CARCINOMA CERVIX

AETIOLOGY

• Human Papilloma Virus(HPV)• High risk- types 16, 18, 31, 33• Low risk- types 6 and 11• HPV viral proteins interact with the tumour

suppressor gene p53

RISK FACTORS

• Young age at first intercourse• Multiple sexual partners• Cigarette smoking (both active and passive)• Increasing parity• Low socioeconomic status• Sexually transmitted diseases• Immunosuppression- HIV, autoimmune diseases

etc.• Oral contraceptive use

PREVENTION

• Safe sexual practices• Regular Pap smears- early detection• HPV vaccine

DOWNSTAGING

• Detection of cancer cervix at an earlier stage by nurses and other health workers using simple speculum and visual inspection of the cervix

HISTOLOGIC TYPES• Squamous cell carcinoma Large cell keratinizing tumours Large cell non- keratinizing tumours Small cell tumours• Adenocarcinoma Adenoma malignum Villoglandular papillary adenocarcinoma Clear cell carcinoma• Adenosquamous carcinoma• Neuroendocrine tumours• Sarcomas• Malignant melanoma

PATTERNS OF SPREAD

• Direct invasion- cervical stroma, parametrium, body of uterus, vagina, anteriorly to the bladder and posteriorly to the rectum and bowel

• Lymphatic spread- pelvic nodes and paraaortic nodes

• Haematogenous spread- lungs, bones and liver

SYMPTOMS

• Vaginal bleeding• Vaginal discharge• Pain• Asymptomatic• Advanced cases- weight loss, obstructive

uropathy

SIGNS

• General examination

Lymphadenopathy (supraclavicular and inguinal)

Cachexia and anaemia in advanced cases

Oedema of legs• Abdominal examination

Hepatomegaly

Ascites

• Speculum examination Cauliflower like growth Barrel- shaped cervix Ulcer Vaginal involvement• Bimanual examination Classic signs of malignancy- friability, induration,

bleeding on touch and fixity due to parametrial spread Enlarged uterus due to tumour invasion or a pyometra• Rectovaginal or rectal examination Induration laterally denoting parametrial spread Fixed mass indicates that the tumour has extended to

the pelvic side walls Thick rectovaginal septum Rectal mucosal involvement

INVESTIGATIONS• Colposcopy Abnormal blood vessels Irregular surface contour Change in colour tone• Examination under anaesthesia to assess parametrial

spread• Barium enema, proctoscopy and sigmoidoscopy if rectal

spread is suspected• Cystoscopy in locally advanced disease• Intravenous pyelogram• Chest X ray• Skeletal X rays if bone spread is suspected

MANGEMENTStage Management

1a1 Cone biopsy or Type 1 simple hysterectomy

1a2 Type 11 (modified radical) hysterectomy and pelvic lymphadenectomy

1b1 Type 111 (radical) hysterectomy and pelvic lymphadenectomy

1b2 and 11a Primary chemoradiation or type 111 (radical) hysterectomy with pelvic and para- aortic lymphadenectomy (former preferred)

11b onwards Primary chemoradiation (primary exenteration in some 1V a)

RADICAL HYSTERECTOMY

Type 3 radical hysterectomy• Pelvic lymphadenectomy (common iliac, external

iliac, internal iliac and obturator nodes)• Removal of uterosacral and cardinal ligaments and

thereby most of the parametrium• Removal of the uterus, cervix and upper one- third

of vagina

Advantages over Radiotherapy

• Ovaries can be conserved• Ovarian transposition can be done at surgery to

prevent ovarian destruction by subsequent radiation

• Vaginal shortening is less than following radiotherapy

• Avoidance of the chronic bowel and bladder problems of radiotherapy

• Surgical complications are easier to treat• Avoids the risk of radiation- induced malignancies

Complications

Immediate• Haemorrhage• Injury to ureter, blader or

bowel• Pulmonary embolism

Delayed• Bladder atony due to

denervation of bladder• Small intestinal

obstruction• Vesicovaginal fistulae

(1%)• Ureterovaginal fistulae

due to avascular necrosis or ureteral injury (1-2%)

• Lymphocyst formation

ADJUVANT THERAPY

Intermediate risk factors

• Size of lesion more than 2 cm

• Cervical stroma invasion to middle or deep third

• Lymphovascular space invasion

High risk factors• Margins positive for

tumour• Positive lymph nodes• Microscopic

parametrial involvement

PRIMARY RADIOTHERAPY

• Brachytherapy• External beam or teletherapy

Complications

Immediate• Perforation during

insertion of uterine tube

• Diarrhoea, abdominal cramps, nausea and frequent urination

• Rarely haematuria or bleeding per rectum

Delayed• Small bowel

obstruction and small bowel fistulas

• Vesicovaginal fistulas• Rectovaginal fistulas• Proctosigmoiditis and

bleeding per rectum

Results of treatment

• Stage 1- 85%• Stage 2- 60%• Stage 3- 45%• Stage 4- 18%

SURGERY RADIOTHERAPY

Survival 85% 85%

Vaginal length and coitus

Better Vaginal stenosis more

Ovarian function Can be preserved Usually destroyed

Fistulas 1-2% 1-5% and less treatable

Serious complications

Less More, especially bowel and bladder

Best candidates Young and in good health

Any patient

THANK YOU