Pre malignant and

malignant lesions of
cervix
GYNAEC UNIT 5
Dr Tushar Shah(HOU)
Dr Hafsa Vohra(AP)
Dr Geeta (SR)
• 3rd most common cancer among
women worldwide, with an estimated
569,847 new cases and 311,365 deaths
in 2018 (GLOBOCAN). The majority
of cases are squamous cell carcinoma
followed by adenocarcinomas. (Vaccine
2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl
10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs
2007, Vol. 90)
Cervical anatomy
Squamocolumnar junction

Metaplasia

Ectropion

Tansformation zone
Active metaplasia in transformation zone
Important points:
Squamocolumnar junction
Metaplasia
Ectropion
Tansformation zone
Dysplasia – abnormal maturation
Proliferating
metaplasia without
mitotic activity
should not be called
dysplasia or CIN
because it does not
progress to invasive
cancer
 Terminology
• Cytologically normal women
No abnormal cells are observed on the surface of their cervix upon
cytology.
• Cervical Intraepithelial Neoplasia (CIN) / Squamous
Intraepithelial Lesions (SIL)
to describe precancerous lesions or the abnormal growth of
squamous cells observed in the cervix.
 SIL is an abnormal result derived from cervical cytological screening or
Pap smear testing
 CIN is a histological diagnosis made upon analysis of cervical tissue
obtained by biopsy or surgical excision.
 Terminology
 Low-grade cervical lesions (LSIL/CIN-1)
early changes in size, shape, and number of abnormal cells formed
on the surface of the cervix and may be referred to as mild dysplasia,
LSIL, or CIN-1

 High-grade cervical lesions (HSIL/ CIN-2 / CIN-3 / CIS)

High-grade cervical lesions are defined by a large number of
precancerous cells on the surface of the cervix that are distinctly
different from normal cells. They have the potential to become
cancerous cells and invade deeper tissues of the cervix. These
lesions may be referred to as moderate or severe dysplasia, HSIL,
CIN-2, CIN-3 or cervical carcinoma in situ (CIS).
 Terminology
• Carcinoma in situ (CIS)
Preinvasive malignancy limited to the epithelium without invasion
of the basement membrane.
CIN 3 encompasses the squamous carcinoma in situ.
• Invasive cervical cancer (ICC) / Cervical cancer
If the high-grade precancerous cells invade the basement
membrane is called ICC.
 Invasive squamous cell carcinoma
Invasive carcinoma composed of cells resembling those of squamous epithelium.
 Adenocarcinoma
Invasive tumour with glandular and squamous elements intermingled .
 Cervical Intraepithelial Neoplasia
Spectrum of potentially premalignant lesions of cervix, characterized
histologically by failure of normal process of maturation in squamous
epithelium of transformation zone together with variable degree of nuclear
enlargement and pleomorphism

The criteria for the diagnosis of intraepithelial neoplasia may vary according to the
pathologist
Significant features are-
• cellular immaturity
• cellular disorganization
• nuclear abnormality
• increased mitotic activity
• The extent of the mitotic activity, immature cellular proliferation, and nuclear atypia
identifies the degree of neoplasia.
• If the presence of mitoses and immature cells is limited to the lower third of the
epithelium, the lesion usually is designated as CIN 1. Involvement of the middle and
upper thirds is diagnosed as CIN 2 and CIN 3, respectively
• CIN is believed to originate as a single focus in the
transformation zone at the advancing SCJ
• The anterior lip of the cervix is twice as likely to develop CIN as the
posterior lip, and CIN rarely originates in the lateral angles
• CIN is most likely to begin either during menarche or after
pregnancy, when metaplasia is most active. Conversely, after
menopause a woman undergoes little metaplasia and is at a lower
risk of developing CIN from de novo human papillomavirus
(HPV) infection
 Human Papilloma Virus
• About 5.0% of women in the general population are estimated to
harbour cervical HPV-16/18 infection at a given time
• Small, non-enveloped DNA virus
 
• Essentially all cervical cancers arise from persistent genital
HPV infections

• KOILOCYTOSIS- Koss and Durfee

• Koilocytes are characterized by perinuclear halos, well-defined
cell borders, and nuclear hyperchromasia, irregularity, and
enlargement
Persistence of HPV infection
•Usually, HPV infections do not persist
•May remain latent for many years
•Most women who are exposed have no clinical evidence of disease, and the
infection is eventually suppressed or eliminated. Other women exhibit low-
grade cervical lesions that mostly regress spontaneously.
•In the vast majority of cases, the infection will clear in 9 to 15 months
•A small minority of women exposed to HPV develops persistent infection
that may progress to CIN
•Factors that may have a role in persistence and progression include
smoking, contraceptive use, infection with other sexually transmitted
diseases, or nutrition
Persistence of HPV infection for 2years
• Portions of the HPV DNA become integrated
into the host cell
• Integration of the transcriptionally active
DNA into the host cell appears to be essential
for malignant transformation
• Malignant transformation requires the
expression of E6 and E7 HPV oncoproteins
• Almost 200 HPV types

• Carcinogenic 12 HPV types: HPV-16, -18, -31, -33, -

35, -39, -45, -51, -52, -56, -58, and -59. 

