CANCER OF THE CERVIX

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 Objectives
By the end of the lesson you will be able to;
• Identify the risks of cancer of cervix.
• Demonstrate understanding on diagnosis and
staging of cancer of cervix
• Able to manage a client with ca. cervix
• Demonstrate understanding on prevention of
ca. cervix
 CANCER OF THE CERVIX
• Cervical cancer is the second most common
cause of cancer-related morbidity and mortality
among women in developing countries
• The occurrence of invasive cervical cancer is
related to age, with a mean age at diagnosis of
47 years in the United States.
• The average age at diagnosis of patients with
cervical cancer is 51 years
• However, the disease can occur in the second
decade of life and during pregnancy
 Risk factors

1. Early onset of sexual activity <16 years old

increased risk by 50%
2. Multiple sexual partners - 6 sexual partners or more
increase risk by 14.2 folds.
3. High-risk sexual /Male related risk factors:e.g.
– Promiscuous sexual activity
– History of multiple sexual partners,
– Sexual exposure to a partner with human
papillomavirus infection
– Lower genital tract neoplasia
– Prior sexual exposure to someone with cervical
neoplasia
 Cont,

4. History of STDs (e.g. Chlamydia trachomatis, herpes

simplex virus)
 HPV (Human papilloma virus ) infection mainly
16,18
• the main aetiological is infection with subtypes of
HPV (16,18)
5. Cigarette smoking - Smoking for> 12 years increase
the risk by 12.7 folds.
-Cigarette smoke carcinogens have been found to
accumulate locally in the cervical mucus and the
cumulative exposure as measured by pack-years
smoked is related to the risk of developing CIN or
carcinoma in situ.
6. Immunodeficiency/immunosuppression
- With increasing immunosuppression there is an increase in
the risk of HPV infection, persistent HPV infection, and
progressive cervical neoplasia
7. Multiparity/high parity
8. Long-term oral contraceptive pill use
9. Low socioeconomic status
10. Previous history of vulvar or vaginal
squamous dysplasia
 Etiology

• Human papillomaviruses (HPVs) are a prime

etiologic factor in the development of cervical
cancer
• Squamous cell carcinomas (SCCs) account for
approximately 80 percent of cervical cancers,
adenocarcinomas 15 percent, and
adenosquamous carcinomas 3 to 5 percent.
• High-risk oncogenic HPV types account for
approximately 80% with HPV 16 -most
prevalent in squamous cell carcinoma, and
HPV 18 most prevalent in adenocarcinoma
 Type of patient:

• Multiparous.
• Low socioeconomic class.
• Poor hygiene.
• Prostitutes.
• Low incidence in Muslims and Jews.
 PATHOGENESIS
• HPV is epitheliotropic.
• Once the epithelium is acutely infected with
HPV, one of three clinical scenarios ensues:
– Asymptomatic latent infection;
– Active infection in which HPV undergoes
vegetative replication, but not integration into the
genome (e.g. leading to condyloma or CIN I); or
– Neoplastic transformation following integration of
oncogenic HPV DNA into the human genome
• Squamous carcinoma of the cervix usually
originates at the squamocolumnar junction
(the transformation zone).
• At least 90% of squamous cell carcinomas of
the cervix develop from the intraepithelial
layers, almost always within 1 cm of the
squamocolumnar junction.
 Spread.

