CERVICAL CANCER

Dr. Sushma Dhakal

 INCIDENCE
• Worldwide incidence approximately 510,000 new cases
annually
• Approximately 288,000 deaths
• 85% of these deaths are reported in low and middle
income countries

Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer: the size

of the problem. Best Pract Res Clin Obstet Gynaecol. 2006;20:207–225

World Health Organization. Comprehensive cervical cancer prevention and control:

a healthier future for girls and women. Geneva, Switzerland: World Health
Organization Press; 2013
• Third common gynecologic neoplasm United
States, behind cancer of the corpus and ovary,
mainly as a result of the effectiveness of
screening programs
• Developing countries, cervical carcinoma is
the second most frequent cause of cancer
death in women
 Epidemiology

• Invasive cancer of the cervix preventable

disease because
long preinvasive state, cervical
cytology screening programs and treatment
of preinvasive lesions is effective
• Inspite of preventable nature of this disease,
12,710 new case ; 4290 deaths were
anticipated in the United States in 2011
lifetime probability of developing cervical cancer
is 1:128
screening programs in United States are well
established, estimated that 30% of cervical
cancer cases will occur in women who have
never had a Papanicolaou (Pap) test
• In developing countries, approaches 60%
• Worldwide incidence of invasive disease is
decreasing, and cervical cancer is being
diagnosed earlier, leading to better survival
rates
• mean age for cervical cancer United States 47
years,
• bimodal, with peaks at 35 to 39 years and 60
to 64 years of age
 IN NEPAL
• World Health Organization estimates a crude
incidence rate of cervical cancer in Nepal is
24.2 per 100,000 women per year
• 3,504 new cases diagnosed every year and
1,872 deaths
• India highest in South Central Asia, with an age-
standardized incidence rate of 30.7 per 100,000
Information Center on HPV and Cervical Cancer. Human papillomavirus and related cancers,

fact sheet 2013  

• The coverage rates for cervical cancer
screening services is very low (2.4%) in Nepal
• Nepal Cervical Cancer Prevention Situation
Analysis, 2008 estimated that there were about
10,020 new cases of invasive cervical cancer
• 26,000- 45,000 pre-cancerous lesion
• World Health Organization (2010) ranked
cervical cancer as the most frequent cancer
among women age 15 to 44 years of age in
Nepal
 Risk factors
• History of sexually transmitted infections (eg,
Chlamydia trachomatis, genital herpes)
• Smoking
• Early age child birth
• Long term use of OCPs
• History of vulvar or vaginal squamous
intraepithelial neoplasia or cancer (HPV infection
is also the etiology of most cases of these
conditions)
 Risk factors
• Not having regular cervical screening
• Not appropriately treated high grade pre-
cancerous lesions (HSIL, ASC-H)
• Persistent high risk HPV infection of cervix
• Low immunity and Immunosuppression (eg,
human immunodeficiency virus infection)
• Multiple sexual partners, a high-risk sexual
partner (eg, a partner with multiple sexual
partners or known HPV infection)
• Early onset of sexual activity
• Relationship to oral contraceptive use was
debated
• use of oral contraceptives might increase the
incidence of cervical glandular abnormalities
• This hypothesis was not supported. Many of
these risk factors are linked to sexual activity
and exposure to sexually transmitted diseases
• Infection with human papillomavirus (HPV)
was determined to be the causal agent in the
development of cervical cancer,
• The initiating event in cervical dysplasia and
carcinogenesis is infection with HPV
• HPV infection detected 99% of women with
squamous cervical carcinoma
• HPV is the causative agent in both squamous
and adenocarcinoma of the cervix
• 14 high-risk HPV subtypes;
• Two of the high-risk subtypes, 16 and 18, are
found in up to 62% of cervical carcinomas
 Pathogenesis: Four major steps in cervical
cancer development

A. Oncogenic HPV infection of the metaplastic epithelium

at the cervical transformation zone

B. Persistence of the HPV infection

C. Progression of a clone of epithelial cells from persistent
viral infection to precancer

D. Development of carcinoma and invasion through the

basement membrane
• HPV genome found in all grades of cervical
neoplasia
• Infection with HPV is the primary cause of
cervical cancer
• CIN lesions become more severe the
koilocytosis disappear
• HPV copy numbers decrease, and the capsid
antigen disappears,
HPV DNA become integrated into the host
cell(basal cell) in persistence infection

