CARCINOMA OF CERVIX

PRESENTED BY

YASIR NAWAZ

FINAL YEAR MBBS

C.NO. 08-215

BATCH: L

• The most preventable female cancer

• January is cervical cancer awareness month

CONTENTS OF PRESENTATION

WHAT IS CERVIX?

INCIDENCE & AETIOLOGY

STAGING

CLINICAL FEATURES

DIAGNOSIS

TREATMENT & FOLLOW UP.

WHAT IS CERVIX?

The cervix is part of a woman's reproductive system. It's in the pelvis. The cervix is the lower, narrow part of the uterus (womb).

The cervix is a passageway:

The cervix connects the uterus to the vagina. During a menstrual period, blood flows from the uterus through the cervix into the vagina. The vagina leads to the outside of the body

The cervix makes mucous. During sex, mucous helps sperm move from the vagina through the cervix into the uterus.

During pregnancy, the cervix is tightly closed to help keep the baby inside the uterus. During childbirth, the cervix opens to allow the baby to pass through the vagina.

INCIDENCE

The incidence of cervical carcinoma in UK is

15 per 100,000 and in USA it is 10 per 100,000. The said ratio varies in different population groups.

Invasive carcinoma may occur at any age but peak incidence is at 45 years, while that of endometrial carcinoma is at 60 years.

AETIOLOGY

Coitus: It's the most important factor and also the number of sexual partners should be taken into consideration. Monks, nuns and virgins are at least risk of developing this disease. Prostitutes and women who suffer from venereal diseases have a higher chance of developing cervical carcinoma.

Age of first coitus: If the sexual intercourse takes place at less than 17 years of age or before adolescence, the risk of carcinoma of cervix is higher.

Multiple pregnancies: 95% of invasive cancers occur in multipara. It may be the reason for higher incidence of cervical carcinoma in women with multiple pregnancies and having first child at an early age.

Social Status: women of low socioeconomic group are at higher risk because of early marriages and poor hygiene.

Race and Religion: Jewish and muslim women are at lower risk than negresses.

Circumcision: once it was believed that jewish and muslim women are at lower risk because partners are circumcised as penile hygiene after circumcision is better.

● Smoking: it's also associated with cervical carcinoma according to recent studies.

● Others: HPV, HIV, HSV and Chlamydia infections are also contributory to the said issue.

● Human Spermatozoa: phagocytosis of spermatozoa by metaplastic epithelium may take place.

incorporation of sperm DNA into cell nucleus may cause genetic mutation and it becomes carcinogenic.

CLINICAL STAGING

FIGO revised the staging of cervical carcin-

oma in Montreal 1994.

●Stage 0: Carcinoma in situ, intraepithelial neoplasia . These shouldn’t be included in any therapeutic statistics.

●Stage 1: Strictly confined to cervix.

1a: preclinical invasive carcinoma with horizontal extension of not more than 7mm.

1b: lesions of greater dimension than stage 1a.

clinically visible lesion of equal to or more than 4cm.

●Stage 2: The carcinoma extends beyond the uterus but hasn’t extended on to the pelvic wall, carcinoma involves vagina , but not as far as the lower third.

Stage 3: The carcinoma has extended on to the pelvic wall.the tumor involves the lower third of the vagina.

Stage 3a: No extension on to the pelvic wall, but involvement of the lower third of the vagina.

Stage 3b: Extension on to the pelvic wall or hydronephrosis.

Stage 4: the carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum.

Stage 4a: spread of growth to adjacent organs involving mucosa of bladder or rectum.

Stage 4b: Spread to distant organs.

TYPES OF CERVICAL CARCINOMA

Squamous Cell Carcinoma: It arises from the stratified squamous epithelium of ect-

ocervix.

● Adenocarcinoma: It arises from the columnar epithelium of the cervical canal.

● Mixed Type: Includes adenosquamous, mucoepidermoid, glassy cell types.

● Undifferentiated type: Very rare.

SPREAD

Direct Spread

Lymphatic Spread

Haematogenous Spread

Direct Spread

It first involves rest of the cervix and then spreads downward, laterally, upward, anteriorly and posteriorly.

Downward Spread: Involving upper part of the vagina, may be in some cases involve whole of the vagina.

Lateral Spread: It's into the parametrial tissue involving walls of the pelvis. It may involve lower end of the

ureters and cause ureteric obstruction.

● Upward Spread: May extend to body of the uterus and cavity.

● Anterior and Posterior Spread: It may extend anteriorly to base of the bladder and posteriorly to rectum, causing formation of fistulae.

