CACX
DR SOLOMON K GUMANGA
DEPT OF OBS AND GYNAE
SMSH-TTH/UDS
LECTURE PLAN
INTRODUCTION
TYPES OF CERVICAL CARCINOMA
GRADES OF TUMOURS
SOME TERMS AND DEFINITIONS
EQUIVALENT CYTOLOGIC DIAGNOSIS
RISK FACTORS FOR CERVICAL NEOPLASIA
HUMAN PAPILLOMAVIRUS (HPV)
SIGNS OF CERVICAL CANCER
CERVICAL CANCER SCREENING
PAP SMEAR AND CERVICAL BIOPSY
INVESTIGATIONS AND EVALUATION
STAGING OF CERVICAL CANCER
SPREAD OF CERVICAL CANCER
TREATMENT OF CERVICAL CANCER
THE WERTHEIM RADICAL HYSTERECTOMY
TYPES OF RADIATION THERAPY
CERVICAL CANCER FOLLOW-UP
SYMPTOMS OF RECURRENCE
PREVENTION
INTRODUCTION
Cervical carcinoma is the third most frequent
malignancy of the lower female genital tract
worldwide, after endometrial and ovarian
cancer, and second most frequent cause of
death, after ovarian cancer.
About 78% of cervical carcinoma occurs in
developing countries.
About 85%-90% are squamous cell
carcinomas and 10%-15% are
adenocarcinomas.
TYPES OF CERVICAL
CARCINOMA
SQUAMOUS CELL CARCINOMA
Large cell (keratinizing or nonkeratinizing)
Small cell
Verrucous
ADENOCARCINOMA
Typical (endocervical)
Endometrioid
Clear cell
Adenoid cystic (basaloid cylindroma)
Adenoma malignum( minimal deviation adenocarcinoma)
MIXED CARCINOMAS
Adenosquamous
Glassy cell
GRADES OF TUMOURS
The degree of differentiation of tumors is
usually designated by three grades:
Grade 1 or G1: Well differentiated tumour
Grade 2 or G2: Moderately differentiated tumour
Grade 3 or G3: Undifferentiated tumour
SOME TERMS AND
DEFINITIONS
SQUAMOCOLUMNAR JUNCTION: The junction of the squamous
epithelium and columnar (glandular) epithelium, usually located near the
external cervical os.
TRANSFORMATION ZONE
The area between the old and new squamocolumnar junction is referred to as the
transformation zone and appears to be the site of origin of the majoroty of
dysplastic and noeplastic cervical lessions.
NORMAL TRANSFORMATION ZONE
Area of columnar epithelium and squamous metaplasia that has a normal
colposcopic pattern
ABNORMAL TRANSFORMATION ZONE
Area on the cervix or vagina that may contain columnar epithelium and squamous
metaplasia and that often contains intraepithelial neoplasia with an abnormal
colposcopic pattern
SOME TERMS AND
DEFINITIONS-2
CERVICAL INTRAEPITHELIAL NEOPLASIA
(CIN): It is a premalignant change in the cervical
epithelium that can progress to the development of
cervical carcinoma. The degree of change from mild
to severe is described as CIN I, CINII or CIN III.
CARCINOMA IN SITU: A morphologic alteration of
the epithelium that usually precedes, occasionally
gives rise to, and is usually present in the vicinity of
invasive carcinoma. The full thickness of the
epithelium is replaced with neoplastic cells.
DYSPLASIA
The process of metaplasia can be disrupted
and can lead to disordered squamous
epithelium called dysplastic epithelium.
Dysplastic epithelium lacks the normal
maturation of cells as they move from the
basal layer to the superficial layer.
The nuclei tend to be larger, more variable in
size and shape and more actively dividing than
healthy squamous epithelium.
EQUIVALENT CYTOLOGIC
DIAGNOSIS
PAP DISEASE CIN CLASSIFICATION BETHESDA
CLASSIFICATION CLASSIFICATION
Atypical cells are present Atypical cells of
but not dysplastic. Mainly None undetermined significance
due to inflammation
Low-grade squamous
Mild dysplasia CIN I intraepithelial lesion
(LGSIL)
Moderate dysplasia CIN II LGSIL, HGSIL
Severe dysplasia or High-grade squamous
carcinoma in situ (CIS) CIN III intraepithelial lesion
(HGSIL)
SOME TERMS AND
DEFINITIONS
MICROINVASIVE CARCINOMA
It is a small (Stage 1A) carcinoma detected by
microscopic examination with little or no risk of
spread to regional lymph nodes. Stromal invasion with
a maximum depth of 5 mm and no wider than 7 mm.
