CERVIX CANCER IN NUTSHELL

DR KANHU CHARAN PATRO
RADIATION ONCOLOGIST
M.D,D.N.B[RT],FAROI[USA],MBA[ICFAI],PDCR,CEPC

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VISAKHAPATNAM,1/7-MVP[AP]
2

Statistics
• >9.7 million cases are detected each
year
• 6.7 million people will die from
cancer
• Every day, around 1700 Americans
die of the disease
• 20.4 million people living with
cancer in the world today
• 1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease

Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin
Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
1000 800 600 400 200 0 200 400 600 8001000
Men Women
From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001)
(Thousands)
Incidence
Mortality
337
293
105
0370
241
318
446
234
165
166
471
233
133
111
76
33
121
68
113
86
47
97
101
101
34
71
192
114
810
902
558
405
255
499
398
384
204
543
279
260
227
99
93
167
144
109
81
170
116
112
57
119
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
The Global Burden of Cancer 2000

Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

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Causes and risk factor
 Coitus at young age: <16 years old increased risk by 50%
 Number of sexual partners: 6 sexual partners or more increase risk
by 14.2 folds.
 Smoking- Smoking for> 12 years increase the risk by 12.7 folds.
 Male related risk factors:
Number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer
(circumcision)
Previous wife with cervical cancer.
 Previous CIN
 Long term use of the contraceptive pill increase the risk due to
increasing exposure to seminal fluids.
 Immuno suppresion risk increased with immuno suppressed renal
transplant patients and in HIV positive women.
 HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
 Low socioecomic class

HPV 16,18
Smoking Cervical cell Male factors
Infhibation of CX
cellp53 tumour
suppression gyne
Protection against
tumour
development lifted
Cancer develops

Type of patient:
• Multiparous.
• Low socioeconomic class.
• Poor hygiene.
• Prostitutes.
• Low incidence in Muslims and Jews.

Predisposing factors:
• Cervical dysplasia.
• (Cervical intraepithelial neoplasia)
• CIN III / CARCINOMA IN SITU
• THE LESION PROCEEDS THE INVASION BY 10-
12 YEARS

Pathology type
• Squamous cell carcinoma- 90%.
• Adenocarcinoma- 10%.
• TYPES OF GROWTH
• Exophytic: is like cauliflower filling up the
vaginal vualt.
• Endophytic: it appears as hard mass with a
good deal of induration.
• Ulcerative: an ulcer in the cervix.

SPREAD:
Direct Lymphatic Dissemination
(late)
- Uteruq.
- Vagina.
- Parametrium.
- Bladder and rectum.
A- primary node:
parametrial.
Paracervical.
Vesicovaginal.
Rectovaginal.
Hypogastric.
Obturator and external iliac
B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Inguinal.
- parametrial spread
causes obstruction of the
ureters, many deaths occur
due to uraemia.
- Obstruction to the
cervical canal results in
pyometria.

Symptoms:
Early symptoms Late symptoms
- None.
- Thin, watery, blood tinged
vaginal discharge frequently
goes unrecognized by the
patient.
- Abnormal vaginal bleeding
Intermenstrual
Postcoital
Perimenopausal
Postmenopausal
- Blood stained foul vaginal
discharge.
- Pain, leg oedema.
- Urinary and rectal
symptoms
dysuria
haematuria
rectal bleeding
constipation
haemorrhoids
- Uraemia

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

2- Examination:
• Mainly vaginal examination using cuscu’s
speculem nothing is found in early stage .
• Mass ,ulcerating fungating in the cervix
• P/V P/R is very helful.

Preoperative evaluation
• Review her history.
• General examination:
o Anaemia.
o Lymphadenopathy-Supraclavicular LN.
o Renal area.
o Liver or any palpable mass.
o Oedema.
• Laboratory tests:
o CBC, LFT, RFT, Urine analysis.
o Tumour markers.
o Chest X- ray, abdominal X- ray, IVU.
o CAT, MRI, if necessary.
o Ultrasound.
o Lymphography, if necessary.

