This presentation covers the management of early stage carcinoma cervix (FIGO stage I to IIA). A brief introuduction to different surgical procedures and the radiation treatment techninques have been described.

1. MANAGEMENT OF EARLY STAGE
CARCINOMA CERVIX
BY DR. SUBHASH THAKUR
PGIMER, CHANDIGARH

2. INTRODUCTION
 India
 2nd Commonest carcinoma in females, Incidence 1.3 lakh/year
 24% of all female malignancies
 At PGI: 25.4% of all female malignancies & 70.7% of
gynaecological malignancies
 Worldwide
 2nd commonest female malignancy
 12% of all female malignancies
 Highest incidence in Zimbabwe

3. PRESENTS WITH
 Discharge P/V
 Bleeding P/V
 Advanced Stage
 pelvic pain, backache
 pressure symptoms pertaining to bowel and bladder

4. CLINICAL EVALUATION OF PATIENTS WITH
INVASIVE CARCINOMA
 Detailed history
 Physical examination : bimanual examination and
rectovaginal examination
INVESTIGATIONS
 CBC, RFT and LFT
 CXR: to rule out lung metastases
 IVP (or CT) : to determine kidneys function and to rule
out ureteral obstruction by tumor
 Cystoscopy or proctoscopy or a barium enema in
patients with suspicious bladder or rectal involvement

5.  CT :
 Sensitivity of 44% and specificity of 93% in the detection of LN
 Fails to detect small metastases, bulky necrotic tumor often have
enlarged reactive LN that may be free of tumor
 MRI :
 distribution and depth of invasion of tumors in cervix
 Vaginal invasion is best assessed by MRI, with accuracies ranging
from 78-94%.
 superior to CT for parametrial staging, with staging accuracy of 75-
90%
 PET scan :
 PET is more accurate than CT or MRI in detecting metastatic
lymphadenopathy

6. DIAGNOSIS
Any patient with abnormal cytologic examination
Gross cervical lesion:
Absent present
colposcopy direct biopsy Cervical cone biopsy
no lesion visible or
entire squamocolumnar junction
not visualised
Endocervical curettage

7.  Squamocolumnar junction is poorly visualized and high grade lesion
is suspected
 Dysplastic epithelium extends into the endocervical canal
 Cytological findings s/o high grade dysplasia or carcinoma in situ
 Microinvasive carcinoma found on directed biopsy
 Endocervical curettage s/o high grade CIN
 cytological findings s/o adenocarcinoma in situ
Cervical Cone Biopsy is beneficial
if :

8. EARLY CA CERVIX
Comprises of :
 Preinvasive Disease
 CIN I, CIN II and CIN III
 Microinvasive carcinoma
(stage IA)
 Invasive cancer identified
only microscopically.
Invasion is limited to a
maximum depth of 5 mm
and no wider than 7 mm.

9.  Stage IB and IIA disease
 Stage IB: Clinical lesions
confined to the cervix or
preclinical lesions greater
than Stage IA
 Stage IIA: No obvious
parametrial involvement.
Involvement of up to the
upper two-thirds of the
vagina.

10. PROGNOSTIC FACTORS
 FIGO stage.
 Characteristics that are not included in FIGO staging:-
 Clinical tumor diameter, >4cm a/w poor prognosis
 LN metastasis
 LVSI
 Deep stromal invasion

11.  Parametrial extension
 Uterine body involvement : increased rate of distant
metastasis
 Histopathological type, poor survival rates with
adenocarcinoma then with squamous cell carcinoma
 Hemoglobin level, Anaemia a/w higher loco regional
recurrence
 patients age

12. FACTORS INFLUENCING THE CHOICE OF LOCAL
TREATMENT :
 Patient’s age : Younger patients : surgery
 Stage
 Associated gynecological conditions
 Histopathological type
 Associated comorbidities
 Expertize available : a person doing surgery should be
experienced such that h/she performs atleast 15
Radical Hysterectomy per year
 Patient preference

13. PRINCIPLES OF TREATMENT
 Both the primary lesion and the potential sites of
spread should be evaluated and treated
 Optimal therapy consists of radiation or surgery
ALONE - Morbidity is higher when both are
combined

14. SURGICAL PROCEDURES
 Fertility sparing surgeries
 Conization
 Trachelectomy
 Radical hysterectomy
 Laparoscopic assisted radical vaginal hysterectomy
 Lymphadenectomy

