MANAGEMENT OF

CARCINOMA CERVIX
Cervical cancer being the fourth most common

cancer
GLOBOCAN 2020 estimated that, worldwide,

there were approximately 604 000 new cases of

cervical cancer, with 342 000 deaths
third most common cancer among women
The cervix is the lowermost part of the uterus and
is a cylindrical structure composed of stroma and
epithelium.
The ectocervix, which projects into the vagina, is
lined by squamous epithelium.
 The endocervical canal, which extends from the
internal os to the external os, is lined by columnar
epithelium.
Almost all cases of cervical carcinoma originate
from the ecto- or endocervical mucosa in the
transformation zone, the area of the cervix
between the old and new squamocolumnar
junction.
TYPES OF CARCINOMA CERVIX
Squamous epithelial tumors
• Squamous cell carcinoma, HPV-associated
• Squamous cell carcinoma, HPV-independent
• Squamous cell carcinoma NOS 5.2 |
Glandular tumors
•Adenocarcinoma NOS
• Adenocarcinoma, HPV-associated
• Adenocarcinoma, HPV-independent, gastric type
• Adenocarcinoma, HPV-independent, clear cell type
• Adenocarcinoma, HPV-independent, mesonephric type
• Adenocarcinoma, HPV-independent, NOS
• Endometrioid adenocarcinoma NOS
• Carcinosarcoma NOS
• Adenosquamous carcinoma
• Mucoepidermoid carcinoma
• Adenoid basal carcinoma
• Carcinoma, undifferentiated, NOS
Mixed epithelial and mesenchymal tumors
• Adenosarcoma |
Germ cell tumors
• Endodermal sinus tumor
• Yolk sac tumor NOS
• Choriocarcinoma NOS
STAGING OF CARCINOMA
CERVIX
  Staging Procedure
Examination Findings

Physical examination i) Palpable lymph

nodesExamine
ii) vagina
iii) Bimanual rectovaginal examination (Under
anaesthesia recommended)

Radiological i) Intravenous pyelogram

ii) Barium enema
iii) Chest X-ray
iv) Skeletal X-ray

Procedure i) Biopsy
( Allowed by FIGO) ii) Conisation
iii) Hysteroscopy
iv) Colposcopy
v) Endocervical curettage
vi) Cystoscopy
vii) Proctoscopy

Optional studies i) CT (axial)-97%% specific

ii) Lymphangiography
iii) USG-99% specific
iv) MRI- more sensitive
v) PET scan
vi) Radionucleotide scanning
STAGE 1A
I The carcinoma is strictly confined to the cervix
(extension to the uterine corpus should be disregarded)

 IA Invasive carcinoma that can be diagnosed only by

microscopy, with maximum depth of invasion ≤5 mm
a IA1 Measured stromal invasion ≤3 mm in depth
 IA2 Measured stromal invasion >3 and ≤5 mm in
depth
TREATMENT 1A1
Cervical conization unless lymphovascular spread
present
If completed childbearing age then extrafascial
hysterctomy
LVSI present then pelvic lymphadenectomy done
with extrafascial hysterectomy
If fertility desired then cervical conization
TREATMENT 1A2
Small risk of lymph node metastases in these cases,
pelvic lymphadenectomy is performed in addition to
type B radical hysterectomy.( modified radical
hysterectomy)

 When the patient desires fertility,

(1) cervical conization with pelvic lymphadenectomy
(open or minimally invasive surgery )
 (2) radical trachelectomy with pelvic
lymphadenectomy by abdominal, vaginal, or MIS
route
STAGE 1B
Invasive carcinoma with measured deepest invasion
>5mm; lesion limited to the cervix uteri with size
measured by maximum tumor diameter

