PALESTINE POLYTECHNIC UNIVERSITY

Faculty of Medicine and Health Sciences

CERVICAL CANCER
MohmmadRjab Seder
The Cervix - Overview
 Squamocolumnar Junction (SCJ)

The area between the original SCJ and the current SCJ is called as
“Transformation Zone” TZ
Cervix Histology
 Cervical Cancer - Overview
o Also called: invasive cervical carcinoma (ICC).

o Cervical cancer is the third/fourth most common cancer among

women globally.

o Classified into:
o Premalignant/Precancer disease of the cervix.
o Malignant disease of the cervix.

o More than 95% of cervical CA is due to HPV.

o Cervical CA can be cured if diagnosed at an early stage and

treated promptly.
 Epidemiology

o About 90% of the new cases and deaths worldwide in 2020 occurred
in low- and middle-income countries.

o According to PHC/MoH; there are only small number of diagnosed

cervical CA in Palestine. (Health Annual Report 2021)
Worldwide - In 2022

604,000 new cases

342,000 deaths
 Clinical Presentation
o Cervical cancer often has no symptoms in its early stages.

o The most common symptom as it develops is vaginal bleeding.

o Irregular and/or abnormally heavy menstrual periods.
o Postcoital bleeding (PCB).
o Postmenopausal bleeding (PMB).
o Other symptoms:
o Urinary incontinence.
o Leg pain or swealing.
o Back pain.
o Unexplained weight loss.
 Aetiologies and Risk Factors
Human papillomavirus (HPV) infection (95% of cases)
NOTE
Having a family history of cervical cancer
Multiple sexual partners
Smoking (2x) Protective Factors:
HIV (6x) o Intrauterine device
Immunosuppression (IUD) use.
Co-infection with Chlamydia or HSV o Condom use in woman
Long-term use of OCPs with multiple sexual
Having multiple full-term pregnancies (Multiparity) partners.
Young age at first full-term pregnancy
A diet low in fruits and vegetables
 Human Papilloma Virus
o Oncogenic viruses.

o There are more than 100 different types of HPV classified as low-risk
or high-risk types, depending on their ability to cause cancer.
o High-risk types 16, 18, 31, 33, and 45  cervical cancer.
o Low-risk types 6 and 11  condylomata acuminata.

o Transmitted by sexual intercourse.

o HPV infection  premalignant  malignant (How??)

 Pathophysiology
o Oncogenes: genes that help cells grow, divide, and stay alive.
o Tumor suppressor genes: genes that help keep cell growth under control
or make cells die at the right time.

o HPV has two proteins known as E6 and E7 which turn off some tumor
suppressor genes, such as p53 and Rb.

o Most women with HPV don’t get cervical cancer. But:

HPV + Coexisting Risk Factors  Cervical CA

Premalignant Disease
of the
CERVIX
 Pre-cancers of the cervix
o Cells in the TZ do not suddenly change into cancer.

o Instead, the normal cells of the cervix first gradually develop

abnormal changes that are called pre-cancerous.

o Several terms are used to describe these pre-cancerous changes,

including:
o Cervical intraepithelial neoplasia (CIN) What is the difference between
the terms SIL and CIN???
o Squamous intraepithelial lesion (SIL)
o Dysplasia
Premalignant Malignant
 Types of Cervical Cancer
o Squamous cell carcinoma NOTE
o 70-80% of cervical cancers.
o Develop from cells in the exocervix. Other rare types of
cancer also can
develop in the
o Adenocarcinoma cervix. Such as
o 20% of cervical cancers. small cell,
o Develop from glandular cells of the endocervix. melanoma,
sarcoma and
lymphoma.
o Adenosquamous (mixed) carcinomas
o Less commonly.
o Have features of both squamous cell carcinomas and adenocarcinomas.
 Investigations and Diagnosis
o HPV testing

o Cervical cytology
o Pap smear
o Liquid-based cytology (LBC)
o Cervical biopsy
o Colposcopy

o Metastatic workup; pelvic examination, CXR, IVP, cystoscopy, and

sigmoidoscopy.
 Pap Smear
o A procedure to test for cervical
cancer in women.

o Used to screen for cervical cancer.

o Cost effective screening method.

Pap Smear – Video
Pap Smear
 Liquid-based cytology (LBC)
o LBC is better than a Pap test.
o Produce a thin layer of cells on the slide.
 LBC

Abnormal cervical cytology shows squamous cells at different stages of

maturity (dyskaryosis)
 Colposcopy
o Used for both diagnosis and treatment.

o Magnification: 5-20 fold.

o The application of acetic acid and iodine

solutions highlights abnormal areas of the cervix
can be biopsied. Cervix with acetic acid

o Acetic acid causes nucleoproteins within cells to

coagulate temporarily; therefore, areas of
increased cell turnover, including CIN, appear
white.
Colposcopy - Video
Colposcopy – Video
 Cervical Biopsy
o Remove tissue from the cervix to test for abnormal cells or
precancerous conditions.
o Gold standard for diagnosis.
 Pelvic Examination
Checking vulva, vagina, cervix, ovaries,
uterus, rectum and pelvis for any
abnormalities.