Staging
Best to follow FIGO system.
• Examination under anaesthesia.
• Bimanual palpation.
• P/V, P/R.
• Cervical biopsy, uterine biopsy.
• Cystoscopy, Proctoscopy, if necessary.

TREATMENT
• Surgical.
• Radiotherapy.
• Radiotherapy & Surgery.
• Radiotherapy and Chemotherapy followed by
Surgery.
• Palliative treatment.

The choice of treatment will depend on
• Fitness of the patients
• Age of the patients
• Stage of disease.
• Type of lesion
• Experience and the resources avalible.

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Treatment Algorithm

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

Surgery offers several advantage
• It allows presentation of the ovaries (radiotherapy will
destroythem).
• There is better chance of preserving sexual function.
• (vaginal stonosis occur in up 85% of irradiates.
• Psychological feeling of removing the disease from the
body .
• More accute staging and prognsis
• Glandular tumours (adenocarcinomas) are not
detectable by screening are associated with skip
lesions and require radical surgery.
•

COMPLICATIONS OF SURGERY
• Haemorrhage: primary or secondary.
• Injury to the bladder, uerters.
• Bladder dysfunction.
• Fistula.
• Lymphocele.
• Shortening of the vagina.

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Indication for post op radiation

• Mediacally inoperable
• Stage II-IV disease
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Definitive radiation

Radiation toxicity
• Bladder related
• Rectum related
• Bowel related
• Acute
• Late
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Chemotherapy
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-PelvicExenteration
- Neoadjuvant chemotherapy or concurrent chemoradiotherapy
- Palliative Radiotherapy
• Surgical Exenteration : Selected patients of stage IV, with no or minimal parametrial invasion
may be treated with primary exenterative surgery, the extent of which (anterior, posterior or
total) would depend on the extent of the lesion.
• Neoadjuvant chemotherapy or concurrent chemoradiotherapy
Selected patients with good general and renal status and not suitable for surgical
exenteration can be treated with this approach with radical intent.
• Palliative Radiotherapy: The majority of stage IVA patients has poor general condition and
extensive local disease in our setting and are best treated with palliative radiation therapy
alone. A short palliative regime of 30 Gy in 10 fractions over two weeks or 30 Gy / 3# / 60
days (10 Gy / every month x 3#) is generally used and in few patients who respond very well,
this is followed by intracavitary application.
Stage IVA :
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• Very bulky disease
• With paraaortic node
• Satge IV A disease[bladder and rectum inv.]
•2cycle NACT
•f/b radiation
Neoadjuvant chemotherapy or
concurrent chemoradiotherapy
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Recurrent ca.cx
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PROGNOSIS
Depends on:
• Age of the patient.
• Fitness of the patient.
• Stage of the disease.
• Type of the tumour.
• Adequacy of treatment.

THE OVERALL 5 YEARS SURVIVAL FOLLOWING
THERAPY:
• Stage I -------80%
• Stage II-------50-60%
• Stage III-------30-40%
• Stage IV-------4%

• I. clinical Examination
– 3monthly for first 2year
– 6monthly for after 2year
– Annually there after
• II. No other investigations in asymptomatic
patients for early detection of metastasis, since it
is -
– Not cost-effective
– Does not prolong survival.
– Detection and disclosure of spread of disease may be
psychologically harmful to an asymptomatic
6/1/2018 3:44:47 AM 48
Follow-up

Vaginal dilator
• On completion of
treatment all
patients are given a
vaginal dilator to use
until vaginal mucosa
healed, this prevents
vaginal stenosis.
• Premenopausal
patients commenced
on HRT:
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6/1/2018 3:44:47 AM 50
With in 3 month follow up
1. No pap smear/bx
2. Confusion about radiation changes
3. Unnecessary investigation
4. Anxiety
5. Unnecessary treatment

Criteria Grade Recommendation
 Cytology only, 21 to 65 years old A Every 3 years
 Cytology + HPV co-testing, 30-65 years old A Every 5 years
 Women under 21 years old D Avoid screening
 Age ≥ 65 with adequate prior screening and
not high risk
D Avoid screening
 Total hysterectomy; benign disease D Avoid screening
 HPV testing, alone or in combination, < 30
years old
D Avoid screening
USPSTF Cervical Cytology Guidelines
March 2012