 IB1 Invasive carcinoma >5 mm depth of stromal

invasion and ≤2 cm in greatest dimension
IB2 Invasive carcinoma >2 and ≤4 cm in greatest
dimension
 IB3 Invasive carcinoma >4 cm in greatest dimension
TREATMENT FOR STAGE 1B1
 Type c radical hysterectomy with pelvic lymphadenectomy.
 A pelvic nerve-sparing surgical procedure is recommended in
patients undergoing radical hysterectomy.
 as intrapelvic injuries to the autonomic nerves (i.e.
hypogastric nerve, splanchnic nerve, and pelvic plexus) often
lead to impairment of urination, defecation, and sexual
function, and consequent deterioration of the postoperative
quality of life.
 Fertility sparing, a radical trachelectomy is performed, for
Stage IA2–IB1 tumors and pelvic lymph node sampling.
 The cervix along with the parametrium is removed followed
by anastomosis of the uterus with the vaginal end.
TRACHELECTOMY
Also known as
cervicectomy
Surgical removal of the
uterine cervix.
Uterine body is preserved.
 Fertility preserving
surgical alternative to a
radical hysterectomy and
applicable in selected
younger women with
early cervical cancer.
STAGE 2
IIA The carcinoma invades beyond the uterus, limited
to the upper two-thirds of the vagina without
parametrial involvement
 IIA1 Invasive carcinoma ≤4 cm in greatest dimension
 IIA2 Invasive carcinoma >4 cm in greatest dimension

 IIB With parametrial involvement but not up to the

pelvic wall
TREATMENT FOR STAGE 1B2 AND
2A1
Surgery or radiotherapy can be chosen as the primary
treatment depending on other patient factors.
 The advantages of surgical treatment are:
(1) Feasible to determine the postoperative stage
precisely on the basis of histopathologic findings.
 (2) Treat cancers that are resistant to radiotherapy
 (3) Possible to conserve ovarian function.
Intraoperative transpositioning of the ovaries high in
the paracolic gutters away from the radiation
field.Preferred mode in younger women
Type C radical hysterectomy is the standard procedure
for the treatment of cervical cancer, consisting of
removal of the
uterus,
 parametrium,
 upper vagina,
 and a part of the paracolpium,
 along with pelvic lymphadenectomy
The regional lymph node excision includes the
parametrial nodes, obturator nodes, external, internal,
and common iliac nodes.
SENTINAL LYMPHNODE
MAPPING
 SLN mapping in cervical
cancer
 FIGO Stages IA, IB1, and
IB2.
 Dual labeling using blue dye
and radiocolloid increases
the accuracy of SLN
detection.
 indocyanine green dye with
near infrared technique has
been used in both the open
and minimally invasive
approache.s
TREATMENT FOR STAGE 1B3 AND
2A2
 Stages IB3 and IIA2, largest tumor diameter >4 cm
there can be LVSI, and invasion of the outer one-third
of the cervical stroma.
Concurrent platinum-based chemoradiation (CCRT) is
the preferred treatment option for Stages IB3 to IIA2
lesions.
Neoadjuvant chemotherapy (NACT) has been used
(1) downstaging of the tumor
(2) inhibition of micrometastasis and distant metastasis.
Followed by type c radical hysterectomy.
STAGE 3
The carcinoma involves the lower third of the vagina and/or
extends to the pelvic wall and/or causes hydronephrosis or
nonfunctioning kidney and/or involves pelvic and/or para-aortic
lymph nodes.
 IIIA The carcinoma involves the lower third of the vagina, with
no extension to the pelvic wall
 IIIB Extension to the pelvic wall and/or hydronephrosis or
nonfunctioning kidney
 IIIC Involvement of pelvic and/or para-aortic lymph nodes
(including micrometastases) , irrespective of tumor size and
extent (with r and p notations)
o IIIC1 Pelvic lymph node metastasis only
o IIIC2 Para-aortic lymph node metastasis
STAGE 4
The carcinoma has extended beyond the true pelvis or has
involved (biopsy proven) the mucosa of the bladder or
rectum.
 A bullous edema, as such, does not permit a case to be
allotted to Stage IV
 IVA Spread of the growth to adjacent pelvic organs
IVB Spread to distant organs

TREATMENT:
Have poor prognosis
Pelvic exenteration is done
CLASSIFICATION OF
HYSTERECTOMY

