
 detects para-aortic metastasis(Sn-72% & Sp-92%)
 Detects metabolically active recurrence or residual