HPV-16 HPV-18
• Most oncogenic • 10% of cervical cancer
• Most common • Adenocarcinogenesis
• More than 50% of • More specific for
cervical cancer invasive cancer
Prevention
Primary Secondary

Barrier
Pap smear
contraception

HPV vaccine VIA

Health
VILI
education

VIAM
 Screening
• Cervical cancer incidence and mortality rates have declined since the
introduction of the Papanicolaou (Pap) test in the mid ‐20th century,
and rates continue to decline
• Goal is the identification and destruction of high-grade CIN lesions
that are presumed pre-cancers
• Methods:
 Cytology- Papanicolaou test
 Conventional
 Liquid based cytology
 Automated image-guided slide screening system
 HPV testing
 Visual detection-
 VIA
 VILI
 VIAM
 Pap test (cytology)
• Cytology is interpretation of all the mutations, methylations and  other
genetic modifcations that alter the nuclear and cytoplasmic  appearance
of cells
• Papanicolaou developed a five-class grading system, from 
normal to invasive  cancer,  with  atypia,  dysplasia,  and 
carcinoma  in  situ between
• reducing the incidence of cervical cancer by 79% and the mortality by
70% since 1950
• Cytology-based  screening  performs  poorly  in younger  women
• Cytology preferentially detects squamous cell carcinomas
•  
• sensitivity of conventional cytologic testing in detecting cervical cancer
precursor lesions was 51%

• the sensitivity of the Pap test in detecting CIN 2 or 3 ranged from 47%
to 62% and the specificity ranged from 60% to 95%

• False negative rate is 49%

Pap

LBC Automated image-

Conventional guided slide
Sn 80% screening system
Pap test
 HPV DNA test
• Hybrid capture 2 test

• Co-testing
When to stop
Women who reach 65 years of
age after multiple negative
cytology results, including three
in the previous decade and two
in the previous 5 years, are at
low risk for cervical cancer, as
are women with two negative
HPV–cytology co-test results,
including one in the previous 5
years
• Women should be screened with cytology alone twice 
within a year of sexual activity, if previously HIV 
infected, or within 1 year of 
HIV diagnosis, regardless of age, followed by lifetime 
annual 
cytology
• Diethylstilbestrol-  (DES-)  exposed  women  continue  Pap 
testing annually for life

• Stop screeningafter total hysterectomy done for indications other 

than high-grade CIN or cervical cancer
In 2014, the Food and Drug Administration approved
HPV testing as a primary screening test for cervical cancer
• Visual inspection of cervix with acetic acid (VIA)
 Naked eye
 3 – 5 % freshly prepared acetic acid
 Within 30 to 90 sec
 Paramedic staff

• Visual inspection with Lugol’s Iodine (VILI)- Schiller’s Iodine

test
 Normal is stained mahogany brown (glycogen)
 Abnormal is unstained ( schiller’s positive)
• VIAM (Visual Inspection with acetic acid under magnification
• Cervicography
 Cervix is visualized 1 minute after application of 5% acetic acid and 2 photographs
are taken and sent for reporting

• Downstaging
 To recognize disease before symptoms develop
 Not screening method
 For paramedics and nursing staff at PHC
 Pick up cases of invasive cancer at early stage

India- VIA is done at PHC level and then further referral to District hospital
Colposcopy
• Colposcope is low power, stereoscopic, binocular field
microscope with powerful variable intensity light source

• Findings:
 Acetowhite areas
 Leukoplakia
 Punctation
 Mosaic
 Atypical vascular pattern
Instruments
• Clinicians should keep in mind that guidelines are for
women with abnormal screening tests; for women with symptoms
such as abnormal bleeding or pain or abnormal examination
findings such as contact bleeding, cervical friability, or cervical
enlargement, biopsy may be indicated regardless of cytology or
HPV results
 Treatment modalities
• Cryotherapy
• Laser ablation
• Conization
• LEEP and LLETZ
• Hysterectomy
 Cryotherapy
• Principle: destroys the surface epithelium of the
cervix by crystallizing the intracellular water

