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