INVASIVE CARCINOMA
These are macroscospic carcinomas of the cervix that
are initially locally invasive then spread to the pelvic
and paraaortic lymph nodes and sometimes to other
organs such as liver, lung and bone.
SOME TERMS AND
DEFINITIONS
ENDOPHYTIC OR ULCERATIVE GROWTH :
A term used to describe a tumour that begins in the
endocervical canal
EXOPHYTIC OR CAULIFLOWER GROWTH :
A term used to describe a cervical tumour that grows on
the outside surface portio of the cervix primary
BARREL-SHAPED CERVIX:
A cervix containing a large carcinoma, generally of
endocervical origin, that has replaced much of the cervix,
causing its diameter to widen usually more than 4cm.
RISK FACTORS FOR
CERVICAL NEOPLASIA
EPIDEMIOLOGICAL OTHER FACTORS
CHARACTERISTICS ? Oral contraceptives
Early intercourse
Multiple sex partners
Cigarette smoking
Early marriage Prior radiation
Early childbearing
Prostitution
VIRAL RELATIONS
Male partner with multiple Papilloma Virus
partners
Herpes Virus
Socioeconomic status
Race Cytomegalo Virus
STD infection
Immune status including HIV
infection
HUMAN PAPILLOMAVIRUS
(HPV)
HPV infection is associated with an increased risk of CIN. HPV types 16,
18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 are considered oncogenic.
HPV DNA is found in about 95% of cervical carcinomas and the precursor
lesions.
Depending on the degree of dysplasia, the progression to invasive cancer
is different.
Natural history of the infection
Approximately 1/3 women with HPV infection will develop CIN
> 80% spontaneous regression after 18 months (mean 13.7)
Those with HR HPV are more likely to develop cancer
Time needed for progression ranges from 1-20 years
HUMAN PAPILLOMAVIRUS
(HPV)
HPV TYPES RISK OF
PROGRESSION TO
LOW RISK CANCER
6,11,42,43,44
INTERMEDIATE RISK All CIN 1%
33,35,39 CIN 1-2 1-10%
HIGH RISK CIN 3 16-40%
16,18,31,45,51,52,56,
58,59,68
LESIONS ASSOCIATED WITH HPV TYPES
Most commonly associated Most commonly associated
with warts: types 6/11 with cervix ca: types 16/18
SYMPTOMS OF CERVICAL
CANCER
Abnormal vaginal bleeding
Post coital
Intermenstrual
Post menopausal
Serosanguinous discharge
Pelvic or low back pain
Leg edema
Rectal or bladder
complaints for advanced
disease
SIGNS OF CERVICAL
CANCER
On general examination: Patient may be ill-looking,
anaemic and foul smelling. Unilateral swelling of the
lower extremity.
Visible lesion on the cervix during speculum
exanimation. It may be exophytic or endophytic
which bleeds easily on contact.
Bimanual examination may reveal a firm, indurated
cervix. Occasional the uterus may be enlarged from
pyometra due to cervical canal blockage. The
uterosacral and parametrium may be thickened
CERVICAL CANCER
SCREENING
Unaided visual inspection: During speculum
examinations where invasive cancer may be seen.
This is not an effective method.
Visual Inspection with acetic acid (VIA)
Visual Inspection with lugol’s iodine (VILI)
Papanicolau smear (paps smear)
Liquid cytology
Testing for human papiloma virus (HPV) DNA for
high risk patients with negative paps smear
PAP SMEAR AND CERVICAL BIOPSY
PAP SMEAR SCREENING INTERVAL:
Begin at the age of 21 or 3 years after the onset of sexual activity
After 3 consecutive annual negative pap smears, low risk women my be
screened every 2 years
Immunosuppressed women screened more frequently
DIAGNOSTIC PROCEDURES:
Cervical biopsy
Blindly
VIA
Coloposcopy
LEEP (loop electro excision procedure)
Conization (cone biopsy)
INVESTIGATIONS AND
EVALUATION
FBC and Sickling
BUE +CR
LFT’s
USG
Chest X-ray
OTHER INVESTIGATIONS THAT MAY DONE BASED ON
INDICATION INCLUDE:
CT scan, MRI
?IVP, barium enema, lymphangiogram
?cystoscopy, sigmoidoscopy,
STAGING OF CERVICAL
CANCER
MICROINVASIVE INVASIVE CANCER
Stage 1A Stage 1B
1A1 < 3mm deep,
1B1 confined to cervix <4cm
< 7 mm wide 1B2 confined to cervix > 4cm
1A2 < 5mm deep
Stage 2a extends to upper vagina
< 7 mm wide Stage 2b extends to parametria
No lymphvascular space
invasion
Stage 3a extends to lower 1/3
vagina
Stage 3b extends to side wall/HU
Essentially 0% risk of LN Stage 4a bladder or bowel
metastasis mucosa
Stage 4b distant metastases
SPREAD OF CERVICAL
CANCER
DIRECT EXTENSION:
Cervical cancer usually spreads by direct extension into the
parametria, vagina, uterine corpus, pertoneal cavity, bladder
or rectum.