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
 mechanism by which HPV affects
Cellular growth and differentiation is through
interaction of viral E6 and E7 proteins with
tumor suppressor genes p53 and Rb

Inhibition of p53 prevents cell cycle arrest and

cellular apoptosis, which normally occurs
when damaged DNA is present
Inhibition of Rb disrupts transcription factor
E2F, resulting in unregulated cellular
proliferation

Both steps are essential for the malignant

transformation of cervical epithelial cells
 SYMPTOMS
• Early cervical cancer frequently
asymptomatic and may be discovered as a
result of cervical cancer screening or
incidentally, if a visible lesion is discovered
upon pelvic examination

• Early stages – no signs and symptoms

 Abnormal vaginal bleeding

• Mostly bleeding is post

coital
• Could be intermenstrual
in the form of
menorrhagia
• Could be post
menopausal
• Could be metrorrhagia
 Vaginal discharge
• Only symptom of carcinoma of cervix
• Is secondary to infection of the tissues or
ulceration
• Watery in nature which is initially white
• Becomes yellowish & changes to dirty
brown then blood Stained
 Late symptoms are due to spread of disease

• Renal – frequency, dysuria, haematuria, renal

colic,urinary incontinence because of fistula
• Rectal – tenesmus, diarrhea, proctitis
• Pelvic symptoms – deep pelvic pain, low back
ache, sciatica
• Swelling of the leg is due to blockage of the
lymphatics
 SIGN
• General physical examination performed to
include evaluation of the supraclavicular,
axillary, and inguinofemoral lymph nodes 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
• Vaginal fornices also should be closely
inspected.
• invasive cancer, the cervix firm and expanded,
and these features should be confirmed by
digital examination
Rectal examination important
• Help to establish cervical
consistency and size, in endocervical
carcinomas(barrel shaped cervix)
• Way to determine cervical size if
the vaginal fornices have been obliterated by
menopausal changes or by the extension of
disease
• Parametrial extension of disease is best
determined by the finding of nodularity
beyond the cervix on rectal examination
• Involvement of rectal mucosa
• Induration of uterosacral ligament
 SIGNS
• Earliest sign on speculum -erosion
-infected ulcer
• Suggestive features of ulcer -hardness
-irregularity
-bleeds on touch
 PS & PV Examination
A. Cauliflower exophytic growth (80%) which is
friable, fixedindurated and it bleeds on touch.
B. Ulcerative growth (20%) which has indurated
base and bleeds on touch.
C. Flat indurate area
 SIGNS
 Tumors: size ,character, mobility (raised,
friable, exophytic, diffusely enlarge or ulcer)
may appear to replace part - or entire cervix
 Extension to vagina, rectum,parametrium
 palpable groin or supraclavicular lymph nodes
 Once the disease is established, 4 cardinal
signs:
• induration
• friability
• fixity
• bleed on touch
 Examination under Anesthesia (EUA )

• Done for staging cervical cancer for a

thorough pelvic examination for assessment of
tumor size and rectovaginal examination done
to assess vaginal or parametrial metastasis
 Investigations

• Cervical cytology: method for cervical cancer screening

• Human papillomavirus (HPV) testing: used in

combination with cervical cytology for cervical cancer

screening and helps to determine which women with

abnormal cytology results require further evaluation

 Cervical biopsy
• Obvious tumor growth
is present, a cervical
biopsy is usually
sufficient for diagnosis
• If gross disease is not present, a colposcopic
examination with cervical biopsies and
endocervical curettage
• If the diagnosis cannot be established
conclusively with colposcopy and directed
biopsies, cervical conization
 Colposcopy
• Suspected early invasive cancer based on cervical
cytology and a grossly normal-appearing cervix
• Colposcopic findings suggest invasion are
(i) abnormal blood vessels,
(ii) irregular surface contour with loss of
surface epithelium, and
(iii) color tone change
Abnormal Blood Vessels
• looped, branched, or reticular
• Abnormal looped vessels are most common
colposcopic finding and arise from the
punctated and mosaic vessels present in
cervical intraepithelial neoplasia (CIN)
• Punctate vessels push surface of the
epithelium in erratic fashion, producing the
looped, corkscrew, or J-shaped pattern of
abnormal vessels characteristic of invasive
disease
• Sharp turns, dilations, and luminal narrowing
also characterize these vessels
• surface epithelium may be lost in these areas,
leading to irregular surface contour and
friability
Irregular Surface Contour
occur as a result of papillary characteristics of
the lesion
• Biopsies should be performed on all papillary
cervical growths to avoid missing invasive
disease
Color Tone
• Color tone may change as a result of
increasing vascularity, surface epithelial
necrosis,
• Color tone is yellow-orange rather than
• Expected pink of intact squamous epithelium
or the red of the endocervical epithelium
 Cervical conization

