1. Cervical Cancer By Salah Taha Fayed Prof. Gynecologic Oncology
Ain-shams Univ. Cairo-Egypt

2. Cervical Cancer: Outline
It is malignant tumor of the cervix uteri
With ovarian and endometrial cancer they comprise the major gynecological cancers
Commonly it is carcinoma (epithelial) but rarely sarcoma and lymphoma arise in the cervix.

3. Epidemiology
In USA it is the third genital cancer after endometrial and ovarian cancer
The incidence is about 10/100000/year
In Latin America it is the first genital cancer
It is more prevalent among black race
It is more common in low social class
Its peak incidence is between years

4. Epidemiology cont. The following Increase the risk of cervical cancer:
Smoking
Early sexual activity
Multiple sexual partners
Exposure to a male with multiple partners
Sexually transmitted diseases namely HPV and HIV infection

5. Epidemiology cont.
Almost all cases of invasive cervical cancer are positive for Human papilloma virus
Concomitant HIV infection increases the aggressiveness and worsen the prognosis
No evidence that HSV type II infection increases the risk of cervical cancer

6. Pathological Types
85-90 % are squamous cell carcinoma SCC arising from the transformation zone
10-15 % are adenocarcinoma arising from the endocervical columnar epithelium or glands
The formerly mentioned risk factors and epidemiological criteria apply only to the SCC type

7. Pathogenesis and Natural History
The exact cause is not yet identified
As in most other cancers, the genetically predisposed patient when exposed to risk factors as HPV infection this starts the malignant transformation
Over-expression of Oncogenes or suppression of Tumor Suppressor Gene could be the mechanism of malignant transformation

8. Pathogenesis cont.
Invasive SCC is a disease that have pre-malignant lesions (CIN)
CIN with its 3 grades is amenable to conservative, relatively simple and curative treatment
Early detection in the pre-malignant stage is the corner stone of decreasing the incidence of invasive SCC in developed countries

9. Cervical Cancer: Stages
Generally speaking 4 stages as other cancers
Stage I Cervix Only
Stage II A Vagina short of lower third
II B Parametrium NOT pelvic wall
Stage III A Vagina lower third
III B Parametrium to pelvic wall
Stage IV A Bladder or Rectal Mucosa
IV B Distant metastases

10. Stage I

11. Stage II

12. Stage I and II

13. Stage III

14. Stage IV

15. Stage III and IV

16. Spread of Cervical Cancer
Local to the vagina, parametrium, uterine body(uncommon), bladder and rectum
Lymphatic to:
(A) parametrial lymphatics,
(B) pelvic LN (externa, internal ileac and obturator)
(C) Common iliac LN and Periaortic LN
Blood: Distant metastases are rare and late

17. Gross Appearance
Exophytic friable polypoid mass arising from the ectocervix that bleeds easily
Endophytic infiltrating appearing as a stony hard cervix with little ulceration
Ulcerative type An ulcer that erodes the cervix and adjacent vagina
Barrel shaped lesion is a variety of exophytic lesions arising within the endocervical canal

18. Clinical Presentation
I. Early: Serosanguinous vaginal discharge
Contact bleeding
II. Late: Offensive vaginal discharge
Irregular spontaneous bleeding
III. Very late: Persistent severe back pain radiating to the lower limb, lower limb edema, Uraemic syndrome, Urine and or stool incontinence

19. Investigations To prove diagnosis: Biopsy & Histopathology
Staging: Examination under anesthesia, Cystoscopy, IVU, and Abdomenopelvic CT with contrast
To prepare for surgery: CBC, blood sugar, Liver functions, kidney functions, Urine analysis, ECG and Chest X-Ray

20. Rectovaginal Examination

21. Treatment Modalities Two main modalities are used:
Surgery: Radical hysterectomy
Radiotherapy: with or without chemotherapy
Surgery may be followed by Radiotherapy

22. Cervical Cancer: Treatment
Early stages: IB and IIA could be managed by either Wertheim’s Radical hysterectomy or Radiotherapy with equal results
Late stages: IIB, III, and IV are treated by radiotherapy with or without chemotherapy
Rarely pelvic exentration is suitable for central disease extending to bladder or rectum without parametrial infiltration or for central recurrence after Radiotherapy

23. Wertheim’s Radical Hysterectomy
Indicated in surgically fit relatively young patients with stage IB or IIA disease
Uterus, parametrium, upper third of the vagina and pelvic lymph nodes are removed in this operation
A major surgery that requires good experience in oncological surgery
Bladder dysfunction, ureteric injury, and vascular injury are its main complications

24. Radiotherapy An alternative to surgery for stages IB and IIA
Is the primary treatment of choice for all higher stages
Can be adjuvant to surgery if positive nodes were found or infiltrated resection margins

25. Radiotherapy cont.
Brachytherapy: Intracavitary applicator that deliver cytotoxic dose to the cervical tumor, parametrium and to the lateral pelvic wall where the pelvic lymph nodes are situated
Teletherapy: External beam of megavoltage X-Ray delivered to the pelvis and sometimes to the para-aortic LN

26. Brachytherapy & Teletherapy

27. Radiotherapy cont.
It can not preserve the ovaries in contrast to the surgery
Radiation cystitis and proctitis, rectal fibrosis, flare up of infections and urinary fistula are among its complications
Intestinal fistulas are serious complications of extended field irradiation

28. Role of Chemotherapy To shrink the tumor size in bulky stage IB2
To enhance the cytotoxic effect of radiotherapy as radiosensitizer
Cis-platinum alone or in combination with 5-fluorouracil (5-fu) are the most commonly used cytotoxic drugs

29. Cervical Cancer prognosis
Prognostic factors include:
Stage (most important)
Tumor size
Lymph node status
Lymph-vascular space invasion
Grade of differentiation
Concomitant HIV infection

30. Prognosis cont. Five year survival for different stages are:
Stage I ………….. 90%
Stage II …………. 75%
Stage III ………… 40%
Stage IV ………… 15%
NB: the above are approximated round figures agreeing with most of the studies using different treatment modalities

31. Less Important Issues
The following are less important issues to know for the under-graduate student

32. Microinvasive Cancer Stage IA
Microscopically diagnosed not clinically apparent disease
Width of the lesion <7mm
Depth of invasion < 5mm
Stage IA1 depth of invasion <3mm
Stage IA2 depth of invasion 3-5 mm

33. Stage IA microinvasive cont.
LN metastases occur in 1% stage IA1
Treatment is extrafascial hysterectomy without resection of LN, vaginal cuff or parametrium
LN metastases occur in 6% stage IA2
Treatment is the same like truly invasive disease

34. Microinvasive Stage IA

35. Cervical Cancer During Pregnancy
The most common genital tract cancer during pregnancy
Usually present by vaginal bleeding which is misdiagnosed early as threatened abortion and later as antepartum hemorrhage

36. Cervical Cancer during pregnancy cont.
Treatment depends on:
stage, gestational age, desire for the baby, religious background of the patient
Modality of treatment dictated by the stage

37. Cervical Cancer during pregnancy cont.
Before 24 weeks pregnancy is usually sacrificed and surgical or radiation treatment start immediately
After 24 weeks viability may be waited

38. Conclusion
The best treatment results can be achieved in the pre-invasive stages
Earlier stages carry better prognosis
Modalities of treatment are surgery, Radiotherapy with or without chemotherapy
Sound sexual behavior is crucial to minimize the risk of STDs and cervical Cancer
Cervical Cancer could be potentially preventable disease through early detection programmes

39. Thank You
Dr. Salah Fayed