Cancer of the uterine cervix is the third most common gynecologic cancer diagnosis and cause of death among gynecologic cancers. Cervical cancer has lower incidence and mortality rates than uterine corpus and ovarian cancer, as well as many other cancer sites. However, in countries that do not have access to cervical cancer screening and prevention programs, cervical cancer remains a significant cause of cancer morbidity and mortality. This PPT intends to teach about surgical management of Ca Cervix.

1. SURGICAL MANAGEMENT OF
CERVICAL CANCER

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
Immediate Past President, MOGS (2023-2024)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
65 publications in International and National Journals with 161 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-
2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)

3. INTRODUCTION
• Cancer of the uterine cervix is the third most common gynecologic
cancer diagnosis and cause of death among gynecologic cancers in
the India.
• Cervical cancer has lower incidence and mortality rates than
uterine corpus and ovarian cancer, as well as many other cancer
sites.
• However, in countries that do not have access to cervical cancer
screening and prevention programs, cervical cancer remains a
significant cause of cancer morbidity and mortality.

4. Human papillomavirus (HPV) is central to the
development of cervical neoplasia and can be detected in
99.7 percent of cervical cancers .
The most common histologic types of cervical cancer are
squamous cell (70 percent of cervical cancers) and
adenocarcinoma (25 percent)

5. INCIDENCE OF CERVICAL CANCER
(Globocon 2022)

6. RISK FACTORS
HPV-related
• Early onset of sexual activity.
• Multiple sexual partners.
• A high-risk sexual partner (eg, a partner with multiple sexual partners, history of prior sexually
transmitted disease[s], or known HPV infection).
• History of sexually transmitted infections (eg, Chlamydia trachomatis, genital herpes).
• Early age at first birth (younger than 20 years old) and increasing parity (three or more full-term
births); these are likely due to exposure to HPV through sexual intercourse.
• History of vulvar or vaginal squamous intraepithelial neoplasia or cancer (HPV infection is also the
etiology of most cases of these conditions).
• Immunosuppression (eg, HIV infection).

7. Non-HPV-related
• Low socioeconomic status
• Oral contraceptive use
• Cigarette smoking
• Genetics

8. PATHOGENESIS
Human papillomavirus (HPV) is central to the development of cervical neoplasia and can be
detected in 99.7 percent of cervical cancers.

9. There are four major steps in cervical cancer development:
• Oncogenic HPV infection of the metaplastic epithelium at the cervical transformation zone
(the junction between the squamous epithelium of the ectocervix and the glandular
epithelium of the endocervical canal).
• Persistence of the HPV infection.
• Progression of a clone of epithelial cells from persistent viral infection to precancer.
• Development of carcinoma and invasion through the basement membrane.

10. SYMPTOMS
• Early on, cervical cancer usually
doesn’t have symptoms, making it hard
to detect. Symptoms usually begin after
the cancer has spread.
• When symptoms of early-stage cervical
cancer do occur, they may include
• Vaginal bleeding after coitus.
• Vaginal bleeding after menopause

11. SYMPTOMS
• Vaginal bleeding between periods
or periods that are heavier or
longer than normal
• Vaginal discharge that is watery
and has a strong odor or that
contains blood
• Pelvic pain or pain during coitus.

12. SYMPTOMS
• Symptoms of advanced cervical cancer (cancer has spread beyond the cervix to other
parts of the body) may include the symptoms of early-stage cervical cancer.
• Difficult or painful bowel movements or bleeding from the rectum when having a bowel
movement.
• Difficult or painful urination or blood in the urine.
• Dull backache.