15. SURGERY
 Advantages:
 possible ovarian conservation and preservation of sexual
function
 Shortening and fibrosis of the vagina can be limited if the
woman is sexually active
 Pelvic relapses can be successfully cured by radiotherapy
 Surgery allows the status of the lymph nodes, the most
dependent variable associated with survival, to be assessed
accurately
 preferred treatment option in young women

16. TREATMENT OPTIONS FOR SQUAMOUS CELL
CARCINOMA IN SITU INCLUDE:
 Loop electrosurgical excision procedure
(LEEP/LEETZ)
 Cold knife conization
 Simple hysterectomy
.

17. CERVICAL CONIZATION
 Defined as excision of a cone-shaped or cylindrical
wedge from the cervix that includes the transformation
zone and all or a portion of the endocervical canal
 Used for
 the definitive diagnosis of squamous or glandular
intraepithelial lesions
 for excluding micro invasive carcinomas, and
 for conservative treatment of cervical intraepithelial
neoplasia (CIN).

18.  Conization is performed with a scalpel (cold-knife
conization), laser, or electrosurgical loop.
 Complications : <2-12%
 Hemorrhage,
 sepsis,
 infertility,
 stenosis and
 cervical incompetence

19. AT LEAST 50% OF THE
ENDOCERVICAL CANAL
SHOULD BEREMOVED
WITHOUT
COMPROMISING THE
INTERNAL
SPHINCTER

20. LEEP: LOOP ELECTROSURGICAL
EXCISION PROCEDURE
 removes abnormal tissue by
cutting it away using a thin wire
loop that carries an electrical
current
 Charged electrode is used to
excise the entire transformation
zone and distal canal

21.  Advantages :
 Outpatient office procedure
and preserves fertility
 Low recurrence rate
 Easily learned and less
expensive
 Preserves the excised lesion
and transformation zone for
histological examination
 Disadvantage :
 Low grade lesions are over
treated

22. TREATMENT OPTIONS FOR ADENOCARCINOMA IN SITU
INCLUDE:
 Hysterectomy
 Cone biopsy : For women who wish to have children
 The cone specimen must have no cancer cells at the
edges
 Must be closely watched after treatment.
 Once the woman has finished having children, a
hysterectomy is recommended

23. TREATMENT OF EARLY STAGE
DISEASE (FIGO IA1 AND IA2)
 Risk of pelvic lymph node metastases
 no more than 1% for stage FIGO IA1
 3-6% for FIGO IA2
 The evidence suggests that there is no need to remove
pelvic lymph nodes when treating IA1 disease.
 Pelvic lymph nodes should be removed if FIGO IA2
disease is present.

24. STAGE IA1 DISEASE
 Recommended options depends on the result of
 Cone biopsy
 And whether patient
 Want to preserve their fertility
 Are medically operable
 Have LVSI

25. FERTILITY SPARING
 patients with negative margins after cone biopsy
and no findings of LVSI
observation
 patients with positive margins after cone biopsy
Radical trachelectomy or repeat cone biopsy

26.  For patients with LVSI positive
Radical trachelectomy and Lymph node dissection
 For patients with negative margins but LVSI positive
Pelvic lymph node dissection with/without Sentinel lymph node mapping
 After childbearing is complete, hysterectomy may be considered for
patients who had either radical trachelectomy or cone biopsy for early
stage disease if they have chronic persistent HPV infection or abnormal
pap test

27. RADICAL TRACHELECTOMY
 In women for whom
preservation of fertility is
desirable
 This involves vaginal
resection of the cervix, the
upper 1 to 2 cm of the
vaginal cuff and the medial
portions of the cardinal
and uterosacral ligaments

28. Selection criteria
 Lesion size < 2 cm
 Absence of overt LN
metastases
 Absence of LVSI
 The cervix is transected at
the lower uterine segment
and a prophylactic circlage is
placed at the time of surgery

29. NON FERTILITY SPARING
 For patients with negative margins after cone biopsy and
without LVSI
Simple hysterectomy
 For patients with positive margins or LVSI Present
modified radical hysterectomy and pelvic lymph node dissection

