Cancer Of The Cervix

Monday, February 27, 2023

Overview of the cervix

Monday, February 27, 2023

Overview of the cervix
The cervix is the lower portion of the
uterus, an organ of the female reproductive
tract. It connects the vagina with the main
body of the uterus, acting as a gateway
between them.
Anatomically and histologically, the cervix is
distinct from the uterus, and hence we
consider it as a separate anatomical
structure.

Monday, February 27, 2023

The cervix is composed of two regions;
the ectocervix and the endocervical canal.
The ectocervix is the portion of the cervix
that projects into the vagina. It is lined by stratified
squamous non-keratinized epithelium. The opening in
the ectocervix, the external os, marks the transition
from the ectocervix to the endocervical canal.
The endocervical canal (or endocervix) is the more
proximal, and ‘inner’ part of the cervix. It is lined by a
mucus-secreting simple columnar epithelium. The
endocervical canal ends, and the uterine cavity begins,
at a narrowing called the internal os.
Monday, February 27, 2023
Cervix

Monday, February 27, 2023

The ectocervix, visible via a speculum inserted
into the vagina. The external os is marked with an
arrow.

Monday, February 27, 2023

Vascular Supply and Lymphatics

• The blood supply to the uterus is via

the uterine artery. Venous drainage is via a
plexus in the broad ligament that drains into
the uterine veins. 
• Lymphatic drainage of the uterus is via
the iliac, sacral, aortic and inguinal lymph
nodes.

Monday, February 27, 2023

Vascular Supply and Lymphatics

Monday, February 27, 2023

 Functions of the cervix

• The cervix performs two main functions:

• It facilitates the passage of sperm into the uterine
cavity. This is achieved via dilation of the external
and internal os.
• Maintains sterility of the upper female reproductive
tract. The cervix, and all structures superior to it, are
sterile. This ultimately protects the uterine cavity and
the upper genital tract by preventing bacterial
invasion. This environment is maintained by the
frequent shedding of the endometrium, thick cervical
mucus and a narrow external os.
Monday, February 27, 2023
 Clinical Relevance: Disorders of the Cervix
• Cervicitis
• Cervicitis is chronic inflammation and infection of the cervix, most commonly
caused by Chlamydia trachomatis or Neisseria gonorrhoeae.
• It is usually asymptomatic although pelvic pain, vaginal discharge, postcoital
bleeding and dyspareunia may be present. Complications of cervicitis include
PID, whilst the potential blockage of mucus ducts and cyst formation increases
the risk of infertility by increasing the hostility of the environment for sperm.
• Cervical Cancer
• Cancer of the cervix the most common cancer affecting the female
reproductive tract. There are two main classifications of cervical cancer:
• Squamous cell carcinoma – cancer of the epithelial lining of the ectocervix.
• Adenocarcinoma – cancer of the glands found within the lining of the cervix.
• Infection of the female genitalia with human papilloma virus (HPV), is widely
known as the cause of the majority of cervical cancers. Latest vaccinations
against cervical cancer are, in essence, a vaccination against HPV.

Monday, February 27, 2023

 Introduction
It is the leading gynecological cancer in developing countries 2nd to
breast cancer.
 In Uganda it is the 3rd following lymphomas and Kaposi’ sarcoma.
It is the disease of sexually active age; it is the disease of females .
Most commonly occurring female malignancy
Statistics vary from country to country, race to race.
Debilitating disease

Squemous cell carcinoma accounting to 95% of all cases

Others 0.01% Negligible.

Monday, February 27, 2023

 Epidemiology:

• Incidence of Ca Cx is inversely related to the

socioeconomic status
• 2% of all women over the age of 40years will
develop Ca Cervix
• True incidence locally is unknown,
• In united kingdom , incidence is 15/100,000 women
over the age of 20 years
• In United States of America 12900 new cases are
diagnosed annually.
Monday, February 27, 2023
 Causes of cancer of the cervix
Idiopathic but the following are the predisposing factors.
HPV 16/18
Hereditary
Immune status
Multiparity
Folic Acid deficiency
Herpes simplex type II
Wife has a positive family History of Ca Cervix (HRF)
Low socio-economic status (HRF)
Genital cancer (HRF)
Multiple sex partners (HRF)
Recurrent STI/STDs (HRF)

Monday, February 27, 2023

Other predisposing factors to cancer of the
cervix.
Age at coitus the earlier the girl has sexual intercourse
the earlier the cancer of cervix (early coitus).
 Smoking
 Alcohol
 NB coitus: Male’s gametes have capacity to replicate
growth. When buried in an ovary they make it grow
squamo-collumnar Junction it is very un stable
Multiple abortions leading to multiple trauma
Pregnancies the squamocollumner junction comes out.