13. ESTABLISHING THE DIAGNOSIS
• General physical examination including examination
of supraclavicular , axillary and inguinofemoral
lymphnodes.
• Colposcopy
• Cervicography
• Cervical biopsy
• Conisation
• Endocervical canal curettage

14. FIGO STAGING OF CERVICAL
CANCER

16. TNM STAGING OF CERVICAL
CANCER

19. SURGICAL MANAGEMENT OF
CERVICAL CANCER

20. PREOP WORKUPAND ITS SIGNIFICANCE
INVESTIGATIONS TO IDENTIFY
CBC Anemia prior to surgery , chemotherapy , or
radiotherapy
Urinanlysis Hematuria
Liver function Liver metastasis
Creatinine and BUN levels Hydronephrosis
Investigation used during Cervical cancer staging

21. Chest Radiograph Lung Metastasis
Intravenous pyelogram Hydronephrosis
CT Scan ( Abdomen and pelvis) Lymphnode metastasis, metastasis to other
different organs and hydronephrosis
PET scan Lymphnode metastasis
MR imaging Local extracervical invasion
RADIOLOGY

22. SURGICAL CONSIDERATIONS
• Patients with FIGO stage I to IIA cervical cancer.
• Operable growth : smaller tumors , not fixed to pelvic wall and no distant metastasis.
• Those who are physically able to tolerate an aggressive surgical procedure.
• Those who wish to avoid the long term effects of radiation therapy.
• Radioresistant growth.
• Typical candidates include young patients who desire ovarion preservation
• Retention of the functional non-irradiated vagina
• Women with pelvic masses, pelvic infection, chronic salpingitis, extensive
bowel adhesion from previous peritonitis, endometriosis

23. 1. (Type I) Extrafascial Hysterectomy
2. (Type II) Modified Radical Hysterectomy/ Wertheim
Hysterectomy
3. (Type III) Radical Hysterectomy/Meigs-Wertheim
Hysterectomy
4. (Type IV) Extended Radical Hysterectomy
5. (Type V) Exenteration
Classification of extent of operation

24. • Also known as an extrafascial hysterectomy or
simple hysterectomy, removes the uterus and
cervix, but does require excision of the
parametrium or paracolpium.
• It is appropriately selected for benign
gynaecologic pathology, preinvasive cervical
disease, and stage IA1 cervical cancer.
Simple Hysterectomy (Type I)

25. • Modified radical hysterectomy removes the
cervix,proximal vagina, and parametrial and
paracervical tissue
• This hysterectomy is well suited for tumors with
3- 5mm depths of invasion and smaller stage IB
tumors
Modified Radical Hysterectomy(Type Il)

26. • Requires greater resection of the parametria, and excision
extends to the pelvic sidewall .
• The ureters are completely dissected from their beds, and
the bladder and rectum are mobilized to permit this more
extensive removal of tissue.
• In addition, at least 2 to 3 cm of proximal vagina is
resected.
• This procedure is performed for larger IB lesions, and for
patients with relative contraindications to radiation such as
diabetes, pelvic inflammatory disease, hypertension,
collagen disease or adnexal masses
Radical Hysterectomy (Type IlI)

27. • Removal of all periureteral tissue, superior
vesicle artery and 66 % of vagina
• Indication: Anteriorly occurring central
recurrences where preservation of bladder
still possible
Extended radical hysterectomy- Type IV

28. TYPE V – EXENTERATION
• Portion of ureter and bladder are also
dissected
• Indication: Central recurrent cancer
involving portion of the distal ureter
or bladder

29. T/t and control of systemic illness like DM,HTN
• PAC and consultation with anesthesiologist
• Blood grouping and cross matching with adequate Mx
of blood for transfusion if required
• Mini-heparisation: s/c heparin 5000IU tid 8-24 hrs
prior to SX
• Bowel preparation. Prophylactic antibiotics
• Optimal RFT, Resp.FT and LFT
Patient Preparation

30. Management Of Cervical Cancer In Nutshell

31. Stage Ia1
≤3 mm
invasion,
no LVSI
Conization or type 1 hysterectomy
≤3 mm
invasion,
w/LVSI
Radical trachelectomy or type II radical hysterectomy
with pelvic lymph node dissection
Ia2 >3-5 mm
invasion
Radical trachelectomy or type II radical hysterectomy with pelvic lymphadenectomy
Ib1 >5 mm
invasion, <
2 cm
Radical trachelectomy or type III radical hysterectomy
with pelvic lymphadenectomy
>5 mm
invasion,
>2 cm
Type III radical hysterectomy with pelvic lymphadenectomy