30. STAGE IA2 DISEASE
Fertility sparing :
Radical trachelectomy + Pelvic lymph node dissection
with/without paraaortic LN sampling
Non fertility sparing : either surgery or
Radiotherapy
– Surgical option : radical hysterectomy and bilateral
Pelvic lymph node dissection with/without Paraaortic
LN sampling
– Pelvic irradiation with brachytherapy (80-85Gy to point
A) : for medically inoperable patients or who refuse
surgery

31. STAGE IB AND IIA
 Pelvic lymph nodes in FIGO IB disease :16%.
 Tumor size <2 cm the incidence of nodal metastases is
6%.
 Tumors >4 cm : LN metastasis 36%
 which increases the likelihood of using adjuvant chemo
radiotherapy to treat positive nodes
 Options include : Surgery, Radiotherapy or concurrent
Chemo radiation

32. STAGE IB1
 Recommended Option : Radical surgery
 Pelvic Lymphadenectomy done and Radical
Hysterectomy Completed

33. Fertility Sparing :
•Radical Trachelectomy and Pelvic lymph nodal dissection
with/without Paraaortic LN sampling for IB1, tumors <2cm
•Small cell neuroendocrine histology and
adenocarcinomas are not suitable for fertility sparing
•No increase in the rate of recurrence compared with Radical
Hysterectomy ( in tumors <2cm and negative LVSI)

34. NON FERTILITY SPARING
 Stage IB1 or IIA1 : Radical hysterectomy and bilateral
pelvic Lymph nodal dissection with/without para-aortic
Lymph node sampling
 Patients not fit for surgery : combined EBRT and ICBT

35. TYPES OF HYSTERECTOMY
GYNECOLOGICAL CANCER GROUP OF THE EUROPEAN
ORGANIZATION FOR RESEARCH AND TREATMENT OF CANCER
 Extrafascial (Type I)
hysterectomy or simple
hysterectomy
 Modified Radical (type
II) Hysterectomy
 Radical (type III) or
Wertheim’s or Meig’s
Hysterectomy
 Extended radical
hysterectomy (Type IV)
 Partial exenteration
(type V)

36. EXTRAFASCIAL (TYPE I) HYSTERECTOMY
OR SIMPLE HYSTERECTOMY
 procedure for treatment of stage
IA1 carcinoma cervix without LVSI
 Consists removal of the cervix and
adjacent tissues as well as small
cuff of the upper vagina in plane
outside the pubocervical fascia
 Minimal disturbance of the ureters
and the trigone of the bladder

37. MODIFIED RADICAL ( TYPE II ) HYSTERECTOMY
 Used for small stage IB lesion (<2cm
diameter)
 En block removal of the uterus, cervix,
paracervical, parametrial and
paravaginal tissues to the pelvic side
walls
 Bilaterally removal of uterosacral
ligaments as much as possible

38.  For premenopausal women,
ovaries are usually not
removed.
 Ovarian mets are rare in
absence of LN mets, if
intraoperative findings s/o –
need for Post operative
irradiation, the ovaries may be
transposed out of pelvis

39. RADICAL (TYPE III) HYSTERECTOMY OR
WERTHEIM’S OR MEIG’S PROCEDURES
 For IB and IIA lesions
 Wider resection of the parametrial
tissues to the pelvic wall with
dissection of the ureters and
mobilisation of bladder as well as the
rectum
 Vaginal cuff of 2-3 cm is always
removed
 Bilateral pelvic lymphadencetomy is
done

40. TYPE II VS TYPE III HYSTERECTOMY
 The therapeutic efficacy of a type II comparable to
that of a type III but with lower morbidity
 The type II operation is associated with
 Shorter mean operative time
 Less late urologic morbidity
 Similar recurrence rates & Cause-specific
mortality
 Type II procedure appears preferable as long as
appropriate tumor clearance can be achieved

41.  TYPE IV - The ureter is completely dissected
from the vesicouterine ligament, the superior
vesical artery is sacrificed, and three-fourths of
the vagina is resected
 TYPE V - There is additional resection of a
portion of the bladder or distal ureter with
ureteral reimplantation into the bladder.
 Rarely used

42. COMPLICATIONS
 Immediate and acute
 Wound infection : 25 to 50%
 Blood loss : 1 to 2 %
 Uterovaginal fistula : 1-2 %
 Vesicovaginal fistula : <1%
 Pulmonary embolus
 Small bowel obstruction
 Sub acute
 Lymphocyst formation : may obstruct ureter : cause
hydroureteronephrosis
 Complications rate are increased with post op Radiotherapy

