Cervical Cancer

Introduction
Third most common gynecologic cancer
Also 3
rd
cause of death in US
Second most common type in places where there
is no preventive screening
HPV is central to its development; detected 99.7%


Epidemiology
530,000 new case cases worldwide, and for
275,00 deaths in 2008.
Mortality rate 52% worldwide
75% decrease due to vaccination and
screening in the past 50 years.
In Women:
10
th
most common type developed country
2
nd
most common type developing countries
Risk Factors
1. Early onset of sexual activity by 2 fold inc
2. Multiple Sexual partners by 2 fold inc
3. Hx of STI (e.g., Chlamydia, genital herpes)
4. Hx of Vulvar or vaginal squamous intraepithelial
neoplasia or cancer
5. Immunosuppression (e.g., AIDS)
6. Oral contraceptives, adenocarcinoma
(5 years' use versus never-use: RR 1.90, 95% CI 1.69-
2.13).
Pathogensis
Four major steps in cervical cancer
development:
Oncogenic HPV infection of metplastic epithelium
at transformation zone
Persistence of HPV infection
Progression of a clone epithelial cells from
persistent viral infection to precancer
Development of carcinoma and invasion through
the basement membrane.
Oncogenic HPV
Histopathology
Route of Spread
Can spread by
Direct extention: involve the uterine corpus,
vagina parametria, perotoneal cavity, bladder and
recturm
Lymphatic: obtruae lymph node pevlic side
wall of common illiac, and then paraortic
Hematogenous: lungs, liver, and bone.
Less frequent: bowel, adrenal glands, spleen and brain
Clinical Manifestations
Early is frequently asymptomatic
Common symptoms at presentation:
Irregular or heavy vaginal bleeding
Post-coital bleeding
Some present with vaginal discharge:
Can be watery, purulent and malodorous
Non specific finding for vaginitis and cervicitis
Advance disease:
Back pain radiate to posterior lower extremities
Bowel or urinary symptoms:
Pressure related complaints, hematuria, hematochezia, vaginal
passage of urine or stool (Uncommon and suggest advance)
Asymptomatic women can be discovered due to screen
Diagnosis
By biopsy, colposcopy with direct biopsy
Physical:
Pelvic exam: visualization of cervix upon speculum
examination may reveal a visible lesion, or sometimes
normal appearance
Lesion that is raised friable or has appearance of condyloma
should be biopsied.
Do not biopsy Nabothian Cyst
Thorough pelvic exam, includes rectovaginal examination
and assessment of tumour size and vaginal parametrial
involvement for staging
Cervical cytology principal of screening (conjoined
with HPV testing)
Colposcopy
Nabothian Cyst
Endophytic
tumors can
result in an
enlarged,
indurated cervix
whose surface is
smooth,
referred to as a
barrel shaped
cervix.
Staging:
Clinical preferred on surgical
Accurate pretreatment staging of cervical
cancer is critical, as it determines therapy (ie,
surgery, chemoradiation, chemotherapy
alone) and prognosis
Diagnosis (histology) the extent of disease


Two parallel clinical stages:
FIGO system:
based upon
physical examination
Endoscopic diagnostic procedures
Imaging studies
TNM system:
T" stages correspond to the FIGO stages with the
exception of carcinoma in situ
Includes a pathologic staging system (pTNM)
STAGING PROCEDURE
Physical examination
Pelvic examination
Examination for distant metastases
Cervical biopsy
Colposcopy with directed cervical biopsy
Endocervical curettage
Conization
Endoscopy
Hysteroscopy
Cystoscopy
Proctoscopy
Imaging studies
Intravenous pyelogram (IVP) (CT, or MRI)
Imaging with a plain chest radiograph and radiograph of the
skeleton


Adequacy of Colposcopy

Must evaluate the entirety of the lesion
Can you follow the entire lesion?
Does it go past the SCJ and into the endocervix?
Does it move into the vagina?

Must evaluate the entirety of the SCJ
Is it obscured by prior treatments?
Does it recede into the endocervix?
Proper evaluation of both the lesion and the SCJ is an adequate
colposcopy

Failure of either criteria is an inadequate colposcopy and
leads to changes
Colposcop
STAGING PROCEDURE
STAGING PROCEDURE
Staging For
Cervical Cancer

Stages of Cervical Cancer

Cervical Cancer
Treatment Modalities
1.Surgery , Radical Hysterectomy + PLND .

2. Chemo / Radiation Therapy , including :
A. Tele - therapy ( External Radiation) .
B. Brachy- therapy ( Intracavitary ) .
C. Neo-adjuvant Chemotherapy .

Types Of Hysterectomies
Radical Hysterectomy
Complications:

Bleeding !
Bladder !
Bowel !
General !

Type I
Type II
Type III
type IV
Radical Hysterectomy
Types Of Radical Hysterectomy

Radiation Therapy Complications

External :
Abdominal organs !
Bone Marrow !
Bowel ( Small / Large).
Skin !

Internal :
Cystitis !
Proctitis !
Vaginal tissues !

Decision depends on :

1. Patient age .
2. Stage of disease .
3. Performance status .
4. Other factors .

Cervical Cancer
Treatment Modalities
Work Up
A chest X-ray looks for spread to the lungs.
IVP can be used to look at the urinary tract.
A CT scan is necessary !!!
The bladder and urethra are evaluated by
cystoscopy.
The rectum is evaluated by a procto signoidoscopy.
Lymph nodes are evaluated by CT scans, invasion of
soft tissues is evaluated by MRI scans !
??? Distal metastases is evaluated by PET scans.