• Technique: “freeze-thaw-freeze” method in which an ice ball is

achieved 5 mm beyond the edge of the probe

• Side effects: white discharge, Cervical stenosis , bleeding

• Following criteria are met:
CIN 1 that has persisted for 24 months, or CIN 2
Small lesion
Ectocervical location only
Negative endocervical sample
No endocervical gland involvement on biopsy
Laser ablation
• CO2 laser is used
Cold knife conisation
• Conization is both a diagnostic and therapeutic procedure

• Indications:
• Limits of the lesion cannot be visualized with colposcopy.
• The SCJ is not seen at colposcopy.
• Endocervical curettage (ECC) histologic findings are positive for CIN 2 or CIN3.
• Substantial lack of correlation between cytology, biopsy, and colposcopy results.
• Microinvasion is suspected based on biopsy, colposcopy, or cytology results.
• The colposcopist is unable to rule out invasive cancer.
Loop Electrosurgical Excision Procedure
• Principle: high voltage electric current and small wire loop

• Side effects:
 preterm delivery
 premature rupture of membranes
 low-birth-weight infants
 Intraoperative and postoperative hemorrhage
 cervical stenosis
Large Loop Excision of Transformation
Zone
Hysterectomy
• Hysterectomy is considered a treatment of last resort for recurrent
high-grade CIN

Indications:
• Microinvasion
• CIN 3 at the endocervical limits of conization specimen in selected
patients
• Poor compliance with follow-up
• Other gynecologic problems requiring hysterectomy, such as fibroids,
prolapse,endometriosis, and pelvic inflammatory disease
• Histologically confirmed recurrent high-grade CIN
 Vaccination
•Primary prevention was the development of a prophylactic vaccine
to protect against HPV infection
•Synthetic HPV L1 capsid antigens results in humor immunity;
current vaccines are created by protein synthesis using cell culture
systems
•Not live vaccine
•Efficacy 100%
•Intramuscular
 Routine HPV vaccination should be initiated at
Vaccination schedules and age group age 11 or 12 y. The vaccination series can be
started beginning at age 9 y (ACS guideline)

0, 1, 6 months 9 to 26 years

0, 2, 6 months 9 to 26 years
V Seropositive for HPV-16 or -18, but DNA negative, the
vaccine efficacy remained at 100%
a
c Do not show efficacy in women who are HPV-16 and -18
c DNA positive at the time of entry onto the study

i
n Cannot be used to treat CIN
a
t
i Not able to clear active infection

o
n
• Common side effects: 
fever, rash, injection site pain, nausea, headache, and dizziness. Anaphylactic
and vagal reactions
• Vaccination is contraindicated for pregnant women
• Interruptionof vaccination does not appear to require reinitiation of the
three-shot series
• Theduration of vaccine effectiveness is unclear, but antibody levels remain
elevated for several years after vaccination
• Booster doses are not recommended at this time
• Screeningpractices for cervical intraepithelial neoplasia and cancer should
remain unchanged in both vaccinated and unvaccinated women
Evaluation of Ca cervix
Epidemiology and risk factors for
Carcinoma cervix