Direct Lymphatic Dissemina

tion (late)
- Uterus A- primary node: - parametrial spread
- Vagina. parametrial. causes obstruction of
the ureters, many
- Parametrium. Paracervical. deaths occur due to
- Bladder and rectum. Vesicovaginal. uraemia.
Rectovaginal. - Obstruction to the
Hypogastric. cervical canal
results in
Obturator and external pyometria.
iliac
B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Routes of spread
• Cervical cancer can spread by direct extension into
the uterine corpus, vagina, parametria, peritoneal
cavity, bladder, or rectum, and by lymphatic or
hematogenous dissemination.
• Any of the pelvic lymph node groups may be the first
site of metastasis
• The risk of lymph node metastasis increases with
increasing depth of invasion
• The most common sites for hematogenous spread are
the lungs, liver, and bone; the bowel, adrenal glands,
spleen, and brain are less frequent sites. ( liver and
lungs most common sites)
• Death can occur from uremia, pulmonary embolism, or
hemorrhage from direct extension of tumor into blood
vessels.
• Life-threatening sepsis from complications of
pyelonephritis or vesicovaginal and rectovaginal
fistulas is possible.
• Large-bowel obstruction from direct extension of
tumor into the rectosigmoid can be the terminal event.
• Pain from perineural extension is a significant
management problem of advanced disease
 PATHOLOGY
• About 70-80% of cervical carcinomas are
squamous cell; the remainders are composed
of various types of adenocarcinomas (20-
25%), adenosquamous carcinomas (3-5%), and
undifferentiated carcinomas
Squamous Cell Carcinomas
• Cervical squamous cell carcinomas have been
classified according to the predominant cell
type:
– large cell nonkeratinizing, - majority
– large cell keratinizing, and
– small cell carcinomas. – poor prognosis
Adenocarcinoma
• Adenocarcinoma of the cervix is derived from
the glandular elements of the cervix.
Verrucous Carcinoma
• Verrucous carcinoma, which has been
associated with HPV 6, is a rare subtype of
well-differentiated squamous carcinoma.
• It is a slow-growing, locally invasive neoplasm.
Adenoma Malignum
• Adenoma malignum or minimal deviation
adenocarcinoma is an extremely well-
differentiated adenocarcinoma that may be
difficult to recognize as a malignant process.
Adenoid Cystic Carcinoma.
• This lesion is considered more aggressive than
most cervical adenocarcinomas and occurs
high parity in their sixth and seventh decades
of life
Adenosquamous Carcinoma
• Adenosquamous carcinomas contain an
admixture of malignant squamous and
glandular cells.
Neuroendocrine Carcinomas
• They have a high frequency of lymphovascular
space invasion, lymph node metastases,
recurrence, and poor survival.
Other Malignant Tumors
• Direct extensions of metastatic tumors to the
cervix include those originating from the
endometrium, rectum, and bladder.
 C/F
Early symptoms Late symptoms
- None. - Pain, leg oedema.
- Thin, watery, blood - Urinary and
tinged vaginal rectal symptoms
discharge frequently dysuria
goes unrecognized by haematuria
the rectal
patient. bleeding
-Abnormal vaginal constipation
bleeding haemorrhoids
Intermenstrual - Uraemia
Postcoital
Perimenopau
sal
Postmenopau
sal
 CLINICAL FEATURES
• Abnormal vaginal bleeding is the most common symptom of
invasive cancer and may take the form of
– a blood-stained leukorrheal discharge,
– scant spotting, or
– frank bleeding.
• Vaginal discharge that may be
– watery,
– mucoid, or
– purulent and malodorous
• History of postcoital bleeding may be elicited
• Pelvic pain, often unilateral and radiating to the hip or thigh, is
a manifestation of advanced disease, as is the involuntary loss
of urine or feces through the vagina, a sign of fistula formation.
• Weakness, weight loss, and anemia are characteristic of the
late stages of the disease
 DIAGNOSIS
1- History.
• Many women are asymptomatic .
• Presented with abnormal routine cx smear
• Complain of abnormal vaginal bleeding
• post coital bleeding
• perimenopausal bleeding
• postmenopausal bleeding
• blood stain vaginal discharge
Cervical examination: speculum exam
• Lesion; Most women with invasive cervical
cancer have a visible cervical lesion; however, its
presentation can range from a normal appearing
cervix with an isolated abnormal cervical
cytology (Papanicolaou) smear, to a grossly
abnormal cervix that is replaced entirely with
tumor …at the squamocolumnar junction.
• Endophytic tumors can result in an enlarged,
irregularity, indurated (hardened) cervix whose
surface is smooth (barrel shaped cervix.
• Exophytic, where the lesion generally appears as
a friable (Easily reduced), bleeding, cauliflower-
like lesion of the portio vaginalis.
• Mass - ulcerating fungating in the cervix
• Ulceration may be the primary manifestation
of invasive carcinoma; in the early stages the
change often is superficial, so that it may
resemble an ectropion or chronic cervicitis.
 CLINICAL STAGING
• The classification adopted by the International
Federation of Gynecology and Obstetrics (FIGO) is
the most widely used staging system
• Cervical cancer is staged by clinical examination,
and evaluation of the bladder, ureters, and rectum
Can be done by;.
• Examination under anaesthesia.
• Bimanual palpation.
• P/V, P/R.
• Cervical biopsy, uterine biopsy.
• Cystoscopy, Proctoscopy, if necessary.
 Cont,
Stage O: Carcinoma in situ
Stage I: Cervical carcinoma confined to the
cervix
A1 - Microscopic invasive stromal not deeper
than 3 mm & not wider than 7mm
A2 – Microscopic invasive stromal deeper than
3mm but < 5mm & not wider than 7mm
B1 - Clinically visible lesion < 4 cm
B2 – Clinically visible lesion > 4cm
Stage II: Tumor extends beyond uterus but not pelvic
side wall or lower third of vagina
• A – Vaginal involvement without parametrial
involvement
• B – Parametrial involvement
Stage III: Tumor extends to pelvic side wall
• A – Involvement of lower third of vagina but no
extension to sidewall
• B – Extension to pelvic side wall and/or
hydronephrosis
Stage IV: Extension beyond the true pelvi
• A – Extension into adjacent organs
• B – Distant metastases
 INVESTIGATION
• Biopsy: In women with a grossly visible lesion,
a suspected diagnosis of cancer should be
confirmed by punch biopsy of the lesion (at
the edge of the tumor).
• Colposcopy:
• Conization:
• Chest x-rays are indicated in all patients with
cervical cancer and an intravenous pyelogram
(IVP) or computed tomography (CT) urogram
should be performed to determine if there is
any ureteral obstruction producing
hydroureter and hydronephrosis.
• Magnetic resonance imaging (MRI),
Differential Diagnosis
• A variety of lesions of the cervix may be
confused with cancer.
– acute or chronic cervicitis, condyloma acuminata,
cervical tuberculosis, ulceration secondary to
sexually transmitted disease (syphilis, granuloma
inguinale, lymphogranuloma venereum,
chancroid), abortion of a cervical pregnancy,
metastatic choriocarcinoma or other cancers, etc
Via vili
 TREATMENT
• Surgical.
• Radiotherapy.
• Radiotherapy & Surgery.
• Radiotherapy and Chemotherapy followed by
Surgery.
• Palliative treatment.
 The choice of treatment will depend on