LYMPHATIC SPREAD

Primary lymphatic spread is into the nodes situated in the tissues around the cervix. Later may involve other groups of nodes, which are, internal , external and common iliac, obturator, sacral and paraortic nodes.

HAEMATOGENOUS SPREAD

This is an uncommon route of spread. In later stages metastases to lungs, bones, brain and other parts may reach through the blood stream.

CLINICAL FEATURES:

SYMPTOMS:

Asymptomatic: in a case of microinvasion there may not be having any symptoms.

Abnormal vaginal bleeding: This is the most common symptom. The amount of bleeding is variable. Bleeding may be in the following forms:

Intermenstrual bleeding, postcoital bleeding and postmenopausal bleeding.

Pain: Pain occurs in advanced cases. Patient may complain of backache, abdominal pain ureteric colic, rectal pain and frequency of micturition and dysuria.

Vaginal discharge: in advanced cases the patient may complain of foul smelling blood stained vaginal discharge.

Others: In advanced stages, there may be anorexia, malaise, loss of weight, anaemia and uraemia.

PHYSICAL SIGNS:

● Normal cervix: in case of microinvasion the cervix may look healthy and no abnormality seen on naked eye examination.

Consistency: If it feels harder and bleeds on touch then it's suspicious.

Excavated ulcer: the ulcer may have ragged margins and the cervix may be indurated and hard.

Polypoidal growth: The size of the growth is variable arising either from ecto or endo cervix.

Enlarged, Hard and Friable cervix: this is a typical feature of infilterating type of carcinoma.

Mobility: the mobility of the uterus is restricted and induration is felt through vaginal fornices.

DIAGNOSIS

Following are the methods for early diagnosis:

Pap Smear: It's done by making smears from scrapings of cervical and vaginal walls. A smear is also prepared from pool of secretions in the posterior fornix. When fixed and stained , these smears show malignant cells.

HPV Testing: It is carried out when cytology is suspicious. If the test is positive then colposcopy is necessary whereas if negative then the patient can be spared from colposcopy.

Schiller's Test: Gram's iodine and KI is instilled into the vagina. The healthy squamous epithelium takes the stain while the diseased area is left unstained. This test is

utilized in deciding the area to be excised.

Acetic Acid Test: By application of 5% acetic acid to cervix, the abnormal cells attain white colour.

Colposcopy and Colpomicroscopy: these procedures are you used to detect cervical lesions at an early stage. This is possible by careful scrutiny of changes in the cellular pattern and vascularity of the covering epithelium and the transformation zone.

Biopsy of the Cervix:

Punch biopsy: punch biopsies are usually taken from squamo-columnar junction unstained or aceto-white areas.

Wedge biopsy: A wedge is resected from the suspected area. This is usually carried out to confirm the diagnosis before embarking upon the treatment.

Cone Biopsy

Cone Biopsy: In this type of biopsy, whole of the squamo-columnar junction along with the columnar epithelium of the cervix is excised in one piece. This is carried out with a scalpel under general anaesthesia. Haemostasis is secured with electro-coagulation or catgut sutures.

TREATMENT

Assessment and Preparation: General Health Assessment of the disease Investigations: routine investigation; Hb estimation Blood grouping and cross matching Blood urea and serum creatinine Urine for culture and sensitivity chest X-ray MRI IVU & Bone Scan

Radiotherapy: It's a treatment of choice especially where facilities are available and for those patients who are not fit to undergo operative treatment.

Techniques: 1. intracavitary irradiation

2. External irradiation

3. Combination

4. interstitial irradiation

Surgical Treatment: Surgery for microinvasion: simple hysterectomy

Radical procedures:

1. Uterus alongwith fallopian tubes

2. Cervix along with a cuff of vagina

3. Parametrial tissue along with parametrial lymphatics and lymph nodes

4. Pelvic lymph nodes5. Evaluation of paraortic glands Techniques: Abdominal operation: Wertheim's Hysterectomy Vaginal operation: Shauta's or Mitras Hysterectomy Chemotherapy: This is called neoadjuvant therapy. These

drugs are used in advanced diseases. These drugs are Cisplatin, Vinblastine, Bleomycin, Methotrexate, 5FU and Mitomycin C.

Combined Treatment: In some centers radiotherapy and surgery are combined for the treatment of invasive carcinoma of cervix.

Palliative Treatment: Aim is to enhance the betterment of the patient symptomatically. Cisplatin, Bleomycin, Vincristine are used for palliative therapy.

SURVIVAL RATE IN RELATION TO STAGING OF CERVICAL CANCER

JADE GOODY

JADE GOODY + CA cervix

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