• Invasive cancer of the cervix has been considered a preventable

cancer as it has a
• long preinvasive state,
• availability of cervical cytology screening program
• effective treatment of preinvasive lesions.
The mean age for cervical cancer is 52.2 years, and the
distribution of cases is bimodal, with peaks at 35 to 39 years and
60 to 64 years of age .
Risk factors
• 1. HPV
• 2. Cigarette smoking
• 3. OCP
• 4. Immunosuppression
• 5. Dietary factors:Deficiency of folic acid, vit. A
• 6. Sexual factors:Multiple sexual partners, Early age of first Sexual
Intercourse
• 7. Reproductive factors: Multparity, >4 live births, early age of first birth,
No of vaginal Deliveries
• 8. Low socioeconomic status:
Signs and symptoms
• Vaginal bleeding( most common )
• Malodorous vaginal discharge, weight loss, or obstructive
uropathy.
• Pelvic pain, leg edema may be evident.
• Bladder symptoms, Diarrhoea , Rectal pain, bleeding per rectum.
• Pyelonephritis and uremia may develop.
ON EXAMINATION
• On general physical examination, the supraclavicular and groin lymph
nodes should be palpated to exclude the presence of metastatic disease.
• On pelvic examination, a speculum is inserted into the vagina, and the
cervix is inspected for suspicious areas. The vagina is inspected for
extension of disease.
• The cervix is usually firm and expanded which bleeds on touch and is
friable. It may be of 3 types
• Exophytic – cauliflower like
• Endophytic or Ulcerative
• Infiltrative –found in endocervical lesions
• Rectal examination –
 To asses cervical size and consistency
 to detect the involvement of parametrium and its extent in relation to
lateral pelvic wall by feeling nodularity
Obvious tumor growth is present
Gross disease is not present
diagnosis cannot be established
conclusively with colposcopy and
directed biopsies-
cervical biopsy
colposcopic examination with
cervical biopsies and endocervical
curettage
cervical conization
• Colposcopy findings:
• Acetowhite epithelium
• Fine punctations
• Atypical vessels
• Iodine negativity
• Cervical conization
• Ultra sonography ,lymphangiography
• CT –to detect nodal involvement
• MRI –useful to measure the size extent of tumor,bladder rectum,parametrium involvement
• PET –is superior to CT and MRI to detect nodal metastasis(size >5mm)
• LAPROSCOPY and LAPROTOMY are optional and not used for FIGO staging.
Investigations
Colposcopy:
Done with suspected early invasive cancer based on cervical cytology and
a grossly normal-appearing
cervix.
Colposcopic findings that suggest invasion are
(i) abnormal blood vessels - looped, branched, or reticular
(ii) irregular surface contour with loss of surface epithelium
(iii) color tone change – yellow orange
• Normal vascular patterns • Atypical vascular patterns
Staging of Ca cervix
It is a clinical staging
Stage I
• The carcinoma is strictly confined to the cervix uteri (extension to
the corpus should be disregarded)
• IA Invasive carcinoma that can be diagnosed only by microscopy,
with maximum depth of invasion <5 mma
 ○IA1 Measured stromal invasion <3 mm in depth
 ○IA2 Measured stromal invasion ≥3 mm and <5 mm in depth
IB Invasive carcinoma with measured deepest invasion ≥5 mm (greater than
stage IA), lesion limited to the cervix uterib
○IB1 Invasive carcinoma ≥5 mm depth of stromal invasion and <2 cm in
greatest dimension

○IB2 Invasive carcinoma ≥2 cm and <4 cm in greatest dimension

○IB3 Invasive carcinoma ≥4 cm in greatest dimension

 Stage II:
• The carcinoma invades beyond the uterus, but has not extended onto the
lower third of the vagina or to the pelvic wall
• IIA Involvement 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

Stage III
• The carcinoma involves the lower third of the vagina and/or extends to the
pelvic wall and/or causes hydronephrosis or non ‐functioning kidney and/or
involves pelvic and/or paraaortic lymph nodesc
• IIIA 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 non ‐functioning
kidney (unless known to be due to another cause)
• IIIC Involvement of pelvic and/or paraaortic lymph nodes, irrespective of
tumor size and extent (with r and p notations)c
 ○IIIC1 Pelvic lymph node metastasis only
 ○IIIC2 Paraaortic lymph node metastasis
Stage IV
• 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 organs
• IVB Spread to distant organs
Staging Procedures
Palpate lymph nodes
Examine vagina
Physical examinationation
Bimanual rectovaginal examination (under anesthesia
recommended)

Intravenous pyelogram
Barium enema
Radiologic studies
Chest x-ray
Skeletal x-ray
Biopsy
Conization
Hysteroscopy
Procedures Colposcopy
Endocervical curettage
Cystoscopy
Proctoscopy
Optional studies (do not change stage)
Computerized axial tomography
Lymphangiography
Ultrasonography
Magnetic resonance imaging
Positron emission tomography
Radionucleotide scanning
Laparoscopy
Hitological classification of cervical cancer
Spread of ca cervix
Cancer of the cervix spreads by
(a) direct invasion into the cervical stroma, corpus, vagina, and
parametrium;
(b) lymphatic metastasis;
(c) blood-borne metastasis(usually by veins rather than arteries)
• Commonly involved organs are Lungs,Liver and Bones and
(d) intraperitoneal implantation: on vault of vagina or Abdominal and
perineal wound is very rare
Management of Cervical Cancer
Surgery
Radio Therapy
Chemo Radiation
Advantages of Surgery over Radiation Therapy
Advantage to younger women for whom conservation of ovaries is important.

Chronic bladder and bowel problems occur in up to 8% of patients undergoing

radiation therapy.

These problems are difficult to treat as they result from fibrosis and decreased
vascularity, while surgical injuries can be repaired without long-term complications.

Sexual dysfunction is less likely to occur because of vaginal shortening, fibrosis and
atrophy of the epithelium associated with radiation .
Advantages of Surgery over Radiation Therapy

Radical hysterectomy is reserved for women who are in good physical condition.

