CARCINOMA OF THE CERVIX

INTRODUCTION

• Is an invasive proliferation of the epithelium of the cervix with

cytological features of malignancy

• Could be microscopic or macroscopic

• Forms the commonest female genital tract cancer and the second
commonest female cancer worldwide

• Originates from the squamocolumnar junction, which is also the origin

of most preinvasive lesions of the cervix.

INCIDENCE
• Unknown

Risk Factors

• Women of lower socio economic group

• Women who had first intercourse at an early age
• Women who have a history of sexual promiscuity
• Multiparous women
• Smokers
Lower incidence is seen in nulliparous, sexually inactive women e g
Nuns, virgins,

Predisposing / Associated Factors

• Infection with Human Papilloma virus types 16, 18, and 33
• Prenatal exposure to DES
No definite evidence exists linking the use of oral contraceptives with
carcinoma of the cervix

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 NATURAL HISTORY/ SPREAD

• Most proceed from preinvasive lesions of the cervix

• A few others occur de novo
• Spread is predominantly by either direct invasion or lymphatic
permeation.
• Haematogenous dissemination occurs less frequently but may be
seen with more advanced stages.
• Common sites of haematogenous spread are the lungs, mediastinal
and supraclavicular lymph nodes, bones and liver

PATHOLOGY
• Up to 95% are squamous cell carcinoma
• About 5% are adenocarcinoma

PRESENTATION
• Asymptomatic – detection is from abnormal cell cytology
• Symptomatic – abnormal vaginal bleeding (postcoital bleeding,
intermenstrual bleeding)
Postmenopausal bleeding
Offensive blood stained vaginal discharge
Others-backache, leg pain/edema, haematuria, bowel
changes, malaise and weight loss.
DIAGNOSIS
Good history
Appropriate / detailed examination
. Cytological smears
. Colposcopy
. Punch biopsies
. Conization
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 .D&C
. EUA including cystoscopy, rectosigmoidoscopy

INVESTIGATIONS
. FBC
. Group and Cross match 2 units of blood
. Serum E/U/Cr + Uric acid
. LFT
. Urinalysis
. IVU
. CXR – PA
. Barium Enema
. USS
. Lymphangiography
. CAT Scan
. MRI

STAGING
. Enables appropriate planning of treatment
. Gives an idea of prognosis i.e survival is stage dependent
. Facilitates exchange of information between treatment centres

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FIGO STAGING OF CERVICAL CANCER (1995)

STAGE DESCRIPTION
0 Preinvasive carcinoma (carcinoma-in-situ,
CIN)

I Carcinoma confined to the cervix

(extension to the corpus should be
disregarded)

Ia Preclinical carcinoma of the cervix i e

invasive cancer identified only
microscopically measured stromal depth
should not be >5 mm and not wider than
7mm

Ia1 Measured invasion not greater 3mm in

depth and not wider than 7mm

Ia2 Measured depth of invasion greater 3mm

in depth, but not more than 5mm, not
wider than 7mm

Ib Clinical lesions confined to the cervix or

preclinical lesions greater than Ia

Ib1 Clinical lesion < 4 cm in diameter

Ib2 Clinical lesions ≥ 4cm in diameter

II Carcinoma extend beyond the cervix &

involving the vagina (but not the lower
3rd) & or infiltrating the parametrium (but
not reaching the pelvic side well)

IIa Carcinoma has involved the vagina

IIb Carcinoma has infiltrated the
parametrium

III carcinoma involving the lower 3rd of the

vagina & / or extending to the pelvic side
wall (there is no free space b/w the
tumour and the pelvic side wall). All
cases with a hydronephrosis or non-
functional kidney should be included
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 unless they are known to be due to
another cause.

IIIa Carcinoma involving the lower 3rd of the

vagina

IIIb Carcinoma extending to the pelvic wall

and/or hydronephosis or non functioning
kidney due to ureterostenosis caused by
tumour

IV Carcinoma has extended beyond the true

pelvis or has clinically involved the
mucosa of the bladder or rectum

IVa Spread of the growth to adjacent organs

IVb Spread to distant organs

MANAGEMENT

Options are . Surgery

. Radiotherapy
. Chemotherapy
. Combinations of these modalities
Close collaboration between the gynaecologic oncologist and the
radiation oncologist is necessary

Stage Management Modalities Remarks

0 total hysterectomy if family size is completed
Conization
Cryotherapy patients desire to retain fertility
Laser ablation

1A Conization Legions upto

3mm in depth
LEEP procedure
Total hysterectomy
Modified radical hysterectomy
Intracavitary brachytherapy Stage 1A2
(5,500 to 7, 500cGy to Point A)

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IB & IIA Radical hysterectomy +
bilateral pelvic
lymphadenectomy +
oophorectomy
. for young women
. Ovaries preserved
. Reduced risk of
sexual dysfunction

Radical radiotherapy .Surgical expertise not

available
. Women with large
tumours (> 4cm in
diameter)
. Medically unfit for
surgery
Combined radical radiotherapy
& Adjuvant Hysterectomy . Not advocated
. Morbidity
. No attendant
gain in cure or
survival rate
Combined primary surgery
& adjuvant radiation therapy . Patient with
pelvic lymph node
. Large tumour
volume (>4cm)
. Tumour at excision
margins
. Risk factors that
make recurrence
likely
Chemotherapy . Only in clinical
trials

IIB – IVA Radical radiotherapy . Intent of cure

Palliative radiotherapy . Does not prolong
survival but can
control symptoms
especially pain
Chemotherapy (either as a neo adjuvant
or radiosensitizers)

Surgery (pelvic exenteration) . Only in stage

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 IVa with Fistular
already present.

IVB No standard modality.

Depends on the location & extend of the
Disease.

RECURRENT CANCER

• Expertise of gynaecological, radiation and medical oncologists

required
• Appropriately equipped intensive care centre with above expertise.
• Refer appropriately
• If the initial treatment was surgery, now radiotherapy with some
protocols including chemotherapy can be used.

• If the initial treatment was radiotherapy and the disease is confined to

the pelvis, pelvic exenteration is done where the patient is surgically
fit. However, where the patient is not surgically fit and or recurrence is
beyond the pelvis, no treatment protocol.

CARCINOMA OF THE CERVIX IN PREGNANCY

• Prior to 24 weeks (viability), treat as in non pregnant women

• After the age of fetal viability, radical caesarean hysterectomy or
caesarean delivery & therapy instituted thereafter.
• B/4 the age of fetal viability or patient’s refusal of therapeutic abortion
based on moral or religious grounds presents the greatest challenge.
• Survival figures stage for stage are the same as those for non-
pregnant women.

FOLLOW UP

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• For life
• Every 3 months for the 1st 2 yrs
• Thereafter every 6 months for the next 3yrs
• Then yearly
At each visit ask of general health, coping with work. Look for anaemia.
Do careful abdominal, vaginal, rectal examination for evidence of
metastasis / recurrence.