• Fitness of the patients

• Age of the patients
• Stage of disease.
• Type of lesion
• Experience and the resources avalible.
 TREATMENT.
• Stage 1A –hysterectomy
• 1A2 and 1B1- Radical trachelectomy with
lymphadenectomy.
• 1A2-IIA - Radical hysterectomy and pelvic
lymphadenectomy or with primary radiation
with concomitant chemotherapy. Adjuvant
radiation with concomitant chemotherapy is
administered to selected patients at increased
risk for recurrence following radical
hysterectomy
• Definitive RT
• Definitive RT and radical surgery are both
accepted treatments for stages IA, IB, and IIA
cervical cancer, since oncologic outcomes are
similar
• IIB –IVA – Radiothery and chemotherapy
• IVB- chemotherapy
– Palliative care
• Total Pelvic Exenteration(removal of the
bladder, rectum, and vagina, along with the
uterus if hysterectomy has not yet been
performed) for Pelvic Recurrence of Disease
 Werthemeim’s hystrectomy
• Total abdominal hystrectomy including the
parametrium.
• Pelvic lymphadenectomy, 3 cm vaginal
cuff
• The original operation conserved the
ovaries
,since squamouss cell carcinoma does not
spread directly to the ovaries.
• Oophorectomy should be performed in cases
of adenocarcinoma as there is 5-10% of
ovarian metastosis
 COMPLICATIONS OF SURGERY
• Haemorrhage: primary or secondary.
• Injury to the bladder, uerters.
• Bladder dysfunction.
• Fistula.
• Lymphocele.
• Shortening of the vagina.
 Chemotherapy