Not prudent to operate on lesions >= 4 cm in diameter, as patients will require

postoperative radiation therapy.

If radiation therapy is needed, transposing the ovaries out of the planned radiation field
may preserve ovarian function.

Transposition provide some protection, studies suggest normal ovarian function is

preserved in fewer than 50% patients.
 Management of Invasive Cancer of the Cervix
Stage IA1 <= 3 mm invasion, no LVSI Conization or type I hysterectomy

<= 3 mm invasion, w/ LVSI Radical trachelectomy or type II radical hysterectomy with pelvic lymphadenectomy

IA2 > 3-5 mm invasion Radical trachelectomy or type II radical hysterectomy with pelvic lymphadenectomy

IB1 > 5 mm invasion, < 2 cm Radical trachelectomy or type III radical hysterectomy with pelvic lymphadenectomy

> 5 mm invasion, > 2 cm Type III radical hysterectomy with pelvic lymphadenectomy

Type III radical hysterectomy with pelvic and para-aortic lymphadenectomy or primary
IB2
chemoradiation

Type III radical hysterectomy with pelvic and para-aortic lymphadenectomy or primary
Stage IIA1, IIA2
chemoradiation
IIB, IIIA,
Primary chemoradiation
IIIB

Stage IVA Primary chemoradiation or primary exenteration

IVB Primary chemotherapy ±6 radiation

Cone Biopsy of the Cervix
To definitively treat stage IA1 disease when preservation of fertility is desired.
For efficient treatment, no evidence of lymph-vascular space invasion and curettage
findings must be -ve for cancer or dysplasia.
Lymphadenectomy is not necessary as stage IA1 cancers have < 1% of risk of
lymph node metastasis.
Further treatment is necessary if the endocervical margin or curettage is +ve for
dysplasia or malignancy, as these are strong predictors of residual disease .
Cone Biopsy of the Cervix
For squamous cell carcinoma, the risk of residual disease is
4% if both the endocervical margin or curettage are -ve for dysplasia or
malignancy
22% if the endocervical margin alone is +ve
33% if both are +ve
Radical Trachelectomy
Surgical management option for women with stage IA2 and IB1 disease who desire
uterine preservation and fertility.

Procedure may be performed vaginally, abdominally, laparoscopically or

robotically and accompanied by pelvic lymphadenectomy and cervical cerclage
placement

Ideal candidates have tumors <2 cm in diameter and -ve lymph nodes

Lymphadenectomy can be performed, at the beginning of the procedure, and

depending on these results, the procedure can be continued or abandoned .
Radical Trachelectomy
A study found that for women attempting to conceive after radical trachelectomy,
the 5-year cumulative pregnancy rate was 52.8%, with an increased risk of
miscarriage.

If a recurrence develops, definitive therapy with surgery or radiation is necessary .

Hystrectomy
Type 1 • Extrafascial hysterectomy

Type 2 • Modified Radical hysterectomy (Wertheim’s)

Type 3 • Radical hysterectomy (Meig’s)

Type 4
Type 5
Simple (Extrafascial) Hysterectomy / Type I
hysterectomy
Appropriate therapy for patients with stage IA1 tumors without lymph-vascular
space invasion who are not desirous of future fertility.

Lymphadenectomy is not recommended.

Modified radical hysterectomy with pelvic lymphadenectomy is appropriate and

effective, if lymph-vascular space invasion is found
 Type 2 hysterectomy Type 3 hysterectomy

Cardinal ligament Medial half From origin

Uterosacral ligament Medial Half From origin

Vagina A smaller margin removed Upper 1/3rd removed

Uterine artery Transected at the level of the ureter At origin

Vesicouterine ligament Anterior divided Anterior and posterior divided

Pelvic lymphadenectomy + +
Radical Hysterectomy - Further classification

In type IV operation, the periureteral tissue, superior vesical artery, and as much
as 3/4th of the vagina are removed

In type V operation, portions of the distal ureter and bladder are resected

In premenopausal patients the ovaries can be conserved .