Indication

 Suspected malignancy but is not found with directed cervical

biopsies

example : some women with high grade cervical

intraepithelial neoplasia, inadequate colposcopy, and in

women with an endocervical curettage that is positive for

moderate to severe dysplasia

 Cervical Conization
 When microinvasive cancer is detected
during punch biopsy to determine whether
conservative or radical surgery is required for
treatment
• USG
• Cystoscopy
• IVP
• MRI and CT for assess lymph nodes
• Chest X-ray
• CBC (anemia)
• Biochemical tests (urea ,creatinine)
• Evaluation of the para-aortic lymph nodes
with lymphangiography
false-positive rate of 20% to 40% and a
false-negative rate of 10% to 20%
sensitivity of 79% specificity of 73%
 Ultrasonography
• Transabdominal sonography can be used to reveal
the presence of hydronephrosis.

• Transvaginal sonography has been used in assessing

bladder invasion
 CT scan
• Detailed cross-sectional images of the body.
• CT also has a role in defining advanced disease
 Monitoring distant metastasis
 Detecting enlarged lymph nodes
 Guiding biopsy of those nodes
 Depicting urinary tract involvement
 Planning the placement of radiation ports
Limitations of CT in staging cervical cancer
• CT is not accurate for assessing
- Subtle parametrial invasion
- Deep cervical stromal invasion.

 This is because of its poor soft-tissue contrast resolution

• Difficulty in enhancing local tumor invasion from normal
parametrium.
• Inability to exclude metastasis in normal-sized lymph nodes
• Node architecture is often poorly defined by CT
CT scan has accuracy of-
• 92% in evaluating patients with stage IIIB-IVB disease.
• 58-88% overall staging of cervical cancer
 Magnetic Resonance Imaging
MRI scans use radio waves and strong magnets instead
of x-rays to take pictures.

MR imaging provides the most benefit in evaluating

 Tumor greater than 2 cm at clinical examination
 Endocervical lesions
 Possible parametrial extension
 Pregnant patient
 Positron Emission Tomography
• PET is a nuclear medicine imaging technique

• A radiolabeled analog of glucose, fluorodeoxyglucose (FDG), is

injected intravenously

• Taken up by metabolically active cells such as tumor cells and

these radioactivity can be detected by special camera..

• FDG-PET is superior to CT or MR imaging for lymph node

metastasis
• CT has poor sensitivity (34%)
specificity (97%)
• Accuracy of CT scanning is 80% to 85%
false-negative rate is 10% to 15%
false-positive rate is 20% to 25%
Systematic review comparing CT scan with MRI
• MRI is significantly more sensitive with
equivalent specificity
• MRI has excellent sensitivity on T2-weighted
images for the detection of parametrial disease
• MRI is the preferred study to evaluate tumor
size, lymph node metastasis and local tumor
extension
PET(Position emission tomography)
lymph node metastasis detection

lymph node involement is not included in FIGO staging but prognosis can be
forecast by imaging(CT/mRI/ PET) detection of lymph node involvement
• Ultrasound has a high false-negative rate
(30%), low sensitivity (19%), but high
specificity (99%)
 Staging

• Cervical cancer is a clinically staged disease

• The FIGO staging system is the standard and is
applicable to all histologic types of cervical
cancer
• Staging for cancer cervix is clinical and
requires a set of investigation-as
recommended by FIGO
• Physical examination
Palpate lymph node
Examine vagina
Bimanual recto vaginal
examination
Radiological studies Procedure
Chest X ray Biopsy
Skeletal Xray Conisation
IVP Endocervical curettage
Barium enema Colposcopy
Hysterescopy
Cystoscopy
Proctoscopy
• USG/CT scan /MRI/laparoscopy/laparotomy
and lymphangiography are not included in the
investigation approved by FIGO
FIGO staging of carcinoma of cervix
• STAGE 1: The carcinoma is strictly confined to
the cervix. Extension to corpus is disregarded
• STAGE 1A: Invasive carcinoma which can be
diagnosed only by microscopy with deepest
invasion no wider than 5mm and largest
extension no wider than 7mm
STAGE 1A1: Measured invasion of
the stroma no greater than 3 mm
in depth and no wider than 7 mm
diameter

