Cancer Cervix

BY
A H M E D M A GD Y E L M O H A N D E S
 Intended Learning Outcomes (ILOs)

Epidemiology of cancer cervix and HPV

Risk Factors
PATHOLOGY
Mode of spread
Clinical Picture
Staging
Prevention and Management
Recurrence of cancer cervix
Cancer cervix and pregnancy
and HPV Epidemiology

Cervical cancer is the most common form of cancer

in women in developing countries and the third
most common form of cancer in women in the
world as a whole.
It is estimated that up to 450,000 new cases of
cancer cervix occur per year leading to 275,000
deaths most of them in developing countries.
Cervical cancer accounts for 6 per cent of all
malignancies in women.
Cervical cancer ranks as the 13th most frequent
cancer among women in Egypt and the 10th most
frequent cancer among women between 15 and 44
years of age.
In Egypt current estimates indicate that every year
866 women are diagnosed with cancer cervix and 373
die from the disease.
The incidence of cervical cancer has fallen in the UK
by 44 per cent since 1975 and mortality from 7.1 per
100,000 in 1988 to 2.4 per 100,000 in 2011 because
of the screening program .
Epidemiological studies demonstrate that the
major risk factor for the development of cancer
cervix is human papillomavirus infection.
HPV DNA was present in 99.7 per cent of cervical
cancers with HPV 16 and 18 were the predominant
types.
Risk Factors

• HPV is the most common risk factor for developing

cancer cervix specially type 16 and 18
• Early age at first sexual intercourse and multiple
sexual partners or sex with uncircumcised men
• Immunocompromised state
• Smoking
• Women on oral contraception for more than 5 years
• Multiparity
• Women with a frst-degree relative with cervical
cancer
low socioeconomic background
Daughters of women who took diethylstilboestrol
during pregnancy are more at risk of developing
cervical cancer (clear cell adenocarcinoma).
Pathology

 Gross Pathology: The site of the lesion is predominantly

in the ectocervix (80%) and the rest (20%) are in the endo-
cervix.
 The lesion may be exophytic , ulcerative or infiltrative
specially in endocervix.
 Histopathology:
Squamous cell carcinoma is the most common type (80%)
Adenocarcinoma (10-15%)
The remainder types are endometrioid, clear cell,
adenosquamous , Neuroendocrine tumors, sarcomas and
lymphomas
Mode of spread

Direct spread to adjacent structures that includes the

ureters in late stage
Hematogenous: Blood borne metastasis is late and
usually by veins rather than the arteries.
Direct implantation: Direct implantation of the
cancer cells at operation on the vault of the vagina or
abdominal or perineal wound is very rare.
Lymphatic spread : The primary group involved are
parametrial nodes, internal iliac nodes, obturator
external iliac nodes and sacral nodes. The secondary
nodes involved are common iliac group, the
inguinal nodes and para aortic nodes .
Staging

Staging of cervical cancer is based principally

on clinical examination under general anesthesia.
 The routine supplementary investigations include X-ray
chest, intravenous pyelography, cystoscopy and proctoscopy .
CT scan, MRI, PET, can detect involvement of the pelvic or
periaortic lymph nodes and parametrium.
FIGO 2009 staging of cancer cervix as follows;
Clinical picture , diagnosis and complication

In early stages of the disease mostly there are no

symptoms in most patients.
Bloody discharge may be present in some patients
despite healthy looking cervix.
Diagnosis in early stages up to Ib is made as follows;
Incidental on histological examination of tissues
removed by biopsy, portio amputation or removal
of the uterus.
During screening procedures.
Cytologically suspicious results are subjected to
colposcopy followed by directed biopsy.
In the absence of colposcopy, Schiller’s test directed
biopsy is to be taken.
With advancing disease Menstrual abnormalities in
the form of contact bleeding or bleeding on straining,
intermenstrual bleeding are very much suspicious,
specially over the age of 35, and also excessive white
discharge which may be at times offensive .
In late stages there are pelvic pain , bladder symptoms ,
rectal symptoms , leg edema and symptoms of ureteral
obstruction as recurrent attacks of pyelonephritis.
In advanced stages cervical biopsy is mandatory.
If the lesion is small, wedge biopsy is taken which should
include a portion of the healthy tissue as well.
If it is big, a bit may be taken from a non infective area.
The following complications may occur as lesions
progresses ; hemorrhage , pyometra, frequent attacks of
ureteric pain,
vesicovaginal fistula and rectovaginal fistula.
causes of Death may include:
Uremia: This is due to ureteric obstruction following
parametrial involvement.
Hemorrhage: The vaginal bleeding from the growth
may be brisk or continuous.
Sepsis: Localized pelvic or generalized peritonitis
may occur which may be fatal.
Metastases to the distant organs
Prevention