Lymphadenectomy
After inspection of the abdomen and pelvis, the pelvic and para-aortic lymph
nodes should be inspected and palpated. Lymph nodes suspicious for gross
disease should be excised and evaluated by frozen section.
If metastatic disease is identified consideration should be given to abandoning
radical surgery in favor of primary chemoradiation therapy.
Pelvic Lymphadenectomy
Para-aortic Lymph Node Evaluation
Dissection of the Bladder
Dissection of the Uterine Artery
The uterine artery, which usually arises from the superior vesical artery, is thus
isolated and dived, preserving the vesical arteries.
Dissection of the Ureter
The posterior ligament is divided in the radical (type III) hysterectomy but
conserved in modified (type II) hysterectomy.
Posterior Dissection
The rectum is rolled free from the uterosacral ligaments, which are divided
midway to the sacrum in a radial (type III) hysterectomy and near the rectum
in the modified radical (type II) operation.
Complications of Radical Hysterectomy
1. Acute Complications
● Blood loss (average, 0.8 L)
● Ureterovaginal fistula (1% - 2%)
● Vesicovaginal fistula (1%)
● Pulmonary embolus (1% - 2%)
● Small bowel obstruction (1%)
● Febrile morbidity (25% - 50%)
Febrile morbidity is most of caused by pulmonary infection (10%), pelvic cellulitis
(7%) and urinary tract infection (6%).

Wound infection, pelvic abscess, and phlebitis in <5% of patients .

Complications of Radical Hysterectomy
2. Subacute Complications
● Postoperative bladder dysfunction
● Lymphocyst formation
After radical hysterectomy, bladder volume is decreased, and filling pressure is
increased. The sensitivity to filling is diminished and patient is unable to initiate
voiding.
The cause of dysfunction is unclear.
Important to maintain adequate bladder drainage during this time to prevent
oversistenton.
Bladder drainage is accomplished with a suprapubic catheter. This allows the
physician to perform cystometrography and determine residual urine volume .
Complications of Radical Hysterectomy
2. Subacute Complications
Cystometrography may be performed 3-4 weeks after surgery.
Patient must be able to sense the fullness of the bladder, initiate voiding and void the
residual urine level of less than 75-100 ml, to discontinue the catheter.
Ureteral obstruction, partial venous obstruction, and thrombosis may occur from
lymphocyst function.
Simple aspiration off the lumphosyst is generally not curative, but percutaneous
catheters with chronic drainage may allow healing.
If this treatment is unsuccessful, operative intervention with excision of a portion of
the lymphocyst wall and placement of either large bowel or omentum into the
lymphocyst should be performed.
Complications of Radical Hysterectomy
3. Chronic complications
● Bladder Hypotonia. Bladder Atony, in extreme instances
Voiding every 4-6 hours, increasing intra-abdominal pressure with Credé's
maneuver, and intermittent self-catheterization may be used for management.
● Ureteral Strictures
Uncommon in the absence of postoperative radiation therapy, recurrent cancer
or lymphocyst formation.
Strictures that occur after radiation therapy should be managed with ureteral
stenting.
If ureteral strictures is noted in absence of radiotherapy or lymphocyst
formation, recurrent carcinoma is the most common cause.
Nerve-Sparing Radical Hysterectomy
Attempt to diminish the bladder dysfunction, sexual dysfunction and colorectal
motility disorders.
Laparoscopic Radical Hysterectomy
Laparoscopic lymphadenectomy followed by radical vaginal hysterectomy.
Robotic Laparoscopic Radical Hysterectomy
Robotic cases had significantly shorter hospital stays and blood loss, while
having significantly larger incidence of postoperative bladder dysfunction .
Sentinel Lymph Node Evaluation
The sentinel node is a specific lymph node that is the first to receive drainage from
a malignancy and is a primary site of nodal metastasis.

Sentinel lymph nodes are detected through perilesional injection if radiolabeled

technicium-99 or blue dye followed by intraoperative identification of the sentinel
lymph nodes utilizing handheld gamma proves or visual identification of blue-
stained nodes.
Prognostic Variables for Early-Stage Cervical Cancer (IA2-IIA)

Intermediate risk factors:

1. Large tumor size
2. Cervical stromal invasion to the middle or deep 1/3rd
3. Lymph-vascular space invasion

High risk factors:

4. +ve or close margins
5. +ve lymph nodes
6. Microscopic parametrial involvement

Patients treated with radical hysterectomy who have intermediate or high risk factors
have a 30% and 40% risk, respectively, of recurrence within 3 years.
Lesion Size
● Patients with lesions smaller than 2 cm have a survival rate of ~90%.
● Patients with lesions larger than 2 cm have a survival rate of ~60%.
● Patients with lesions larger than 4 cm have a survival rate of ~40%.
Depth of Invasion
● Depth of invasion is less than 1 cm have a 5-year survival rate of ~90%.
● The survival rate falls to 63%-78% if the depth of invasion is more than 1 cm.
Parametrial Spread
● With spread to the parametrium patients have 5-year survival rate of ~69%.
● When the parametrium is -ve, the survival rate is 95%.
Lymph-Vascular Space Involvement
● 5-year survival rate of 50%-70
● When the space invasion is absent, the survival rate is 90%.
Lymph Nodes
● Patients with -ve nodes have 85%-90% 5-year survival rate.
● The survival rate falls to 20%-74% with +ve nodes, depending on the number
of nodes involved, location and size of the metastases.
Primary Radiation Therapy

Radiotherapy can be used to treat all stages of cervical cancer, with cure rates of
about 70% for stage I, 60% for stage II, 45% of stage III and 18% of stage IV.