43. INDICATIONS OF ADJUVANT TREATMENT
 Ca cervix stages IA2, IB, and IIA initially treated with
radical hysterectomy and pelvic lymphadenectomy-
 High risk disease
Positive pelvic lymph nodes and/or
Positive / close margins and/or
Microscopic parametrial involvement
 High risk group-Concurrent chemotherapy and Pelvic RT

44.  Intermediate risk group-Stage IB cervical cancer
with negative lymph nodes but with ≥2 following
features:
 >1/3 (deep) stromal invasion
 LVSI
 Tumor ≥ 4 cm
are given 46-50 GY by external
radiation after 4-6 weeks of surgery
 Low risk- If none of the above mention factors are
present

45. STAGE IB2 OR IIA2 TUMORS
 Concurrent chemo radiation is the standard of care

46. ROLE OF RADIOTHERAPY
 The carcinoma cervix has two component
 Central tumor - growth in the cervix: best treated by
brachytherapy
 Peripheral - growth in the parametrium: controlled by
EBRT
 Early stage cancer - ICBT+EBRT
 Advanced stage -XRT f/b ICBT

47. EBRT IS DELIVERED BEFORE ICBT IN
PATIENTS WITH
 Bulky cervical lesions or tumors beyond stage IIA to
improve the intracavitary geometry
 Exophytic, easily bleeding tumors
 Tumors with necrosis or infection or parametrial
invasion
External irradiation should be given prior to brachytherapy
as it reduces the tumor volume, restores normal anatomy
and improves the geometry of brachytherapy

48. EBRT
 Conventional RadioTherapy
 3D-Conformal RadioTherapy
 Intensity Modulated RadioTherapy (IMRT)

49. TARGET VOLUME
 Entire cervix
 Uterus and tubes
 Upper third of vagina
 Parametrial tissues (cardinal, uterosacral and pubocervical
ligaments)
 Pelvic nodes (external and internal iliac, in selected cases up
to common iliac)

50. MANUAL MARKING
 center of anterior field
 is 3 cm above the pubic tubercle ,draw a square 15 x 15
 post field
 center 5 cm above tip of coccyx ,draw a square 15 x 15
 lateral field
 8 cm above table top 15 x 10 field
 All treated by SSD technique
 verified with x rays

51. CONVENTIONAL FIELD BORDERS
For AP/PA Portal
 Superior: L4 - L5 inter space.
 Inferior: Inferior border of
obturator foramen (if no vaginal
extension).
 Lateral borders: 2 cm margin
lateral to bony pelvis.

52. ADDITIONAL FIELD BORDERS FOR 4-FIELD BOX
LATERAL FIELDS
 Anterior margin of lateral
portals: anterior cortex
Pubic symphisis .
 Posterior margin of lateral
portals: Should extend to
sacral hollow, traversing
S2/S3 inter space

53. TWO FIELD
VS
 Less time required
 More skin reaction
 Can treat lower presacral
lymph nodes
 Useful when lower part of
vagina involved
FOUR FIELD
 Skin reaction are decreased
 More homogenous dose distribution
(especially in large separation)
 Lateral most part of parametrium also
gets effective dose
 If beam weightage is adjusted the
dose to bladder and rectum can be
decreased

54. BEAM ENERGIES
 Can be treated with cobalt, 6 MV or 15 MV LINAC

55. DOSES OF RADIATION
 Stage IA-IB1 : overall doses of 80 – 85 Gy
 Stage IB2-IVA : cumulative dose of atleast 85 Gy to point A
 The relative contributions of EBRT and brachytherapy to the overall
dose vary according to institutional preferences.
 At our institute we give dose of 46 Gy/23# with EBRT followed by 2
sessions of ICBT with 9 Gy each session
 Recommedations : to limit the rectal and bladder reference points to
maximal doses of 65-70 Gy and 70-75 Gy, respectively
 It is recognised that the most important consideration is to deliver
adequate tumoricidal doses, even if the normal tissue
recommendations are somewhat exceeded.