6/1/2018 3:44:47 AM 42
THE OVERALL 5 YEARS SURVIVAL FOLLOWING
THERAPY:
• Stage I -------80%
• Stage II-------50-60%
• Stage III-------30-40%
• Stage IV-------4%
 Assignment.
• Read on managent of cancer of cervix in
pregnancy.
 In pregnancy;
• Cervical punch biopsies can be safely performed without a
significantly increased risk of excessive bleeding, but
endocervical curettage should be avoided.
• In comparison, cone biopsy should be performed only if
strictly indicated to avoid preterm labour haemorrhage.
• Stage I or IIA, radical hysterectomy and therapeutic
lymphadenectomy can be performed with the fetus left in-
situ unless the patient is unwilling to terminate the
pregnancy.
• Women at a gestational age closer to fetal viability or who
are unwilling to lose the baby may decide to continue the
pregnancy, after careful discussion regarding the maternal
risks
• Pregnant women with carcinoma in situ or microinvasive
disease may be followed to term and deliver vaginally, with
reevaluation and treatment six weeks postpartum
• Cs to mothers with large invasive cancer
Prognosis
• The major prognostic factors affecting survival are stage,
lymph node status, tumor volume, depth of cervical stromal
invasion, lymphovascular space invasion and, to a lesser
extent, histologic type and grade.
Prevention
• Prevention of morbidity and death from cervical cancer
largely involves recognition and treatment of preinvasive
and early invasive disease.
• Risk factors must be recognized, and screening, treatment
intervention,
• Women with preinvasive cervical neoplasia should be
treated and followed up closely
• Sexual abstinence is an effective
• Education of young women and men about risk factors and
 Visual inspection.
• Visual inspection (VIA and VILI) — Visual inspection
with acetic acid (VIA) and visual inspection with Lugol's
iodine (VILI) have been employed in low resource
settings as an alternative method of cervical cancer
screening.
• Biopsy of visible lesions — A visible lesion on the cervix
that is raised, friable, or has the appearance of
condyloma should be biopsied, even in the presence of
normal cytology results.
• Cervicoscopy — Cervicoscopy refers to visual inspection
of the cervix for evidence of abnormality after an
acetic-acid wash (VIA) using a 3 to 5 percent solution.
• The cervix is then examined with the naked eye or a
hand-held magnifying lens for areas of whitening.
HPV vaccination
• The bivalent HPV 16/18 VLP vaccine and the
quadrivalent HPV 6/11/16/18 VLP vaccine
• The quadrivalent vaccine would also prevent most
genital warts
• The currently suggested immunization schedule is in
girls and women 9 to 26 years of age.
• Quadrivalent HPV 6/11/16/18 L1 VLP vaccine
(Gardasil™) is administered in three doses at 0, 2, and 6
months.
• Vaccination can be offered to females as young as nine
years of age.
• Cervical screening is not appropriate until pubertal,
physiologic, and psychological development has been
established and at least three years from onset of
 Triple A Guideline: ACS, ASCCP,
American Society for Clinical Pathology
CA Cancer J CLIN March 2012

Age Screening

< 21 No Screening

21-29 Cytology alone every 3 years

30-65 Preferred: Cytology + HPV every 5 years* OR

Acceptable: Cytology alone every 3 years*

> 65 No screening, following adequate neg prior screens

After total hysterectomy No screening, if no history of CIN2+ in the past 20

years of cervical cancer ever
* If cytology result is negative or ASCUS + HPV negative