32. Ib2 >5 mm invasion Type III radical hysterectomy with pelvic
and paraaortic lymphadenectomy or
primary chemoradiation
Stage IIa Type III radical hysterectomy with pelvic
and paraaortic lymphadenectomy or
primary chemoradiation
IIb, IIIa , IIIb Primary chemoradiatoon
Stage IVa Primary chemoradiation or
primary exenteration
IVb Primary chemotherapy ±6 radiation

33. MICROINVASIVE (IA1 AND IA2)
DISEASE
• Stage IA1 – For patients wishing to preserve fertility, cold knife conization with widely
negative margins is acceptable. For patients who have completed childbearing or for
postmenopausal patients, simple hysterectomy is a reasonable option since surveillance of
the endocervical canal is challenging over time. Pelvic lymphadenectomy is not necessary.
• Stage IA2 – We tend to perform a modified radical hysterectomy for stage IA2 lesions; the
added surgical morbidity of this approach compared with simple hysterectomy is minimal
when performed by experienced gynecologic oncologists. In a modified radical
hysterectomy, the uterine artery is ligated where it crosses over the ureter; the uterosacral
and cardinal ligaments are divided midway toward their attachment to the sacrum and the
pelvic side wall, respectively, so that the parametrium medial to the ureter is removed; and
the upper one-third of the vagina is resected.

34. INVASIVE EARLY STAGE (IB AND
IIA) DISEASE
• Stage IB and IIA cervical cancer can be cured by either surgery (usually
radical hysterectomy, bilateral salpingo-oophorectomy, and sentinel node
biopsy or pelvic lymph node dissection) or radiation therapy (RT), which is
typically administered with concurrent chemotherapy (ie,
chemoradiotherapy).

35. LOCOREGIONALLY ADVANCED
(IIB TO IVA) DISEASE
• For patients with locoregionally advanced cervical SCC, primary RT has
been the treatment of choice at most institutions, although practice varies.
Guidelines from the National Comprehensive Cancer Network (NCCN)
suggest either radical hysterectomy or initial chemoradiotherapy in this
setting .

36. STAGE IVB - PERSISTENT AND
RECURRENT DISEASE
Surgery and/or RT for localized recurrence — Following radical hysterectomy or
definitive chemoradiotherapy for early-stage cervical SCC, the predominant site of
disease recurrence is local (vaginal apex) or regional (pelvic sidewall). The same
holds true for adenocarcinoma. Exenterative surgery is an option only for those few
patients with centrally relapsed disease

37. SURGERY FOR METASTATIC
DISEASE
Surgical resection may be useful in carefully selected patients with cervical
adenocarcinomas who have isolated pulmonary metastases.

38. COMPLICATIONS OF RADICAL
HYSTERECTOMY
Acute Complications:
1.Blood loss (average, 0.8 L) and shock
2.Ureterovaginal fistula (1% - 2%)
3.Vesicovaginal fistula (1%)
4.Pulmonary thrombo-embolism (1% - 2%)
5.Small bowel obstruction, ileus (1%)
6.Sepsis, pelvic cellulitis (7%) and urinary tract infection (6%). Wound infection, pelvic
abscess, and phlebitis in <5% of patients.
7.Damage to adjacent organs

39. FERTILITY PRESERVATION
• For patients who are appropriate candidates for fertility-sparing surgery and desire
this approach, options may include cervical conization, simple trachelectomy, and
radical trachelectomy.
• For those in whom fertility-sparing surgery is not an appropriate option, the
psychosocial impact of cancer treatment-related infertility is significant, with a high
proportion experiencing feelings of depression, grief, stress, and sexual dysfunction

40. • Postoperative bladder dysfunction
•
• Ureteric fistula
• Urine retention
• Lymphocyst formation
SUBACUTE COMPLICATIONS

