Cervical cancer arises from persistent HPV infection and progresses through defined stages. Treatment depends on cancer stage, with radical hysterectomy for early stages and chemoradiation for advanced stages. Surgery aims to remove the cervix, uterus, and surrounding tissues while preserving organs. Complications include bleeding, fistulas and organ injury. Adjuvant radiation improves local control for high-risk cancers. Screening and HPV vaccination allow for early detection and primary prevention, improving outcomes.

1. SURGICAL MANAGEMENT OF
CERVICAL CARCINOMA
Dr. Niranjan Chavan
Professor and Head of Unit
Dept. Of OBGY
LTMMC & LTMGH, Sion Mumbai.
FOGSI PRESIDENTIAL CONFERENCE
“ FEMMTEK CONFERENCE- IV ’’
Grand Hyatt, Mumbai.
25th November, 2023

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
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
68 publications in International and National Journals with 176 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.LM.LE 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. OVERVIEW
• INTRODUCTION
• THE CENTURY OF SURGEONS
• CAUSES OF CERVICAL CANCER
• PATHOGENESIS
• SYMPTOMS
• CLASSIFICATION OF CERVICAL CANCER
• MANAGEMENT OF CERVICAL CANCER
• PREVENTION
• RECENT ADVANCES

4. INTRODUCTION
• Cancer of the cervix is the third most common gynaecologic
cancer diagnosis in India.
• Cervical cancer has lower incidence and mortality rates than
uterine corpus and ovarian cancer.
• 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.

5. ‘THE CENTURY OF THE SURGEONS’
• Surgery was the only treatment option for malignant diseases for
many years.
• In 1846, John Collins Warren performed the first major cancer
operation under general anesthesia, removing a patient’s
cancerous salivary glands. The following century saw rapid
progress and is often referred to as ‘‘The Century of the
Surgeon.’’
• The development of antiseptic techniques by Joseph Lister in
1867, the ability to transfuse blood in the 1930s, and the
discovery of antibiotics in the 1940s are all milestones in the
history of surgery.

6. • The German surgeon Wilhelm Alexander
Freund undertook the first-ever
abdominal extirpation of a cancerous uterus on
January 30, 1878.

7. • Radical hysterectomy (RH), abandoned by almost
all gynecologists after the advent of radiotherapy
(RT) in the early part of the 20th century.
• The primitive form of RH was first described by
Clark and Reis in 1895.

8. • Radical hysterectomy was then described in detail and
performed by Wertheim, a Viennese physician, more than
100 years ago.
• In 1905, he reported the outcomes of his first 270 patients.
The operative mortality rate was 18%, and the major
morbidity rate was 31%.
• In 1912, Wertheim reported his first 500 operations and had
his name assigned to the operation.
• RH was then modified and popularized by Meigs in the
1950s.

10. • Human Papilloma Virus [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] and
adenocarcinoma [25 percent].

11. PATHOGENESIS

12. There are four major steps in cervical cancer development:
• Oncogenic HPV infection of the metaplastic epithelium at the cervical transformation
zone.
• Persistence of the HPV infection.
• Progression of a clone of epithelial cells from persistent viral infection to precancer.
• Development of a carcinoma and invasion through the basement membrane.

14. GLOBOCON 2020

15. SYMPTOMS
• Early on, cervical cancer usually
doesn’t have symptoms, making it hard
to detect.
• Symptoms of early-stage cervical
cancer
1. Vaginal bleeding after coitus.
2. Vaginal bleeding after menopause.

16. 3. Vaginal bleeding between periods or periods that are heavier or longer than
normal.
4. Vaginal discharge that is watery and has a strong odor or that contains blood.
5. Pelvic pain or pain during coitus.

17. Symptoms of advanced cervical cancer
• Difficult or painful bowel movements or bleeding from the rectum when having a
bowel movement.
• Difficult or painful urination or hematuria.