STAGE 1 A2: Measured invasion of

stroma greater than 3 mm but no
greater than 5 mm in depth and
no wider than 7 mm in diameter.
Stage IB: Stage IB: Clinically visible
lesions limited to cervix uteri or
preclinical cancer greater than
Stage IA

Stage IB1: Stage IB1: Clinical lesions

no greater than 4 cm in size.

Stage IB2: Stage IB2: Clinical lesions

greater than 4 cm in size.
Stage IIStage II is carcinoma that extends
beyond the cervix, but does not extend into
the pelvic wall. The carcinoma involves the
vagina, but not as far as the lower third.

Stage IIA: without parametrial invasion

STAGE IIA1: clinically visible lesion no wider
than 4 cm in greatest diameter
Stage II A2: Clinically visible lesion more than
4cm in greatest dimension.
STAGE II B: with obvious parametrial
invasion.
Stage IIIStage III is carcinoma that has
extended into the pelvic sidewall. The
tumour involves the lower third of the
vagina OR causes hydronephrosis or
a non-functioning kidney .

Stage IIIA: No extension into the

pelvic sidewall but involvement of the
lower third of the vagina.
Stage IIIB: Extension into the pelvic
sidewall or hydronephrosis or non-
functioning kidney.
Stage IVStage IV is
carcinoma that has
extended beyond the true
pelvis or has clinically
involved the mucosa of the
bladder and/or rectum.

Stage IVA: Spread of the

tumour into adjacent
pelvic organs.
Stage IVB: Spread to
distant organs.
FIGO Committee on Gynecologic Oncology. Revised FIGO

• All macroscopically visible lesions, even those with

superficial invasion, are allotted to stage IB carcinomas.
• The depth of invasion should always be reported in
millimeters, even those cases with “early minimal
stromal invasion” (∼1mm)
• The involvement of vascular/lymphatic spaces should
not change stage allotment
• All cases with hydronephrosis or non-functioning
kidney are included, unless they are known to be due
to another cause
 CERVICAL CANCER

Dr. Sushma Dhakal

 Gross Pathology
 Site of Lesion

• Ectocervix-80%

• Endocervix-20%
 Naked Eye Appearance

Exophytic-
• Arises from the ectocervix.
• Fraible, cauliflower like growth filling up the vaginal
vault.

--
Ulcerative
• Excavates the cervix and involves the vaginal fornices.
• Clean punched out with bleeding and foul smelling
discharge.
Infiltrative:
• Grows beneath the mucosa of endocervix.

• Infiltrate the cervical stroma.

• Cause expansion of cervix and becomes barrel shaped.

 Types based on Histopathology

1. Squamous cell carcinoma- 85-90%.

2. Adenocarcinoma- 10-15%.
Squamous cell Carcinoma
• It arise from ectocervix.

• Further divided histologically into three groups:

i. Large Cell Keratinizing
ii. Large cell Non-Keratinizing
iii. Small cell Type
 Poorly Differentiated
 Small cell anaplastic Carcinoma
• Common
• moderately or poorly differentiated
• Source Sqamocolumnar junction, squamous
metaplasia of the columnar epithelium
• Small cell type has poor prognosis compared
to large cell type
• Poorly Differentiated-
small to medium sized nuclei
abundant cytoplasm
• small cell anaplastic: Oval to round nuclei
scanty cytoplasm coarsely granular
chromatin with high mitotic activity
Adenocarcinoma
• Develops from endocervical canal
• Common in younger age- 20s - 30s

 Varients of Adenocarcinoma
• Adenoma Malignum
• Villoglandular Papillary adenocarcinoma
 Mode of Spread
Direct Spread Lymphatic Spread Hematogenous

To adjacent Primary group: Blood borne:

structures-  Parametrium metastasis by veins
 Vagina  Internal iliac rather than arteries
 Body of Uterus  Obturator To Lungs, Liver, and
 Parametrium  External iliac Bones
 Paracervical  Hypogastric
 Paravaginal
 Rectum Secondary group:
 Bladder  Common iliac
 Sacral
 Vaginal
 Para aortic
 Inguinal
 Prognosis