41. CHRONIC COMPLICATIONS
• Bladder hypotonia
• Bladder Atony
• Ureteric strictures :rare

42. INDICATIONS FOR ADJUVANT
THERAPY AFTER HYSTERECTOMY
As with cervical SCC, patients with one or more of the following findings are
considered to be at high risk for recurrent disease and should receive adjuvant
chemoradiotherapy following hysterectomy:
• Positive or close resection margins
• Positive lymph nodes
• Microscopic parametrial involvement

43. NEOADJUVANT CHEMOTHERAPY
• SCC of the cervix is a chemosensitive neoplasm particularly when cisplatin-based
regimens are used, and neoadjuvant chemotherapy is an accepted approach for
patients with locally advanced disease.
• Adenocarcinomas are similarly chemotherapy sensitive, at least in the setting of
advanced disease .
• The use of neoadjuvant chemotherapy may be beneficial in selected patients , but
whether this strategy provides superior outcomes over chemoradiotherapy is
unknown.

44. PALLIATIVE CARE
Radiotherapy and Chemotherapy
Pain Management
Intrathecal injection of phenol
Analgesics
Good nursing care
Psychological and physical support
Follow up

45. PREVENTION AND CONTROL
OF CERVICAL CANCER

46. PRIMARY PREVENTION OF CERVICAL CANCER
• Prevention of HPV infection is included in primary cervical prevention and control.
There are different subtypes of HPV that can cause cervical cancer but, the major
subtypes are 16 and 18 .
• The public health goal of primary prevention of cervical cancer is to reduce HPV
infections. Primary prevention can be realized through behavioral change
approaches and the use of biological mechanisms, including HPV vaccination. The
interventions for primary prevention of cervical cancer include: providing
immunization for girls aged 9–14 years before the start sexual intercourse, health
education on healthy sexuality for both boys and girls and promotion of condom
use. HPV vaccines are not intended to treat women with past or present HPV
infection [9, 11].

47. HPV VACCINATION
• The HPV vaccines prevent over 95% of HPV
infections caused by HPV types 16 and 18. It may
have some cross-protection against other less
common HPV types which cause cervical cancer .
There are three various vaccines, which vary in the
number of HPV types they comprise and target.
However, not all are obtainable in everywhere.
• Quadrivalent HPV vaccine (Gardasil®) targets
HPV types 6, 11, 16 and 18.
• 9-valent vaccine (Gardasil 9®) targets the same
HPV types as the quadrivalent vaccine as well as
types 31, 33, 45, 52 and 58.
• Bivalent vaccine (Cervarix ®) targets HPV types
16 and 18

48. SECONDARY PREVENTION
• In secondary prevention of cervical cancer, screening
and treatment as desired is included.
• Screening comprises testing women who are at risk for
a cervical pre-cancer. The aim of screening is to detect
and treat those people identified as having early signs of
the illness, usually by means of inexpensive, precise,
and reliable test that can be practical widely.
• The other aim of screening is to decrease the death
related with cervical cancer through identifying the
illness when still at an early treatable stage or through
detecting precursor lesions. The systematic removal of
CIN lesion during screening also leads to reductions of
the incidence of invasive cervical cancers of all stages.

49. TERTIARY PREVENTION
• Tertiary prevention of cervical cancer comprises
treatment of cervical cancer and palliative care.
• Surgical treatment, chemotherapy, radiotherapy
and palliative are included in tertiary cervical
cancer prevention . The public health goal of
tertiary prevention of cervical cancer is to reduce
the number of mortality due to cervical cancer.

50. CERVICAL CANCER DURING
PREGNANCY
• One to 3 percent of women diagnosed with cervical cancer are
pregnant or postpartum at the time of diagnosis .
• Approximately one-half of these cases are diagnosed prenatally,
and the other half are diagnosed in the 12 months after delivery.
• Cervical cancer is one of the most common malignancies in
pregnancy, with an estimated incidence of 0.8 to 1.5 cases per
10,000 births

51. MANAGEMENT OF CANCER CERVIX
IN PREGNANCY

52. THANK YOU