Monday, February 27, 2023

 Risk factors to cancer of the cervix

 Early coitus is dangerous because the sqamo-collumnar

Junction is yet exposed out and it is very unstable hence
high chances of cancer of cervix since it has receptors for
HPV.
 The squamocollumner junction has receptors for HPV.
Changes take place 10-15years.
 Semegma also settles at squamo-collumar junction.
 At 18 years the squamo-collumar junction deepens hence
fewer risks of cervical cancer
 Smoking;- Nicotine causes Vasoconstriction leading to
ischemia the ischaemic changes on the cervix causing
dysplasia, metaplasia which are malignant changes.
Pathophysiology of cancer of the cervix:

• It starts as a Slow developing malignancy

• Begins as dysplasia
• Pre-invasive form may remain static for 7-8 years.
• Early stromal invasion is 1-2mm below the basement
membrane
• Spread locally , lymphatic, blood

Monday, February 27, 2023

Signs and symptoms of cancer of the cervix

This depends on the time of the presentation.

This is either early or late stage
Most patients come at late stage like IIb and
above.
Continuous bleeding (post coital bleeding).
Increased discharge (Amount) Foul smell fish
Anemia due to constant bleeding
Monday, February 27, 2023
Early stages of cancer of the cervix

Asymptomatic

Intermenstrual bleeding

Post coital bleeding

menometrorrhagia

Monday, February 27, 2023

Late features of cancer of the cervix

• Fecal incontinence
• urinary incontinence
• Pelvic mass
• Friable tumour mass
• Pelvic pain
• Constitutional signs of malignancy

Monday, February 27, 2023

Diagnosis of cancer of the cervix:
investigations
• Fbc
• VI
• VIA
• Pap smear
• Biopsy
• Colposcopy
• Cone biopsy
• EUA

Monday, February 27, 2023

 Staging of cancer of the cervix

• Stage Ia)- the tumour is confined to the cervix—Micro

invasion. Ib) -the tumour is visualized.
Stage II :The Ca extends beyond the cx but not to the pelvic
wall. The vagina is involved but not the lower third.
• IIa) no parametrial involvement IIb) parametrial involvement

• Stage III :Ca extended to the pelvic wall.On PR there is no

cancer free space between tumour and the pelvic wall.Tumour
involves lower 1/3 of the vagina. All cases of hydronephrosis/
or non-functioning kidneys. IIIa) no extension to the pelvic
wall. IIIb)extension to the pelvic wall.

• Stage IV:Involvement beyond the true pelvis,Spread to the

adjacent organs, Distant spread. Urinary incontinence or fecal
incontinence
Monday, February 27, 2023
Importance of classification of cancer
of the cervix
• For Planning treatment

• Comparing the treatment modalities

• For source of Statistics for research

purposes.
• For predicting the prognosis

Monday, February 27, 2023

Management of cancer of the cervix

• Surgical :Wertheim's hysterectomy, Only applicable to cases of up to

stage 11a. However, the surgery has a number of complications such
as: Mortality < 1%,Fistulae formation,UTI,Sepsis,Thromboembolic
disease, Paralytic ileus and Hemorrhage.
• Radiotherapy :For all stages, but commonly stages 11b and above.
Make sure all the clinical parameters are normal. Complications of
radiotherapy include:Nausea,vomiting,Anaemia, Skin reaction,Weight
Loss.

• Chemotherapy: Usually can be used in combination with the above

two methods. Drugs used are doxyrubicin, bleomycin, cisplatin
paclitaxel, trinotecan etc

Monday, February 27, 2023

General management of cancer of the cervix

• Treat secondary and associated

infections
• Correct the anaemia and its
complications
• Psychological support to patient or
family
• Improve the nutrition of the patient
• Palliative care

Monday, February 27, 2023

DDX of cancer of the cervix

• Cervicitis
• Condylomata acuminata
• Cervical TB
• Choriocarcinoma

Monday, February 27, 2023

 Complications of cancer of the cervix

Infection
Depression
Anxiety
Anemia
Metabolic problems
Immunosuppression
Related to the treatment
RVF
VVF
Hydronephrosis
Monday, February 27, 2023
Prognosis of cancer of the cervix

It depends on the following factors

•Age of the patient
•General physical condition
•Cytological features of the cancer
•Histological characteristics of the cancer
•Skill of the therapist
•Socio economic status of the patient
•Stage of the cancer.

Monday, February 27, 2023

Cancer of the cervix Screening

• Always identify the risk factors

• VI
• VIA
• Pap smear
• Biopsy for histology.

Monday, February 27, 2023

 Prevention
Prevent early marriage

Stop smoking and alcoholism

Encourage girl child education

Screening( routine) :Regular Papsmear test (Sexually

active age) and every year.
Treat all those who have got the disease.

Immunization against HPV.