Cancer of the cervix is the most common

female genital cancer in developing

countries every year about 500,000
women , acquire the disease and 75% are
from frame developing countries.
About 300,000 women also die from the
disease annually and of these 75% are
from developing countries

Finland which has an advanced

population based screening program has
one of the lowest rates in the world.

4-6 % of female genital cancers.

40-50 years old

Risk factors and aetiology

Coitus
at young
young age:
age: <16
<16 years
years old
oldincreased
increasedrisk
riskby
by50%
50%
Coitus at
Number
Number of
of sexual
sexual partners:
partners: 66 sexual
sexualpartners
partnersor
ormore
moreincrease
increase
risk
by
14.2
folds.
risk by 14.2 folds.
Smoking
Smoking
Smoking
Smoking for>
for> 12
12 years
years increase
increasethe
therisk
riskby
by12.7
12.7folds.
folds.
Male
Male related
related risk
risk factors:
factors:
number
number of
of the
the partners
partners previous
previoussexual
sexualrelationships
relationshipsisis
relevant
relevant ..
cervical
cancer
risk
increased
ififpartners
has
penile
cancer
cervical
cancer
risk
increased
partners
has
penile
cancer
(circumcision)
(circumcision)
Previous wife with cervical cancer.
Previous wife with cervical cancer.
Previous CIN
Previous CIN
Poor uptake of screening program.
Poor uptake
of of
screening
program. pill increase the risk due to
Long
term use
the contraceptive
Long term exposure
use of thetocontraceptive
pill increase the risk due to
increasing
seminal fluids.
increasing
exposure
to seminal
Barrier
method
decrease
the riskfluids.
(condan)
Barrier method
decrease
the risk (condan)
Immuno
suppresion
risk increased
with immuno suppressed renal
Immuno suppresion
riskinincreased
withwomen.
immuno suppressed
transplant
patients and
HIV positive
renal (Human
transplant
patientsvirus
and )ininfection
HIV positive
women.
HPV
papilloma
mainly
16,18
HPV (Human
virus
) infection
mainly
16,18of HPV
the mainpapilloma
aetiological
is infection
with
subtypes
(16,18)the main aetiological is infection with subtypes of HPV
(16,18)

HPV 16,18

Smoking

Cervical cell

Male factors

Infhibation of CX
cellp53 tumour
suppression gyne
Protection against
tumour
development lifted

Cancer develops

Multiparous.
Low socioeconomic class.
Poor hygiene.
Prostitutes.
Low incidence in Muslims and Jews.

Cervical dysplasia.
(Cervical intraepithelial neoplasia)
CIN III / CARCINOMA IN SITU
THE LESION PROCEEDS THE INVASION BY
10-12 YEARS

Early symptoms
- None.
- Thin, watery, blood
tinged vaginal
discharge frequently
goes unrecognized by
the patient.
- Abnormal vaginal
bleeding
Intermenstrual
Postcoital
Perimenopausal
Postmenopausal
- Blood stained foul

Late symptoms
- Pain, leg oedema.
- Urinary and rectal
symptoms
dysuria
haematuria
rectal bleeding
constipation
haemorrhoids
- Uraemia

Squamous cell carcinoma- 90%.

Adenocarcinoma- 10%.

Exophytic: is like cauliflower filling up the

vaginal vualt.
Endophytic: it appears as hard mass with
a good deal of induration.
Ulcerative: an ulcer in the cervix.

1- History.

Many women are a symptomatic .

Presented with abnormal routine cx

smear

Complain of abnormal vaginal bleeding

I M bleeding

post coital bleeding

perimenopausal bleeding

postmenopausal bleeding

blood stain vaginal discharge

2- Examination:
Mainly vaginal examination using cuscus
speculem nothing is found in early stage .
Mass ,ulcerating fungating in the cervix
P/V P/R is very helful.

Cytology

Histology

calposcopy

o
o
o
o
o

o
o
o
o
o
o

Review her history.

General examination:
Anaemia.
Lymphadenopathy-Supraclavicular LN.
Renal area.
Liver or any palpable mass.
Oedema.
Laboratory tests:
CBC, LFT, RFT, Urine analysis.
Tumour markers.
Chest X- ray, abdominal X- ray, IVU.
CAT, MRI, if necessary.
Ultrasound.
Lymphography, if necessary.

Best to follow FIGO system.

Examination under anaesthesia.
Bimanual palpation.
P/V, P/R.
Cervical biopsy, uterine biopsy.
Cystoscopy, Proctoscopy, if necessary.

Once cancer cervix is found (diagnosed),

more tests will be done to find out if the
cancer cells have spread to other parts of
the body. This testing is called staging.
TO PLAN TREATMENT, A DOCTOR NEEDS
TO KNOW THE STAGE OF THE DISEASE.