Age Screening
< 21 No Screening
21-29 Cytology alone every 3 years
30-65 Preferred: Cytology + HPV every 5 years* OR
Acceptable: Cytology alone every 3 years*
> 65 No screening, following adequate neg prior screens
After total hysterectomy No screening, if no history of CIN2+ in the past 20
years of cervical cancer ever
Triple A Guideline: ACS, ASCCP,
American Society for Clinical Pathology
CA Cancer J CLIN March 2012
*If cytology result is negative or ASCUS + HPV negative

Summary of Important Guideline Changes
• 1st time that all 3 organizations involved with cervical cancer
prevention and the USPSTF have endorsed equivalent
guidelines
• Co-testing is “ready for primetime” for women ≥ 30
-But, co-testing every 5 years (NOT every 3 years)
• Women 21-29: cytology every 3 years (NOT 1 or 2)
• Stop screening women under 21 years of age
• Stop screening women 65 and older if negative results and
adequate prior screening

• There are two HPV vaccines (Gardasil and Cervarix) which
reduce the risk of cancerous or precancerous changes of the
cervix and perineum by about 93%.
• HPV vaccines are typically given to women age 13 to 26 as the
vaccine is only effective if given before infection occurs.
• The vaccines have been shown to be effective for at least 4 to
6 years, and it is believed they will be effective for longer;
however, the duration of effectiveness and whether a booster
will be needed is unknown
6/1/2018 3:44:47 AM 54
Vaccination strategy

Delivered 5 days per week over 6-8 weeks
Typical treatment takes around 5 minutes
Treatment is painless--like having an X-ray taken
No radioactive substances involved; beam goes
on/off
Side effects usually temporary; controlled with
medication/diet
Covered by Medicare and many other insurance
companies

6/1/2018 3:44:47 AM 55
Treatment

Evolution of
radiotherapy
treatment
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6/1/2018 3:44:47 AM 57
Radiation –Part of life

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Wilhelm Conrad Rontgen

6/1/2018 3:44:47 AM 59
Types of radiotherapy
TELETHERAPY
BRACHYTHERAPY

GOALS
 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
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6/1/2018 3:44:47 AM 61
Evolution of Treatment Techniques
CONVENTIONAL RT
Collimator shapes Beam
Rectangular Treatment Field
Shaped Treatment Field
1970s and earlier

IMRT
• Divides each treatment field into
multiple segments
• Modulates beam intensity,
giving discrete dose to each
segment
• Uses multiple, shaped beams
(~9) and thousands of segments
IMRT Initiated in 1995
Reached the clinic in 2000

IMMOBILIZATION
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PLANNING-

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3 Abdomen and Pelvis

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Conventional Radiotherapy
4 Field Box
• Uniform dose to simple shapes
• Circa 1930-1960

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Target Motion in
Radiotherapy
Caveman et al
Oops! The target
moves!
IGRT

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Treatment Set-up verification

Electronic Portal Imaging Device (EPID)
iView GT- Electa
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Ref image
First EPID
2 nd EPID
OK
Set-up verification
Using EPID

• Short distance /contact with tumor
• Expertise needed
• Invasive procedure
• Adequetly sparing normal structure
• Well established
6/1/2018 3:44:47 AM 76
Brachytherapy

HDR ICA APPLICATORS
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Uterine Sound
Foley’s Bulb
Bladder
Picture No. 3
Transabdominal Ultrasonography
Picture No. 5
ICA HDR application
Picture No. 4
US Guided Brachytherapy

MUPIT IMPLANT IN CA CERVIX
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Brachytherapy machines
Low dose rate brachytherapy High dose rate brachytherapy

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Special procedures in our unique
hospital

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Dose prescription and Treatment
delivery
• Dose: 34Gy in 10 fraction bid
• Dose per fraction: 340cGy

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Intra- operative Brachytherapy
procedure

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3D Brachytherapy Planning
CT Loading Dose distribution

TONGUE IMPLANT IN PROGRESS
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ILRT-dosimetry