Pelvic exam findings

o Friable cervix
o Erosions
o Cervical mass
o Bleeding
o Fixed adnexa
A progressive cervical adenocarcinoma:
The image shows a rapidly progressing mass protruding from the cervix.
Cystoscopy
Prevention
 Treatment of Premalignant Disease of the
Cervix
o Aim of treatment: eradicate CIN.

o Low-grade CIN:
o 60% regresses spontaneously.
o Cold coagulation.
o Cone biopsy (Conization).

o High-grade CIN:
o Treatment + excision or ablation.
o Diathermy (thermal ablation).
o Cold coagulation.
o Cone biopsy (Conization).
 Cold Coagulation.
o Procedure to treat women with abnormal cells on their cervix, by
destroying the abnormal cells with a heated probe.
 Conization
o A procedure in which a cone-
shaped piece of abnormal tissue is
removed from the cervix.
 Diathermy
o AKA: cervical cautery.
Malignant Disease
of the
CERVIX
Cancer is diagnosed when CIN breaks the basement
membrane.
 Clinical Presentation
o Cervical cancer often has no symptoms in its early stages.

o The most common symptom as it develops is vaginal bleeding.

o Irregular and/or abnormally heavy menstrual periods.
o Postcoital bleeding (PCB).
o Postmenopausal bleeding (PMB).
o Other symptoms:
o Urinary incontinence.
o Leg pain or swealing.
o Back pain.
o Unexplained weight loss.
 Pathophysiology
o Cervical tumours are locally infiltrative in the pelvic area, but also
spread via lymphatics.

o In the late stages, spread via blood vessels.

o The tumour can grow through the cervix to reach the parametria,
bladder, vagina and rectum.

o Metastases can occur, therefore, in pelvic (iliac and obturator) and

para-aortic nodes and, in the later stages, liver and lungs.
 Types of Cervical Cancer
o Squamous cell carcinoma NOTE
o 70-80% of cervical cancers.
o Develop from cells in the exocervix. Other rare types of
cancer also can
develop in the
o Adenocarcinoma cervix. Such as
o 20% of cervical cancers. small cell,
o Develop from glandular cells of the endocervix. melanoma,
sarcoma and
lymphoma.
o Adenosquamous/mixed carcinomas
o Less commonly.
o Have features of both squamous cell carcinomas and adenocarcinomas.
 Staging
Clinical Staging may be done through:
o Clinical examination
o Cervical biopsy (Assess malignancy and tumour type)
o Endoscopy
o Hysteroscopy
o Cystoscopy
o Proctoscopy
o Imaging studies
o Intravenous pyelogram (IVP): to evaluate for urinary tract obstruction
o CT
o CXR (exclude lung metastases)
o MRI (Assess local spread)
o PET
Staging and
prognosis of
cervical
cancer

(By FIGO)
Staging - Video
 Management
Depends on the stage.
o Preclinical lesions; stage IA
o Clinical invasive cervical carcinoma: stages IB-IV

o Surgery
o Radiotherapy
o Palliative care
 Preclinical lesions; stage IA
o Local excision.
o Total simple hysterectomy.
o Modified radical hysterectomy: surgery to remove the uterus, cervix,
upper part of the vagina, and nearby ligaments and tissues.
 Clinical invasive cervical carcinoma:
stages IB
o Radical hysterectomy.

o Bilateral pelvic node dissection (Wertheim’s hysterectomy).

o Radical trachelectomy (surgical removal of the cervix and upper part of

the vagina).
 Clinical invasive cervical carcinoma:
stages II-IV
o Chemoradiotherapy.

o Radiotherapy:
o External beam radiotherapy.
o Internal radiotherapy (brachytherapy).
External beam radiotherapy Brachytherapy
 References
o Kenny, L., & Bickerstaff, H. (Eds.). (2017). Gynaecology by ten teachers, 20th edition (20th ed.). CRC Press.

o Kaplan Medical. (2018). USMLE Step 2 CK Lecture Notes 2019: 5-book set. Kaplan Publishing.

o American Cancer Society. Retrieved September 18, 2022, from https://www.cancer.org/search.html?q=cervix.

o World Health Organization. (2022, February 22). Cervical Cancer.

https://www.who.int/news-room/fact-sheets/detail/cervical-cancer#:~:text=Cervical%20cancer%20is%20the%20fourth,%2Dincome%20
countries%20(1)
.
Thank You