Direct

Lymphatic

Dissemination
(late)

- Uteruq.

A- primary node:
parametrial.
Paracervical.
Vesicovaginal.
Rectovaginal.
Hypogastric.
Obturator and external
iliac

- parametrial spread
causes obstruction of
the ureters, many
deaths occur due to
uraemia.
- Obstruction to the
cervical canal results in
pyometria.

- Vagina.
- Parametrium.
- Bladder and
rectum.

B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Inguinal.

Cervical ectropion.
Cervical tuberculosis.
Cervical syphilis, Schistosomiasis, and
Choriocarcinoma are rare causes.

Surgical.
Radiotherapy.
Radiotherapy & Surgery.
Radiotherapy and Chemotherapy
followed by Surgery.
Palliative treatment.

Fitness of the patients

Age of the patients
Stage of disease.
Type of lesion
Experience and the resources avalible.

The classic surgical procedure is the

wertheims hystrectomy for stage Ib,IIa,
and some cases of IIb in young and fat
patient

Total abdominal hystrectomy including

the parametrium.
Pelvic lymphadenectomy
3 cm vaginal cuf
The original operation conserved the
ovaries ,since squamouss cell carcinoma
does not spread dirctly to the ovaries.
Oophorectomy should be performed in
cases of adenocarcinoma as there is 510% of ovarian metastosis

It allows presentation of the ovaries

(radiotherapy will destroythem).
There is better chance of preserving
sexual function.
(vaginal stonosis occur in up 85% of
irradiates.
Psychological feeling of removing the
disease from the body .
More accute staging and prognsis

Haemorrhage: primary or secondary.

Injury to the bladder, uerters.
Bladder dysfunction.
Fistula.
Lymphocele.
Shortening of the vagina.

INDICATIONS OF P/O XRT FOLLOWING

WERTHEIMS HYSTERECTOMY (STAGE I ,
IIa):
Positive pelvic lymph nodes.
Tumour close to resection margins and/or
parametrial extension.

Stage IIb and III

Radical Radiotherapy
External irradiation (Teletherapy).
Intracavitary radiation (Brachytherapy).
In some cases of stage IIa or b radio and
chemotherapy to be given then followed
by simple hysterectomy -------

For stage IV individualized therapy.

Some suitable for palliative XRT ( usually intracavitary
Caesium).
Some suitable for extensive surgery.
Some suitable for chemotherapy.
Good nursing care.
Analgesia-must be used in sufficient amount to ----- pain
(Codein sulfate, Pethidine, Morphine, Diamorphine).
Antiemetic if necessary.
IV drip, entral, and parentral feeding.
Urinary Catheterization.
Other measures for symptom relief.

Depends on:

Age of the patient.

Fitness of the patient.

Stage of the disease.

Type of the tumour.

Adequacy of treatment.

THE OVERALL 5 YEARS SURVIVAL

FOLLOWING THERAPY:
Stage I -------80%
Stage II-------50-60%
Stage III-------30-40%
Stage IV-------4%

1. Local recurrence:
Radiation if not used.
Pelvic exenturation.
2. Distant disease
Chemotherapy.

On completion of treatment all patients are

given a vaginal dilator to use until vaginal
mucosa healed, this prevents vaginal stenosis.
Premenopausal patients commenced on HRT:
post hysterectomy-Extraderm skin patches 50
meg twice weekly.
No hysterectomy- Cycloprogyn 1mg daily.
The patient to be seen 1/12 post-treatment.
3 monthly for 2 years.
4 monthly for 3rd year.
6 monthly until 5years.
Then yearly all her life.
Patients with stage I and II disease treated
with radical radiotherapy will be assessed by
EUA approximately 3 months after completing
treatment.

Cancer of the cervix is still quite

common, reduction in incidence depends
on the quality of the screening program.

The aetiology appears to be multifactorial

the prime oncogenic agent is probably
[HPV-16,18].
Clinical presentation is with
inermenstrul,postcoital, postmenospausal
bleeding or following abnormal cytology.
Tumour spreads locally to involve the
uterus bladder , vagina, parametrium,
ureters, rectum and bone.

Spread also to the internal and external

iliac , obdurater and common iliac nodes
then to para- aortic nodes.
Blood borne metastasis spread to liver,
lung and bone occur .
Microinvasion squamous tumour carry a
good prognosis allowing conservative
treatment initially if required.

Early invasive squamous cell disease

(stage Ib,IIa and in some cases of IIb)
may be treated by either a wertheimes
hysterectomy or radiotherapy as first line
treatment.
Advanced stage (IIb, III,IV) treated by
radio or chemotherapy.

Glandular tumours (adenocarcinomas)

are not detectable by screening are
associated with skip lesions and require
radical surgery.