18. TNM AND FIGO STAGING OF
CARCINOMA CERVIX

19. 2018 FIGO AND TNM STAGING CLASSIFICATION

20. MANAGEMENT OF INVASIVE
CERVICAL CARCINOMA

21. CLASSIFICATION OF EXTENT OF
OPERATION
• Simple / Extrafascial hysterectomy (Type I)
• Modified radical hysterectomy / Wertheim hysterectomy (Type II)
• Radical hysterectomy/ Meigs-Wertheim hysterectomy (Type III)
• Extended radical hysterectomy (Type IV)
• Exenteration (Type V)

22. 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,
a total hysterectomy is a reasonable option
since surveillance of the endocervical canal
is challenging over time.
• Pelvic lymphadenectomy is not necessary.
MICROINVASIVE (IA1 AND IA2)
DISEASE

24. SIMPLE HYSTERECTOMY (TYPE -I)
• Also known as an extra fascial hysterectomy or simple hysterectomy,
removes the uterus and cervix, but does require excision of the
parametrium or paracolpium.

25. Stage IA2 -
• Modified Radical Hysterectomy [MRH] is the
approach of choice.
• In MRH, 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.

26. MODIFIED RADICAL
HYSTERECTOMY(TYPE II)
• • 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.

27. RADICAL HYSTERECTOMY
(TYPE III)
• 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 with 2 to 3 cm of proximal
vagina is resected.
• Performed for larger IB lesions.

28. 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%)
7.Damage to adjacent organs

29. SUBACUTE COMPLICATIONS:
• Postoperative bladder dysfunction
• Ureteric fistula,
• Urine retention.
• Lymphocyst formation.

30. CHRONIC
COMPLICATIONS:
• Bladder hypotonia
• Bladder Atony
• Ureteric strictures

31. EXTENDED RADICAL
HYSTERECTOMY (TYPE-IV)
• Removal of all periureteral tissue,
superior vesicle artery, and ¾ of the
vagina.
• Indication: Anteriorly occurring
central recurrences where
preservation of the bladder is still
possible.

32. EXENTERATION (TYPE-V)
• A portion of the ureter and
bladder are also dissected.
• Indication: Central recurrent
cancer involving a portion of the
distal ureter or bladder.

33. FERTILITY-SPARING SURGERY
• Radical vaginal trachelectomy was originally pioneered by Dargent in the late
1980s. This involved radical resection of the primary cervical tumor with an
adequate clear margin of surrounding paracervical and vaginal tissues, with a
pelvic node dissection performed laparoscopically.

34. • Bladder injury during the trachelectomy procedure was the most common complication
followed by vascular injury during lymphadenectomy.
• Bladder dysfunction, the most common postoperative complication, was found in
approximately 12%, which is similar to that seen after radical hysterectomy.

35. LAPAROSCOPIC-ASSISTED RADICAL
VAGINAL HYSTERECTOMY
The original radical vaginal hysterectomy alone
(Schauta operation) is replaced by radical
abdominal hysterectomy with pelvic
lymphadenectomy done laparoscopically.

36. Management Of Cervical Cancer In Nut-shell

40. MANAGEMENT OF RECURRENCE

41. POST-OPERATIVE RADIATION
• Adjuvant radiation therapy could
contribute to improve local control in
patients who have unfavorable
pathologic risk factors found in
surgical specimen by sterilizing
remaining microscopic or gross
residual disease left behind even with
radical surgery.

42. • It is done in cases with :
• positive pelvic lymph nodes
• deep stromal invasion
• positive surgical margins
• lymphovascular space invasion
• large tumor size

43. • For advanced local tumours, chemoradiation is the standard treatment,
followed by brachytherapy boost, which is not optional.

44. PRESERVATION OF OVARIAN
FUNCTION
The ovaries are transposed into the paracolic
gutters by pediculization of the ovarian vessels
either during laparotomy or laparoscopically in
females requiring pelvic irradiation.
TRANSPOSTION OF OVARIES:

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

46. 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.

47. MANAGEMENT OF CANCER CERVIX
IN PREGNANCY

48. PREVENTION OF CERVICAL
CANCER
• PRIMARY PREVENTION : Prevention of HPV
infection is included in primary cervical prevention
and control. The HPV vaccines prevent over 95% of
HPV infections caused by HPV types 16 and 18.

49. • SECONDARY PREVENTION: Screening
and identifying the illness when still at an
early treatable stage or through detecting
precursor lesions.
• TERTIARY PREVENTION: Treatment of
cervical cancer. Surgical treatment,
chemotherapy, radiotherapy, and palliative
care.

50. RECENT ADVANCES IN SCREENING
AND TREATMENT OF CA CX

53. TAKE HOME MESSAGE