Depends on :
• Stage of the lesion
• Lymph node involvement (pelvic and paraaortic)
reduces the survival rate by 50 percent
• Depth of tumor invasion
• Depth of Invasion
less than 1 cm 5-year survival rate 90%
survival rate 63% to 78% if depth of invasion is
more than 1 cm
Lesion Size
• lesions smaller than 2 cm have a survival rate
90%,
• lesions larger than 2 cm have a 60% survival
rate
• When the primary tumor is larger than 4 cm,
the survival rate drops to 40%
• Young age is usually associated with poorly
differentiated squamous cell carcinoma or
adenocarcinoma and is prognostically poor
• HPV positive younger patients have better
prognosis
 Survival rates for cervical cancer by stage

The 5-year survival rate refers to

the percentage of patients who STAGE 5 years survival rate
live at least 5 years after their
cancer is diagnosed I 90-80 %

II 50-60 %

III 40-30 %

IV 4-5 %
 Treatment Modalities of Carcinoma
Cervix
The types of treatment employed for the invasive
carcinoma are as follows:
• Primary surgery
• Primary radiotherapy
• Chemotherapy
• Combination therapy
• Palliative treatment
 Surgery
 Simple hysterectomy(Extrafascial Hysterectomy)or Type I
Hysterectomy

 Radical Trachelectomy

 Radical hysterectomy
• Type I
• Type II (Wertheim Hysterectomy)
• Type III
• Type IV
• Type V
 Management options based on staging

1. Conization or Type 1 Hysterectomy

 Stage I A1 <3mm invasion without Lympho-vascular

space invasion

 Not desirous of future fertility

.Microinvasive cervical cancer carries a minor
risk of lymph node involvement and excellent
prognosis following treatment
 Stage IA1
• Squamous cervical cancers with stromal
invasion less than 1 mm have a 1-percent risk
of nodal metastasis, and
with 1 to 3 mm of stromal invasion c
1.5-percent risk
• Cervical conization with a clear margin is considered
adequate & is diagnostic as well as therapeutic
• However, a total intrafascial hysterectomy (type I
hysterectomy) via an abdominal, vaginal, or
laparoscopic approach is preferred for women who
have completed childbearing or having a diseased
uterus
• Lymphadenectomy is not required, but life long
follow-up is necessary
• Presence of LVSI in stage IA1 microinvasive
cancers are traditionally managed with
modified radical hysterectomy (type II
hysterectomy) and pelvic lymphadenectomy.

• Of microinvasive cervical adenocarcinomas,

uterine preservation and conization is done
2. Radical Trachelectomy

 Stage IA1 ≤3 mm invasion with lymphovascular involvement

 Stage IA 2 3-5mm invasion
 Stage IB 1

 A radical trachelectomy is surgery to remove the cervix, the

upper part of the vagina and lymph nodes in the pelvis
 Who desire to preserve uterus and Fertility

 Usually accompanied by pelvic

lymphadenectomy

 Ideal Candidates- tumor <2cm in diameter and

have negative lymph nodes
 Stage IA2

• Several studies have also recommended that a

nonabsorbable cerclage be placed
concurrently with such radical trachelectomy
to improve cervical competence during
pregnancy.
 Stage IA2

• In a young woman desirous of childbearing,

conservative treatment comprising laparoscopic
lymphadenectomy followed by vaginal
trachelectomy is done.
• Fertility-conserving trachelectomy consists of
whole or at least 80% removal of the cervix,
upper vagina & cutting Mackenrodt’s ligament
on either side.
• If tumor has extended past the internal
cervical os, then trachelectomy is
contraindicated
3. Radical Hysterectomy
Modified Type II radical hysterectomy(Werthims hysterectomy)
 Stage I A2, IB1

 The uterine artery is transected at the level of the ureter

 Removal of the medial half of the Utero sacral ligament and cardinal
ligaments.
 The anterior vesiocouterine artery is divided but the posterior vesicouterine
ligament is conserved.
 A smaller margin of vagina is removed.

 No Pelvic Lymphadenectomy but removal of selective enlarged lymph nodes.