56. 3D CONFORMAL RADIOTHERAPY
 Is used to plan and deliver treatment based on 3D-
anatomic information
 Resultant dose distribution conforms to the target
volume closely in terms of
 Adequate dose to tumor and
 Minimum dose to normal tissue
 3D-CRT plan generally use increased number of
radiation beams

57. IMRT
 Able to shape a dose distribution that delivers a lower dose
to small and large bowel than to the surrounding pelvic
lymph nodes.
 This makes it possible to increase the dose of radiation to
the target (to improve pelvic disease control rates) or
reduce the acute and late side effects of treatment.
 Useful to deliver high doses of radiation to gross regional
metastases without causing an unacceptable risk of serious
normal tissue toxicity.

58.  Disadvantage :
 Uncertainty of margins
 Image guidance is necessary to ensure accuracy
of treatment delivery
 Labor intensive

60. PATIENT POSITIONING, IMMOBILIZATION
 Supine Position
 Hand over the chest
and with a Foot Rest

61. Image acquisition:
• Fasting for 4 hours prior to planning CT scan
• Oral contrast : 20 ml urograffin dissolved in 1 litre water given
over 1 hour
Void Urine and then take 500 ml of water over
½ hr
planning CT scan ½ hr after this
• Rectal contrast: urograffin + 50 ml of Normal saline

62.  CT scan with 3.75 mm slice thickness
 Mid Chest level
 upper third of femur,
 Images are transferred to Eclipse treatment planning system
(TPS) Varian associates, Palo Alto, CA, USA workstation
 Contouring is done

63.  PGI Guidelines for contouring carcinoma Cervix

64. CTV NODAL (CTV 1)
Aortic
Bifurcation
Appearance of
Femoral Head
Margin of 7 mm

72. THE INTERNAL TARGET VOLUME (ITV)
MARGIN
 For Uterine Motion
 An asymmetrical margin with CTV tumor – ITV
expansion of
 15 mm antero-posteriorly,
 15mm superoinferiorly and
 7 mm laterally.

75. CTV TOTAL

76. PTV FINAL = PTV TOTAL + ITV UTERUS

77. CONFORMAL PLANNING
 3DCRT
 Dose 46 Gy/23#/4.5 weeks. @ PGI
 45 Gy/25#/5 weeks
 50 Gy/25#/5 weeks
 IMRT
 Same dose can be delivered to the pelvis
 Simultaneous integrated boost (SIB) can be done to a
dose of 55 Gy delivered in 25 fractions over 5 weeks

78. planning:
•3D CRT :
• Forward Planning
•IMRT
• INVERSE PLANNING
• 95% of PTV should get 100% of Dose
• 100% of CTV should get 100% of dose
OAR CONSTRAINTS:
•BOWEL BAG: V45<195 cc
•Urinary Bladder: Dmax<50 Gy, V40<40%
•Rectum: Dmax<50 Gy, V40<40 Gy
•Femoral Head: Dmax<50 Gy

79. ASSESSMENT POST - EBRT
 Status of disease –
 shrinkage of tumor (objective
response vs gross residual)
 suitability for intracavitary
application
 Tumor size <4cm
 Vaginal wall involved less than
upper one third
 adequate space
 Parametrial invasion <1-2 cm
(medial one third)
 No VVF or VRF
 No Medical contraindication
 Patients unsuitable for
brachytherapy
 Supplementary RT
(20Gy/10#/2weeks)
Brachytherapy will be discussed b

80. SURGERY VS RADIOTHERAPY
 5-year overall and disease-free survival were identical in
the surgery and radiotherapy groups (83% and 74%,
respectively, for both groups)

81. FOLLOW UP
 Completion of treatment
 First follow up-6 weeks, asses the response.
 2monthly follow up for 1 year, 4 monthly for 2nd
year, 6 monthly then till the 5th year , annually
there after.

