Carcinoma Cervix

PATHOLOGY
A. EPITHELIAL TUMORS B. MESENCHYMAL TUMORS
1. Squamous Tumors 1. Leiomyosarcoma
(a) CIN I, II, III 2. Stromal sarcoma
(b) Sq Cell Ca
3. Sarcoma botryoides
2. Glandular Tumors
(a) CGIN C. MIXED TUMORS
(b) Adenocarcinoma 1. Adenosarcoma
3. Others 2. Carcinosarcoma
(a) Adenosquamous D. MISCELLANEOUS
(b) Small cell ca TUMORS
Clinical Features
SYMPTOMS
Asymptomatic in pre-invasive and early stage
Abnormal vaginal bleeding
Abnormal vaginal discharge
Pelvic pain
Flank pain
Hematuria/ incontinence
Clinical Features
SIGNS
(To be elicited on inspection & palpation by
bimanual & recto-vaginal exam)
Cachexia and pallor
Lymphadenopathy
Cervical growth
Bleeds on touch
May extend to vagina &/or parametrium
Exclude involvement of rectal mucosa &
pyometra
Early stage cervical cancer
Advanced cervical cancer
Investigative Work-up
To confirm diagnosis

To assess the extent of disease

Pre-treatment investigations
Investigative Work-up
Cervical biopsy (and rarely by colposcopy)
Chest X-ray for all patients
USG/IVP to evaluate renal status
Cystoscopy/ proctoscopy if indicated by
patients symptoms
Role of CT/MRI/PET for nodal status evaluation
doubtful
Std lab tests including CBC, LFT & RFT
 FIGO Staging
Stage 0 Carcinoma in situ
Stage I Ca confined to cervix
IA Invasive ca limited to a depth of 5mm
and width of 7mm
IA1 Invasion not > 3mm
IA2 Invasion > 3mm but < 5mm
IB Clinical lesions confined to cx or
preclinical lesions > IA
IB1 Lesions not > 4cm
IB2 Lesions > 4cm
FIGO Staging contd

Stage II Ca extends beyond cx but not

upto LPW or lower 1/3 vagina
IIA No obvious para involvement
IIB Obvious para involvement
Stage III Ca extends upto LPW or lower 1/3
vagina or hydronephrosis
IIIA No extn to LPW but lower 1/3
vagina
IIIB Extn to LPW or hydronephrosis
Stage IV Extn beyond true pelvis or to
bladder/rectal mucosa
Treatment
FACTORS INFLUENCING TREATMENT
Tumor stage

Tumor size

Evidence of nodal involvement

Risk factors for surgery or radiotherapy

Patient preference

Physician preference
Treatment options
Surgery

Radiotherapy

Concurrent chemoradiation
Options for surgery
Conisation of cervix

Simple hysterectomy

Modified radical hysterectomy (Class II)

Radical hysterectomy (Class III)

Exenteration operations
What is radical hysterectomy
Also known as Wertheims hysterectomy or
Meigs hysterectomy or Class III hysterectomy
Involves removal of
Uterus with cervix
Cuff of vagina
Total parametrium
Bilateral pelvic lymph nodes
Major complications
Ureteric injury
Vascular injury
Bladder dysfunction
Lymphocyst formation
What are Exenteration
operations

Anterior exenteration

Posterior exenteration

Total exenteration
 Treatment
Role of surgery
Pre-invasive lesions Superficial ablation

For IA1 Conisation or extrafascial hysterectomy

For IA2 Class II Wertheims with BPLND

For IB & IIA Class III Wertheims with BPLND

In central recurrence Exenterative surgery

 How do we give radiotherapy
Usually as concurrent chemoradiation
Total dose to Pt A is 7000-8000 cGy & 5500 cGy to
Pt B
Initially external beam therapy
Through two or four portals
180-200 cGy/25 #/4500-5000cGy
Aim to sterilize peripheral disease and reduce the size of
the cervical growth
Then brachytherapy
Through uterine tandems and ovoids
Fletcher-Suit afterloading technique
LDR or HDR in 1-5 sittings
Approx 3000 cGy to Pt A
 Treatment
Role of radiotherapy

As primary therapy
In IB & IIA disease - alternative to
surgery
In IIB, III & IVA - only choice for therapy
In locoregional recurrence after surgery
Adjuvant to surgery
When nodal metastasis +
Positive cut margins
Parametrial involvement
Treatment
Role of Chemotherapy
Chemotherapy used concurrently with RT has
been found to improve survival. Usually cis-
platinum on a weekly basis till RT is
completed.

Chemotherapy is also used for palliation in

recurrent or advanced cases beyond the scope
of curative intent
Follow-up
3-monthly for two years; then, 6-
monthly for next three years
By symptoms such as vaginal bleeding,
pelvic masses, renal lumps, chest
symptoms
Findings suggestive of recurrence
Pap smear, colposcopy and imaging
Annual X-rays
Possible questions
LAQ

Discuss the diagnosis and management of

pre-invasive lesions of the cervix
Discuss the management of Stage IIA
cervical cancer
How do we stage cervical cancer? Discuss
the role of radiotherapy in the management
of cervical cancer
Possible questions
SAQs
Colposcopy
CIN III
Pap Smear
Staging of cervical cancer
Diagnosis of cervical cancer
Down-staging of cervical cancer
LEEP
Possible questions
MCQs
Ca cervix involving upper 2/3 of the vagina
is classed as

IIA

IIB
IIIA

IIIB
For ca cervix IIIB, treatment of choice is

Chemotherapy

Surgery
Surgery + radiotherapy

Chemoradiation
Possible questions
MCQs
The commonest malignancy in women in India
is
Ca endometrium

Oral ca

Ca cervix

Ca ovary
Ca cervix commonly starts at

Portio vaginalis

Squamocolumnar junction
Erosions of the cervix
Endocervical canal
Possible questions
MCQs
Earliest symptom of cervical cancer is

Pelvic pain

Pelvic lump due to pyometra
Post-coital bleeding
Foul-smelling vaginal discharge
Commonest cause of death in cervical cancer
is
Infection
Uremia
Cachexia
Distant metastasis
Possible questions
MCQs
How will you evaluate an HSIL report on pap
smear?

Multiple punch biopsies

Cold knife conisation

Colposcopically directed biopsy
Follow-up with Pap smears at 6-monthly intervals
Which of the following is Schiller test
positive?
Erosion cervix
Ectropion
CIN III

All of the above
Possible questions
MCQs
Staging of ca cervix is assigned by

Physical examination

Exploratory laparotomy
Biopsy

All of the above
Treatment of choice for CIN III of cervix is

Chemotherapy

Radiotherapy
Surgery

Chemoradiation
Possible questions
MCQs

All of the following about ca cervix are

correct EXCEPT

Coital bleeding is an early sign
HPV is a known causative factor

Disease is fairly common in celibate nuns

Screening programme is quite effective in
prevention
Possible questions
MCQs
A patient with unilateral renal shutdown and
hydronephrosis will be staged as:

Stage IIA
Stage IIIB

Stage IVA

Stage IVB
Possible questions
MCQs
The best method for diagnosis of an ulcero-
proliferative lesion of the cervix suspected
of ca cervix is

Cervical smear

Cervical punch biopsy

Colposcopy
CT scan or MRI
Possible questions
MCQs
In Stage 1A1 Ca cervix, invasion is limited to
1 mm

3 mm

5 mm
7 mm
Thank you