Radical hysterectomy. An intraoperative photograph showing the lateral dissection during a
radical
hysterectomy. Note the ureter running beneath the uterine artery (tissue in the clamp).
Radical Hysterectomy
 Type III radical Hysterectomy with Pelvic Lymphadenectomy
Stage IB 1, Stage IB2, Stage II A1 Stage II A2

It includes:
1.Pelvic Lymphadenectomy
2.Removal of most of the uterosacral and cardinal ligament
3.The upper third of the vagina.
Radical Hysterectomy
Type IV Radical Hysterectomy-
• The per-urethral tissue
• Superior vesical artery
• As much as three-fourth of vaginal is removed

Type V Radical Hysterectomy-

• Portion of distal ureter and bladder is resected.
Complication of Surgery

• Hemorrhage • Neuropathies due to

nerve injuries.
• Injury to bladder and ureter
• Lymphocyst in the pelvis
• Ureteric fistula (1-2%) and
• Dyspareunia
Vesicovaginal fistula (1%) • Recurrence
• Bladder dysfunction, cystitis,

pyelonephritis

• Rectal dysfunction
RADIOTHERAPY
 Useful in all stages of cervical cancer
• Stage I B2 , II and III
• Stage IIa or b radio and chemotherapy to be given then followed by simple
hysterectomy

It Can be:

• External irradiation (Teletherapy)

• Intensity Modulated Radiation Therapy(IMRT)

or External beam Therapy

• Intracavitary radiation (Brachytherapy)

 External irradiation (Teletherapy)

• In this x-rays are given externally

• To treat the regional lymph node and decrease the tumour

volume.

• Larger lesions require External radiotherapy first to shrink the

tumor and to decrease the anatomic distortion caused by the
Cancer
 Dose o f radiotherapy
Location Radiation
Point A 2 cm superior to external 7000-8000cGy
cervical os and 2 cm lateral to
the uterine canal is point of
crossing of uterine artery and
urter
Point B 3 cm lateral to point A 6000cGy
approximately at the site of
obturator gland

For cervical cancer, this type of radiation therapy is often given

along with low doses of chemotherapy with a drug called
cisplatin
 Tolerance of radiation In cGy
The vagina and the cervix can tolerate about 20000 to
30000- cGy.
Bladder ureter and rectum tolerate upto 7000cGy
Small gut tolerance limit is 4500 cGy
Intensity Modulated Radiation Therapy(IMRT)
or External beam Therapy

• Uses computer generated algorithms

• That accurately distinguish between target treatment
volume and normal tissues
• The delivery of radiation is optimized to the specified
treatment volume while adjacent normal tissue are
spared
Brachytherapy or Internal radiation therapy

• Used in early stages when incidence of lymph node metastasis

is negligible.

• Small radioactive sources, mainly radium sulphate is mixed

with some inert powder and packed in small needles or tubes.

• The container is made up of platinum, gold or alloy steel to

absorb alpha and beta particles and allowing the gamma rays
to sterilize the cancer cells.
 Brachytherapy or Internal radiation
therapy
• In carcinoma cervix, the tandems are inserted in the
uterine cavity and the ovoids and colpostats are placed in
the vaginal vault under anesthesia.

• Can be given - High dose rate treatment

- Low dose rate treatment

Dose Radiation Source

Low dose Caesium 137
High dose Iridium 192 or Cobalt 60 co
Brachytherapy or Internal radiation
therapy
 Radiotherapy

Advantages:
• Applicable to all stages between stages IB and
IV
• Survival rate 85%, comparable with that of
surgery in early stages
• Less primary mortality and morbidity
• Individualization of dose distributions/
requirements possible
• OPD procedure
 Contraindication of radiotherapy
• Associated myoma, prolapse (procidentia)
• Ovarian tumor or genital fistula.
• Associated PID—acute or chronic, pelvic kidney.
• Young patient (to preserve ovarian function).
• Vaginal stenosis — placement of radiation source is
inadequate.
• Cases with adenocarcinoma or adenosquamous
carcinoma — surgery is preferred.
 Complication of radiotheraoy

• Diarrhea or loose stools • Fistula formation(2–6%)

• Nausea and vomiting • Vaginal fibrosis and stenosis

causing dyspareunia
• Radiation cystitis
• Radiation menopause
• Anemia , Leukopenia
• Fibrosis of bowel and
• Weakness of bones bladder
• Lymphedema

• Intestinal and urinary stricture

 Adjuvant Radiation
Recommended for patient with risk factors like:
• Metastasis to pelvic lymph nodes
• Invasion of paracervical tissue
• Deep cervical invasion
• Positive surgical margins

Pelvic lymphadenectomy does not remove all the nodal and

lymphatic tissue and subsequent radiotherapy can eradicate
Microscopic disease.
• The rationale on giving treatment is the
knowledge that the
• Based on the retrospective studies ,post
operative radiation therapy for positive pelvic
lymph nodes can decrease the pelvic
recurrence but does not improve the 5 year
survival rates
 Neoadjuvant chemotherapy

• Chemotherapy is given before surgery.