• Primary prevention: includes the following

 Identification of risk factors for the women and
their partners and try to eliminate them.
 Prophylactic HPV vaccine is approved for use, it
is either (Bivalent 0–2–6 month, Quadrivalent
0–1–6 month)
 Removal of cervix during hysterectomy.
Secondary prevention: It involves identifying and
treating the disease earlier in the more treatable stage.
This is done by screening procedures using Pap
smear
It is effective therapy reduces dramatically the
incidence of invasive carcinoma and even when the
invasive carcinoma is detected, it is so early that a
85–100 percent 5-year survival rate could be
achieved.
Management of invasive cancer

 The types of treatment employed for the invasive

carcinoma are as follows:
 Primary surgery

 Primary Radiotherapy
 Chemotherapy

 Combination therapy

• Primary surgery is employed for early stages up to stage IIa

popular as Wertheim operation.
• It includes removal of uterus, tubes , ovaries on both sides
(may be spared in young patients), upper half of vagina,
parametrium and the draining primary cervical lymph
nodes , Para aortic lymph node evaluation is done.
Pelvic exentration is ultraradical surgery done in a
very selected cases as ; Stage IVA disease, Central
pelvic recurrent carcinoma, Completely resectable
tumor mass and the patient should accept
permanent urinary and fecal stomas.
It includes anterior , posterior or total exentration.
Radiation therapy is to be considered if lymph nodes
are found involved .
Advantages of surgery over radiotherapy:
 Spread of the disease can be determined more thoroughly.
 Preservation of ovarian function in young women.
 Retention of more functional and pliable vagina for sexual
function.
 Psychological benefit to the patient in that her cancer bearing
organ has been removed.
Complications of surgery may include ; ureteric
fistula (about 1%), vesicovaginal fistula (0.5%),
bladder dysfunction, cystitis pyelonephritis and
rectal dysfunction. There may be lymphocyst in the
pelvis, lymphoedema of one or both the legs,
dyspareunia and recurrence. The mortality rate of
the procedure is less than 1 percent.
Radical Radiotherapy: is indicated for women unfit
for surgery or in advanced stages.
The goals of such treatment are to treat primary
disease and to control metastatic pelvic lymph nodes.
The radiation dose is delivered by external-beam
(teletherapy) and intracavitary treatment
(brachytherapy).
Intracavitary treatment is designed to give high
doses locally to the primary site.
 Teletherapy is designed to treat any pelvic spread.
The challenge in administering radiotherapy is in
achieving an optimal dose throughout the primary
tumour and pelvic sidewall without causing high
morbidity.
Routine extended field radiotherapy designed to
include para-aortic nodes has not been proven to
improve survival compared with pelvic radiotherapy
alone, and it is associated with significantly more
gastrointestinal complications.
 Complications may include; Intestinal and urinary
strictures, fistula formation (2–6%), vaginal fibrosis and
stenosis causing dyspareunia, radiation menopause,
fibrosis of bowel and bladder.
 Contraindication of radiotherapy :
 Associated PID—acute or chronic, pelvic kidney
 Associated myoma, prolapse ovarian tumor or genital
fistula
 Young patient (to preserve ovarian function)
 Vaginal stenosis — placement of radiation source is
inadequate.
Chemoradiation: Five randomised trials from the US
have shown an overall survival advantage for
cisplatin-based therapy given concurrently with
radiation therapy.
Recurrent cervical cancer

Treatment for recurrent cervical cancer depends on

the mode of primary therapy and the site of
recurrence.
Women who have had initial treatment by surgery
should be considered for radiotherapy, and those
who have had radiotherapy should be considered for
exenterative surgery.
Exenterative surgery in carefully selected cases can
result in five-year survival of 50 per cent
Palliation of progressive cervical disease

Chemotherapy is palliative and should be reserved

for patients who are not considered curable by
surgery or radiotherapy.
Urinary tract symptoms are particularly common
in advanced cervical disease as ureteric obstruction,
pain , infection and finally lost renal function.
PCN or ureteric stenting may be done If there is a
prospect of surviving more than 8 weeks.
Sever pain may be present in late stages and can be
controlled by radiotherapy or narcotics.
Cancer cervix and pregnancy

About 1 – 3 percent of patients with cancer cervix are

diagnosed during pregnancy or in postpartum period
Diagnosis is often late and confirmed by cone biopsy
Management depends on stage of the disease and
gestational age.
Patient with microinvasive carcinoma may be
followed up to term and reevaluated after delivery
and managed accordingly.
 Advanced stage: In the first trimester, treatment
modality is the same as in the nonpregnant state.
In late pregnancy, following maturity, fetus is
delivered by classical cesarean section. Subsequent
treatment with either radical surgery or radiotherapy
is the same as in the nonpregnant state.
Prognosis depends on the clinical stage of the
disease and there is no different between pregnancy
and nonpregnant state in survival rate.
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