32
COMPLICATIONS

33
  Radiotherapy Procedures
 External Irradiation: External Beam Radiotherapy (EBRT)
using cobalt 60 is given in short daily treatment over a period
of 3-6 weeks.It covers the area extends from just above the
urethral orifice to the lower border of the fourth lumber
vertebra and laterally to cover the whole pelvis with the
femoral heads protected.
  Radiotherapy Procedures
Cont.
 Intracavitary Radiotherapy (ICRT):
A.Stockholm Technique: The process involves
placing radium in applicators in the uterus and vaginal
fornices for 27-30 hours & then remove it. After that give
a similar course of treatment either on 3 occasion at
interval of 3 weeks.
B.Manchester Technique: Placing radium in
intrauterine tube therapy given for 72 hours on 2
occasion repeating the first course after an interval of 1
week.
C.Low dose Rate (LDR) Therapy: Selectron was
used.
D.High Dose Rate (HDR) Therapy: Cathetron is
the oldest Cobalt 60 based HDR but recently Californium-
252 is used. A.outpatient basis
B. short course duration
C.less morbidity and more cost effective
Procedure Amount & Type No. of Duration

of Radiation Application

Intrauterine Tube 48 hours each

50mg one vaginal with gap of one
Stockholm 3
ovoid 50-60mg week between 1st
& 2nd and gap of
two weeks
between 2nd & 3rd

Intrauterine Tube 72 fours at

50mg vaginal 2 interval of 1 week
Manchester
colpostat 30-
50mg

Intrauterine Tube 5 days (each day

33.3mg and two 1 radium
Paris
vaginal ovoids removed,
13.3mg cleaned &
replaced)
 Radiotherapy Procedures
Cont.
 Interstitial Brachytherapy: In patient with advanced
parametrial disease, distorted anatomy or post operative
recurrences.
 Parametrial implants using Radium needles were used
earlier.
 Currently afterloading transperineal perforated
templates with Iridium 192 and Iodine 125 are used.
In classical 2D cervix brachytherapy
7000-8000 cGy to point A ( 2cm superior to external
cervical os ans 2cm lateral to internal uterine canal)
6000 cGY to point B ( 3 cm lateral to point A)
limiting blader and rectal dose to 6000
 Complication of Radiotherapy
1. During Treatment:
 Diarrhoea
 Abdominal Cramps
 Nausea
 Bleeding from Bowel
 Haematuria in case of urinary infection.

2. Early Complications:
 Uterine Perforation: Occurs at the time of insertion of
the uterine tandem specially in pt. with previous
conisation or advanced disease.
 Pelvic Inflammatory Disease (PID)
 Diverticulitis
3. Late Complications:
 Continuous formation of Arteritis & Fibrosis
 Blood loss from Pelvic Colon & Rectum
 Subacute or Acute Obstruction of Bowel
 Vesicovaginal Fistula (VVF)
 Rectovaginal Fistula (RVF)
 Narrowing & Shortening of Vagina
 Loss of Ovarian Function
 Chemotherapy
 Single agents used are:
Cisplatinum (Best Response)
carboplatin
Paclitaxel
Bleomycin
Ifosfamide
Methotrixate
5 flurouracil

 Neoadjuvant Chemotherapy: Used in cases

with bulky tumors preoperatively & in combination
with radiotherapy.
 Ultraredical Surgery &
Palliation
 General Treatment:
1) General Care
2) Relief of Pain:
» NSAIDs
» Cordoromy (Division of spinothalamic tract)
» Colostomy for rectal pain
» Drainage for pyometra
» Presacral or lumber sympathectomy
 Haemorrhage:
1) Hot vaginal douches
2) Diathermy in the bleeding site
3)Packing with application of the cytotoxic drugs
 Swelling of the leg: Controlled by elastic bandage or posture.
 Incontinence of the urine: Urinary diversion.
 Incontinence of faeces: Colostomy
 3 months interval for 1 year.
 6 months interval for next 1 year.
 Then yearly afterwards.
CERVICAL CANCER IN
PREGNANCY
Before 16– 20 weeks of gestation, patients are treated
without delay.
MODE -surgery or chemoradiation depending on the
stage of the disease.
Radiation results in spontaneous abortion of the
conceptus.
After 20 weeks, delaying definitive for Stages IA2 and
IB1 and 1B2.
tertiary center delivery by classical cesarean section
and radical hysterectomy at the same time no later
than 34 weeks of gestation.