82. SPECIAL TREATMENT PROBLEMS
 Carcinoma of the cervical stump
 Natural history, staging and work up of cervical stump
carcinomas are same for carcinoma of intact uterus
 Patients with stage IA : simple trachelectomy
 Stage IA2 or small stage Ib : radical trachelectomy and pelvic
LN dissection
 However most patients are treated with irradiation alone using a
combination of EBRT and Brachytherapy
 Altered geometry and short uterine canal : complicate treatment
planning

83. CARCINOMA CERVIX INADVERTENTLY
TREATED WITH SIMPLE HYSTERECTOMY
 Invasive carcinoma cervix is incidentally found in the
surgical specimen after simple or total abdominal
hysterectomy
 If only microinasive carcinoma is found : No additional
therapy
 Lesions with deeper stromal invasion : HDR
brachytherapy with 36 Gy in 5 or 6 fractions to the vault
 Fully invasive tumor : EBRT to whole pelvis combined
with vault brachytherapy

84. CARCINOMA CERVIX DURING PREGNANCY
 Incidence : 0.02 to 0.9%
 Diagnosis delayed, bleeding attributed to pregnancy
related conditions
 So careful pelvic examination and pap smear at 1st ANC
visit must be done
 If pap smear for malignanct cells positive
Colposcopy directed biopsy
if not confirmed
Diagnostic conization

85.  Performed only in second trimester to avoid maternal and
fetal complications (1st trimester abortion rate : 33%)
 Performed only in patients with strong cytologic evidence of
invasive carcinoma
Treatment
 Carcinoma in situ or stage IA diseases : treatement delayed
upto fetal maturity
 Patients with IA1 and no LVSI : followed to term and delivered
vaginally
 Vaginal hysterectomy performed after 6 weeks of delivery

86.  Patients with IA2 and LVSI : may also be followed to term
 Delivery to be done by CS followed by hysterectomy and
pelvic lymph node dissection
 Delays in therapy should not be more than 4 weeks wherever
possible

87.  Treatment of more advanced ca cervix depends on
the age of gestation and wishes of the patient
 Patients with stage II – IV, or with bulky IB are
treated with Radiotherapy
 If viable fetus : delivery by CS f/b RT
 If 1st trimester pregnancy : EBRT started
 Abortion occurs before delivery of 40 Gy

88.  Compared with other ca cervix patients, these patients
have better Over all survival, because of an early stage I
disease
 Patients diagnosed in post partum period are usually of
advanced stage so they have poor over all survival
 Patients diagnosed with invasive carcinoma cervix and
delivery by vagina and had an episiotomy are at
increased risk of recurrence at the site of episiotomy.

89. COMPLICATIONS
Acute complication (cell loss in rapidly dividing tissue)
 Acute radiation enteritis(diarrhoea, abdominal
cramping, rectal discomfort and rectal bleeding)
 Skin reaction( erythma,& dry and moist
desquamotion)
 Nausea
 Anorexia
 Fatigue,Weakness
 Cystourethritis (Dysuria, frequency)

90. CHRONIC COMPLICATION (ENDOTHELIAL
DAMAGE)
 Ureteral stricture.
 Cervix and vagina-obliteration of os, shortening of
vagina, fistula.
 Ovary-early menopause.
 Radiation proctitis, GI-ulceration ,hemorrhage ,
stricture, small bowel obstruction, malabsorbtion.
 Mucosal thinning, telangiectasia and fibrotic contracture
in bladder.
 Skin- thinning ,loss of appendage, telangiectasia, subcut
fibrosis.
 Lumbosacral plexopathy, radiation myelopathy.
 Femoral neck fracture.

91. OVERVIEW OF MANAGEMENT
 HSIL : Loop Electrosurgical Excision Procedure (LEEP)
 Microinvasive cancers, <3mm stromal invasion,
stage IA1 – conservative surgery (excisional conization
or extrafascial hysterectomy, type I)
 Early invasive cancers (IA2 and IB, and some small
stage IIA) : Modified Radical (type II) or radical (type III)
hysterectomy or Radiotherapy
 Locally advanced cancers : stage IB2 to IVA :
Concurrent chemo radiation

92. CONCLUSIONS
 Lymph nodal metastasis is the most important
prognostic factor
 Two forms of radical treatment are surgery and radiation
 Optimal therapy consists of radiation or surgery
ALONE
 The standard of treatment depends on the FIGO
stage, histopathology and the fertility issue
 External radiation is needed for all but the earliest of
tumors, for treatment of the regional lymphatics
 Intracavitary Brachytherapy plays an important and
predominant role in the cure of cancer of cervix

93. THANK YOU

94. LN Involvement (%)
 Stage Pelvic Para-Aortic
 IA1 0.5 0
IA2 4.8 2.0
Ib 15.9 2.2
II 30.0 15
III 50 25