Primary radiation treatment plans consists of

External therapy - to treat regional lymph nodes and to decrease the tumor
volume
Brachytherapy - delivered by intracavitary applicators or interstitial implants to
provide a treatment boost to the central tumor
Primary Radiation Therapy

Stage IB lesions < 2 cm are treated first with an intracavitary source, followed by
external therapy to treat pelvic lymph nodes. Larger lesions require external
radiotherapy to shrink the tumor.

The usual dosage are 7000-800 cGy to point A (2 cm superior to external cervical
os) and 6000 cGy to point B (3 cm lateral to point A)

Low-dose rates are cesium-137 as source

High-dose rates are iridium-192 as source

There may be slight stage related differences in survival between patients treated
with low- and high-dose rate regimens.
 Comparison of Surgery vs Radiation for stage IB/IIA Cancer of the Cervix
Surgery Radiation
Survival 85% 85%

Serious
complicatio Urological fistulas 1%-2% Intestine and urinary strictures and fistulas 1.4%-5.1%
ns
Initially shortened, but may lengthen with regular Fibrosis and possible stenosis, particularly in
Vagina intercourse postmenopausal patients

Ovaries Can be conserved Destroyed

Chronic Bladder atony 3% Radiation fibrosis of bowel and bladder 6%-8%

effects
Applicabilit Best candidates are younger than 65 years of age,
All patients are potential candidates
y <200 lb (~90 kg), and in good health

Surgical 1%
1% (from pulmonary embolism during intracavitary
mortality therapy)
Intensity Modulated Radiation Therapy - IMRT

Know as Intensity Modulated Radiation Therapy - IMRT

External beam therapy.

The beam intensity is modulated to optimize the delivery of radiation to the specific
treatment volume while sparing adjacent normal tissue .
Adjuvant Radiation

To improve survival rates, postoperative radiotherapy was recommended for

patients with high and intermediate risk factors such as metastasis to pelvic lymph
nodes, invasion of paracervical tissue, deep cervical invasion, or +ve surgical
margins.
Increasing evidence supports the use of adjuvant radiation.
Postoperative radiation therapy for +ve pelvic nodes can decrease pelvic recurrence
but does not improve 5-year actuarial survival rates.
The location of lymph nodes is relevant to postirradiation recurrence rates.
Adjuvant Radiation

Recommended extended-field radiotherapy to patients with +ve pelvic lymph nodes

in an attempt to treat undetected extra pelvic nodal disease.
Randomized controlled trial found to have at least two of the:
● Capillary lymphatic space invasion
● More than 1/3rd stromal invasion
● Large tumor burden
Patients with these risk factors had a statistically significant (47%) decrease in
recurrent disease
Concurrent Chemoradiation

Radiation therapy fails to control tumor in 20%-65% of advanced cervical cancer

cases.

Chemotherapy, despite relative lack of success, evaluated as neoadjuvant treatment

in combination with surgery.

Patients with high-risk factors after radical hysterectomy for stage IA2, IB and IIA
disease, chemoradiation is the postoperative treatment of choice.
Complications of Radiation Therapy

Perforation of uterus with the observation of the uterine tandem.

Elderly patients and those who has a previous diagnostic conization procedure.
When perforation is recognized, the tandem should be removed and patients should
be observed for bleeding or signs of peritonitis .
Acute Morbidity

Caused by ionizing radiation on epithelium of the intestine and bladder

● Diarrhea
● Abdominal cramps
● Nausea
● Frequent urination
● Occasional bleeding from bladder and bowel mucosa.

Bowel symptoms can be treated with a low-gluten, low-lactose and low-

protein diet. Antidiarrheal and antispasmodic agents may help.

Bladder symptoms can be treated with antispasmodic medication .

