obstetrics & gynecology,

2. CARCINOMA OF
CERVIX
PRESENTED BY
YASIR NAWAZ
FINAL YEAR MBBS
C.NO. 08-215
BATCH: L

3. • The most preventable female cancer
• January is cervical cancer awareness
month

4. CONTENTS OF PRESENTATION
 WHAT IS CERVIX?
 INCIDENCE & AETIOLOGY
 STAGING
 CLINICAL FEATURES
 DIAGNOSIS
 TREATMENT & FOLLOW UP.

5. WHAT IS CERVIX?
 The cervix is part of a woman's reproductive system. It's in
the pelvis. The cervix is the lower, narrow part of the uterus
(womb).
 The cervix is a passageway:
 The cervix connects the uterus to the vagina. During a
menstrual period, blood flows from the uterus through the
cervix into the vagina. The vagina leads to the outside of
the body
 The cervix makes mucous. During sex, mucous helps sperm
move from the vagina through the cervix into the uterus.
 During pregnancy, the cervix is tightly closed to help keep
the baby inside the uterus. During childbirth, the cervix
opens to allow the baby to pass through the vagina.

8. INCIDENCE
The incidence of cervical carcinoma in UK is
15 per 100,000 and in USA it is 10 per 100,000.
The said ratio varies in different population
groups.
Invasive carcinoma may occur at any age but
peak incidence is at 45 years, while that of
endometrial carcinoma is at 60 years.

10. AETIOLOGY
 Coitus: It's the most important factor and also the number of
sexual partners should be taken into consideration. Monks,
nuns and virgins are at least risk of developing this disease.
Prostitutes and women who suffer from venereal diseases
have a higher chance of developing cervical carcinoma.
 Age of first coitus: If the sexual intercourse takes place at less
than 17 years of age or before adolescence, the risk of
carcinoma of cervix is higher.

11.  Multiple pregnancies: 95% of invasive cancers occur in
multipara. It may be the reason for higher incidence of
cervical carcinoma in women with multiple pregnancies
and having first child at an early age.
 Social Status: women of low socioeconomic group are at
higher risk because of early marriages and poor hygiene.
 Race and Religion: Jewish and muslim women are at
lower risk than negresses.
 Circumcision: once it was believed that jewish and
muslim women are at lower risk because partners are
circumcised as penile hygiene after circumcision is
better.

12. ● Smoking: it's also associated with cervical carcinoma
according to recent studies.
● Others: HPV, HIV, HSV and Chlamydia infections are also
contributory to the said issue.
● Human Spermatozoa: phagocytosis of spermatozoa by
metaplastic epithelium may take place.
incorporation of sperm DNA into cell nucleus may cause
genetic mutation and it becomes carcinogenic.

13. CLINICAL STAGING
FIGO revised the staging of cervical carcin-
oma in Montreal 1994.
●Stage 0: Carcinoma in situ, intraepithelial neoplasia . These
shouldn’t be included in any therapeutic statistics.
●Stage 1: Strictly confined to cervix.
1a: preclinical invasive carcinoma with horizontal extension
of not more than 7mm.
1b: lesions of greater dimension than stage 1a.
clinically visible lesion of equal to or more than 4cm.
●Stage 2: The carcinoma extends beyond the uterus but
hasn’t extended on to the pelvic wall, carcinoma involves
vagina , but not as far as the lower third.

14.  Stage 3: The carcinoma has extended on to the pelvic
wall.the tumor involves the lower third of the vagina.
 Stage 3a: No extension on to the pelvic wall, but
involvement of the lower third of the vagina.
 Stage 3b: Extension on to the pelvic wall or hydronephrosis.
 Stage 4: the carcinoma has extended beyond the true
pelvis or has clinically involved the mucosa of the bladder
or rectum.
 Stage 4a: spread of growth to adjacent organs involving
mucosa of bladder or rectum.
 Stage 4b: Spread to distant organs.