LYMPHATIC SPREAD:
The cervix is drained by preureteral, postureteral and
uterosacral lymphatic channels. The obturator, external illiac,
hypogastric, parametrial, presacral and common illiac are first
station nodes. Para-aortic nodes are second station nodes.
BLOOD –BORNE METASTASIS: This is less frequent
route of spread seen only in late disease
TREATMENT OF CERVICAL
CANCER
SURGERY:
Patients with microinvasion can be treated using cone biopsy
or by simple histerectomy -/+ BSO
Variety of hysterectomies (Radical hysterectomy) (type I-V)
can be done for patients with invasive disease.
RADIATION THERAPY:
External or teletherapy
Internal or brachytherapy
CHEMORADIATION: Cisplatin plus radiation therapy
PALLIATIVE
THE WERTHEIM RADICAL
HYSTERECTOMY
THIS IS EFFECTIVE FOR TREATMENT OF
STAGE 1B AND 2A CANCERS
Superior portions of paravaginal and pararectal
spaces are developed
Ureter is completely mobilized from the level of the
uterine artery to the the bladder
More lateral resection of cardinal lig.
The upper 1 to 2 cm of vagina are resected
The dissection of the pelvic nodes: External illiac,
Internal illiac, common illiac, obturator and presacral
nodes
Radical hysterectomy side effects
Immediate
Anesthesia complications
Pain
Infection
Blood loss
Bladder atony 33% short term
Mortality <2%
Long term
Vaginal
Sexual
Ovarian function
Urinary fistula1-2%
Bladder atony 4-5%
Bladder dysfunction retention-incontinence
Rectal dysfunctionloss of sensation to defecate
TYPES OF RADIATION
THERAPY
TELETHERAPY
External beam radiotherapy
BRACHYTHERAPY
Radiation placed directly within or adjacent to the target tumor volume
INTERSTITIAL RADIOTHERAPY
radiation placed into tumor volume using needles
RADIOACTIVE SOLUTIONS
I 131
P 32
Radiation therapy is measured using the “Gray” - measure of
amount of energy absorbed per unit of mass of tissue
1 Gy = 1 joule/kg of absorbing material
1 Gy = 100 rads
1cGy = 1 rad
BRACHYTHERAPY
Tumor close to sources receives a
considerable amount of radiation
Substantial fall-off of radiation as
distance from sources increases
Radioactive isotopes placed into body
cavity
tandem and ovoids
Treatment is limited and ruled by
inverse square law. Dissipation of energy
at any point is related to inverse square of
distance from sources.
BRACHYTHERAPY -2
INTRACAVITARY
TREATMENT USES
REFERENCE POINTS:
Point A - 2 cm superior to
external os and 2 cm lateral to
the midline ( correspond to
where the uterine artery crosses
the ureter)
Point B - 3 cm lateral to point A
(corresponds to pelvic
sidewall)
How radiation is used for
cervical cancer
Primary treatment for cervical cancer
Adjuvant treatment after radical surgery with positive pelvic
nodes
Treatment of recurrences after radical surgery
Palliative
Control of bleeding
Alleviation of pain
RADIATION SIDE EFFECTS
Cystitis and proctitis
Diarrhea
Hematuria
Stricture and obstruction of GU and GI tracts
Leg edema
Vaginal stenosis
Dyspareunia
Lumbarsacral plexopathy
Femoral head necrosis
CERVICAL CANCER
FOLLOW-UP
FOLLOW UP FIVE YEAR SURVIVAL
Physical exams Stage 1 92%
Pap smears Stage 2 77%
Chest X-rays Stage 2b 60-
CT scan
65%
FBC and Sickling
Stage 3 25-48%
BUE +CR
Stage 4 18-34%
SYMPTOMS OF
RECURRENCE
Pain
Bleeding
Lower extremity edema
Back pain
Hydronephrosis
DIAGNOSIS OF RECURRENCE
Exam
Biopsy
Radiologic study
X-ray
CT scan
MRI
PREVENTION
PRIMARY PREVENTION
Strategies that will eliminate risk of exposure to HPV
and infection by other STI
HPV vaccination
SECONDARY PREVENTION
VIA, VILI, PAPS SMEAR AND LIQUID CYTOLOGY
TERTIARY PREVENTION
EARLY TREATMENT AND REDUCTION OF
MORBIDITY AND MORTALITY
Thank you