• Shrinks the tumor and surgical resection is then possible.

• Three cycles of platinum-based combination chemotherapy with

radiation therapy

• The drugs used are in combination of Cisplatin, Ifosfamide or

Paclitaxel

• Followed 3–6 weeks by radical hysterectomy and

lymphadenectomy is done.
• This has improved the resectability of the bulky ≥ 4 cm (stage
IB2 and bulky IIA) disease.

• This regimen had shown better overall disease free survival

rate and reduced recurrence.
 Concurrent Chemoradiation
• Includes radiation and weekly cisplatin-based
combination chemotherapy.

• Chemotherapy sensitizes the cancer cells to radiation

and improves the survival rate.
• Concurrent chemoradiation is used as a treatment of choice
in:
• Early stage (IA2, IB, IIA) disease after radical hysterectomy.
• As a primary treatment for patients:
⁻ With bulky (>4 cm) tumor (stage IB and IIA)
⁻ Locally advanced(stage IIB to IVA) disease.
 Side Effects
• Nausea and vomiting
• Loss of appetite
• Loss of hair
• Mouth sores
• Fatigue (tiredness)
• Bleeding or bruising
 Palliative treatment
• Treatment of cancer in the advanced stage not curable by
Surgery or Radiation therapy.

• Primarily aimed to provide comprehensive care for relief of

symptoms
Cervical Cancer during Pregnancy
• Incidence : 1.2 in 10000

• Pap test should be done on all pregnant ladies at the initial

prenatal visit, and any suspicious lesion should be biopsied

• Colposcopy, biopsy or diagnostic conization is required.

• Following the conization ,the definitive treatment can be

delayed until Fetal maturity is achieved in ladies with Stage
I A cervical cancer
• Conization in first trimester is associated with
Hemorrhage, infections and Abortion rate is
33% higher than normal
• Conization if required should be performed
after Second trimester and in only in ladies
with Colposcopy findings consistent with
cancer, biopsy proven microinvasive cervical
cancer or strong cytologic evidence of Invasive
cancer
 Treatment
<3mm-5mm >5mm Invasion Stage II to IV

Pregnancy can be carried Depends on the gestational Radiotherapy

out till term or till fetal lung age and the wish of the
is matured patient If the fetus is in utero ,fetus
is delivered by classical
Cesarean section followed Cesarean delivery followed cesarean delivery and
by modified radical by Radical Hysterectomy therapy is started
hysterectomy with Pelvic Postoperatively.
Lymphadenectomy
1st trimester-external beam
radiation

2nd trimester- treatment

can be delayed to improve
the chance of fetal survival
 Recurrent cervical cancer

Risk factors for recurrent disease are:

• Large tumor size
• Lymphovascular space invasion
• positive lymph nodes
• advanced stage disease.

• Treatment depends upon the mode of primary

treatment and the site of recurrence.
 Recurrent cervical cancer

Distant disease
• Single agent or multi-agent chemotherapy
with cisplatin, paclitaxel or ifosfamide is used.

Local recurrence
• Radiation – if not used
• Pelvic exenteration
 Follow up
• The majority of the recurrences occur in the first 2 years.

• As such, the follow up protocols should be at 3–4 months

interval for the first 2 years

• Then at 6 months interval for next 2 years and thereafter

annually.
 Follow Up
• Thorough physical examination is done.
• Examination of supraclavicular and inguinal lymph nodes.
• Cervical or vaginal cytology and smear- yearly
• Chest X-ray is done annually.
• CT Scan of Abdomen and Pelvis, Cystoscopy
• THANK you
Reference
• Jeffcoates Principles of Gynaecology ,17th edition
• Te Linde`s Operative Surgery ,10th Edition
• Novak and Berek`s Gynaecology ,15th edition
• DC Dutta'ss Textbook of Gynecology
• Williams gynaecology 2nd edition.