Chronic Morbidity
Radiation-induced vasculitis and fibrosis and are more serious than the acute
effects.
The bowel and bladder fistula rate after pelvic radiation therapy for cervical
cancer is 1.4%-5.3%, respectively.
Proctosigmoiditis
Bleeding from proctosigmoiditis should be treated with low-residue diet,
antidiarrheal medications and steroid enemas.
Rectovaginal Fistula
Occurs in < 2% of patients
Small Bowel Complications
Urinary Tract
Occurs in 1%-5% of patients and depends on the dose of radiation to the base
of the bladder
Special cases
Cervical cancer in
pregnancy
• Incidence : 1 in 2,200 pregnancy
• Pap test Should be performed in all pregnant patient.
• Grossly suspicious lesions biopsy should be taken
• Pap positive : coloscopy / biopsy
• Conization is done only when 1) coloscopy findings are cofirmatory of cancer 2)
biopsy proven microinvasive carcinoma.
• Can induce abortion in 33% of cases.
 Treatment
Stage 1
A) If <3 cm with no vascular and lymphatic involvement : NVD at term followed
by hystrectomy to be planned at 6 weeks post partum. ( If Further childbearing is
not desired.)
B) If >3mm and <5mm with vascular and lymphatic involvemet : C section at term
with Modified radical hystrectomy with PLND.
C) It >5 mm same treatment as that of invasive carcinoma should be started
Stage 2 to stage 4

Stage 2 to 4 should be treated with radiotherapy.

In the first trimester external radiation therapy should be considered
with 4000 cgy ( can induce abortion )
In the second trimester delay to improve the fetal survival should
be considered. It is important to ensure fetal lung maturity Before
delivery is undertaken.
 2) Cancer of cervical stump
Was more common decade ago when Supravaginal hystrectomy was popular.
1) Early stage disease : Surgery
2) Advanced stages
a) if the cervical length is satisfactory tandem can used
b) if the cervical length is not adequate tandem along
with ovoid can be used
c) external treatment plan in which lateral ports are used. To augment the standard
anterior and Posterior port( less damaging to bowel and bladder )
Cervical carcinoma after extrafascial
hysterectomy.
• Radiotherapy and reoperation can be done.
• Reoperation : radical excision of parametrial tissues with cardinal ligament
with vaginal stump ( indicated in young patients with small lesions whose
ovarian function preservation is desirable ). It is not recommended in patients
having positive margins or obvious residual disease
• Radiation therapy:
depends on volume , status of margin and length of delay from surgery
To radiation therapy.
• Micro invasive carcinoma with free margin : 95-100% survival rate
• Macro invasive carcinoma with free margins : 82-94% survival rate
• Micro invasive Carcinoma with positive margins : 38-87% survival
rate
 Stage IV A
• Exentaration in patients with direct involvement of bladder and Rectum ( not
done )
• External beam radiation therapy followed by removal of bladder.
• If bowel is involved diversion of fecal stream before therapy to avoid septic
episode from fecal contamination.
 Acute haemorrhage
• Can be because of large lesions.
Treatment
• Vaginal packing with monsels solution ( rapid replacement should
be done to avoid infections along with broad spectrum antibiotics
to be started. ) . More preferable then explortaion and vascular
ligation.
• In some cases vascular embolization may be required (reduced
blood flow to the lesion and hence can affect radiation therapy. )
Barrel shaped cervix.
• Patient having lesion >6 cm have 17.5 % chances of central
failure rate with radiation therapy alone .
• When the tumor expands to upper endocervix and lower uterine
segment it is known as barrel shaped cervix.
• Treatment
• Radiation therapy ( 4000 cgy intracavitatory 1 dose ) followed by
extrafascial hystrectomy. Reduces the rate by 2%
Recurrent cervical cancer
• Patient initially treated with radiation should be considered for
surgery and vice versa.
• Chemotherapy is palliative if radiation / surgery not possible..
• Radiation therapy reserved only for who had suboptimal or
incomplete primary therapy.
• Surgery for post op radiation is limited to patient with complete
pelvic disease.
 Chemotherapy : recurrent cervical cancer is not considered
curable with chemotherapy .
 Single agent chemotherapy : cisplatin and carboplatin ( 10-25,%
response rate
 GOG 149/169 study has been going . 169 combines cisplatin
with paclitaxel.
Vaginal ovoid for vaginal cuff recurrence .
Exenteration

Anterior Exenteration Includes bladder /

Cervix/ vagina/ uterus. Done in cases of
involving cervix and Anterior wall of
upper part of vagina .
Posterior
exenteration
includes cervix,
vagina, uterus,
rectum.
Indicated in
posterior wall
reoccurence.
Total exenteraton : when
recurrence is in lower part
of vagina that leaves the
patient with a permanent
colostomy as well as a
urinary conduit.
 Thank
You
Nobel prize in medicine went to Dr. Harald Zur Hausen in 2008 regarding his discoveries
in HPV relation to cervical cancer