Stage IV: Metastatic Breast Cancer

95
METASTASIS
-please do not watch crying

METASTASIS- give a smiling death
97

Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

Superscan-extensive bone mets
105

CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

Change in bowel habits
10/20/12 01:12 PM 110

Change in bladder habits
10/20/12 01:12 PM 111

A sore that does not heal
10/20/12 01:12 PM 112

Unusual bleeding or discharge
10/20/12 01:12 PM 113

Thickening or lump in the
breast or any part of the body
10/20/12 01:12 PM 114

Indigestion or difficulty swallowing
10/20/12 01:12 PM 115

Obvious change in a wart or mole
10/20/12 01:12 PM 116

Nagging cough or hoarseness
10/20/12 01:12 PM 117

Liver cancer-
hepatitis B vaccine

Cervix cancer vaccine
10/20/12 01:12 PM 124

Promise-Stop drinking alcohol
10/20/12 01:12 PM 125

Meditation
10/20/12 01:12 PM 127

128
Dietary protective factors

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LOTS OF BLOOD REQUIRE

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TABLET FORMS

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All specialities under one roof

TEAM OF EXPERTS IN SURGICAL ONCOLOGY
1. Dr.Murali Krishna Voonna M.S.,M.Ch.,
(Adyar Cancer Institute ,Chennai)
2. Dr.Karthik Chandra Vallam M.S., M.Ch,DNB.,
(TATA Memorial ,Mumbai)
3. Dr.M.P.S.Chandra Kalyan M.S,, M.Ch.,
(TATA Memorial ,Mumbai)

TEAM OF EXPERTS IN RADIATION ONCOLOGY
Dr. Kanhu Charan Patro M.D(RT).DNB(RT)
(ex. TATA Memorial ,Mumbai)
Dr. Partha Sarathi Bhattacharyya M.D (RT)
(ex. AIIMS,NEW DELHI)
Dr. Chittaranjan Kundhu M.D(RT)
(S.C.B.M.C ,Cuttack)
Dr. Venkata Krishna Reddy M.D (RT)
(ex.Christian Medical College ,Vellore)

TEAM OF EXPERTS IN MEDICAL ONCOLOGY
1. Dr. B.Rakesh Reddy M.D(Paed).,DM
(Medical Oncology) (AIIMS ,New Delhi)
2. Dr. M.Vamshi Krishna M.D.,D.M., (Medical Oncology)
(Tata Memorial ,Mumbai)
3. Dr.R.Madhan Mohan M.D. (Hematology)
(AIIMS ,New Delhi)

TEAM OF EXPERTS IN CRITICAL CARE AND PAIN
1. Dr. K.V.D. Praveen M.D(Anesthesiology)
(PGIMER, Chandigarh)
2. Dr. A.Shirisha M.D (Anesthesiology)
(AMC ,Visakhapatnam)
3. Dr. Surendra Nadh D.A, DNB(Anesthesiology)
(ISPAT General Hospital, Odisha)

TEAM OF EXPERTS-- Radiology
1. Dr. P.Madhuri D.M.R.D
( AMC ,Visakhapatnam)
2. Dr. B.Revathi D.M.R.D
( RMC ,Kakinada)

GYNAEC ONCOLOGY :
Dr.Jyoti Doki M.D. (Gynaec & Obg)
(AMC,Visakhapatnam)

Nuclear Medicine :
Dr. K.Raghava Kashyap M.D (Nuclear Medicine)
(PGIMER, Chandigarh)

EXPERTS FROM VARIOUS PRESTIGIOUS
INSTITUTIONS
1. ADYAR CANCER INSTITUTE, CHENNAI-1
2. TATA MEMORIAL HOSPITAL, MUMBAI-3
3. AIIMS,NEWDELHI-2
4. CMC-VELLORE-1
5. PGI-CHANDIGARH-2

Young radiation oncology conference

EMPOWER
•EQUIPMENT
•EXPERT
•EXPERIENCE
•EASY ACCESSES

Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
10/20/12 01:12 PM 162

CERVIX CANCER IN NUTSHELL

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