16. TYPES OF CERVICAL
CARCINOMA
 Squamous Cell Carcinoma: It arises from the
stratified squamous epithelium of ect-
ocervix.
● Adenocarcinoma: It arises from the columnar
epithelium of the cervical canal.
● Mixed Type: Includes adenosquamous,
mucoepidermoid, glassy cell types.
● Undifferentiated type: Very rare.

17. SPREAD
 Direct Spread
 Lymphatic Spread
 Haematogenous Spread

18. Direct Spread
 It first involves rest of the cervix and then spreads
downward, laterally, upward, anteriorly and posteriorly.
 Downward Spread: Involving upper part of the vagina,
may be in some cases involve whole of the vagina.
 Lateral Spread: It's into the parametrial tissue involving
walls of the pelvis. It may involve lower end of the
ureters and cause ureteric obstruction.
● Upward Spread: May extend to body of the uterus and
cavity.
● Anterior and Posterior Spread: It may extend anteriorly to
base of the bladder and posteriorly to rectum, causing
formation of fistulae.

19. LYMPHATIC SPREAD
Primary lymphatic spread is into the nodes situated in the tissues
around the cervix. Later may involve other groups of nodes,
which are, internal , external and common iliac, obturator,
sacral and paraortic nodes.

20. HAEMATOGENOUS SPREAD
This is an uncommon route of spread. In later stages
metastases to lungs, bones, brain and other parts may
reach through the blood stream.
CLINICAL FEATURES:
SYMPTOMS:
Asymptomatic: in a case of microinvasion there may not
be having any symptoms.
Abnormal vaginal bleeding: This is the most common
symptom. The amount of bleeding is variable. Bleeding
may be in the following forms:
Intermenstrual bleeding, postcoital bleeding and
postmenopausal bleeding.

21.  Pain: Pain occurs in advanced cases. Patient may complain of
backache, abdominal pain ureteric colic, rectal pain and
frequency of micturition and dysuria.
 Vaginal discharge: in advanced cases the patient may complain
of foul smelling blood stained vaginal discharge.
 Others: In advanced stages, there may be anorexia, malaise, loss
of weight, anaemia and uraemia.
PHYSICAL SIGNS:
● Normal cervix: in case of microinvasion the cervix may look healthy
and no abnormality seen on naked eye examination.

22.  Consistency: If it feels harder and bleeds on touch then it's
suspicious.
 Excavated ulcer: the ulcer may have ragged margins and the
cervix may be indurated and hard.
 Polypoidal growth: The size of the growth is variable arising either
from ecto or endo cervix.
 Enlarged, Hard and Friable cervix: this is a typical feature of
infilterating type of carcinoma.
 Mobility: the mobility of the uterus is restricted and induration is felt
through vaginal fornices.

23. DIAGNOSIS
Following are the methods for early diagnosis:
Pap Smear: It's done by making smears from scrapings of
cervical and vaginal walls. A smear is also prepared from
pool of secretions in the posterior fornix. When fixed and
stained , these smears show malignant cells.
HPV Testing: It is carried out when cytology is suspicious. If the
test is positive then colposcopy is necessary whereas if
negative then the patient can be spared from colposcopy.
Schiller's Test: Gram's iodine and KI is instilled into the vagina.
The healthy squamous epithelium takes the stain while the
diseased area is left unstained. This test is

24. utilized in deciding the area to be excised.
Acetic Acid Test: By application of 5% acetic acid to cervix, the
abnormal cells attain white colour.
Colposcopy and Colpomicroscopy: these procedures are you
used to detect cervical lesions at an early stage. This is possible
by careful scrutiny of changes in the cellular pattern and
vascularity of the covering epithelium and the transformation
zone.
Biopsy of the Cervix:
Punch biopsy: punch biopsies are usually taken from squamo-
columnar junction unstained or aceto-white areas.

25. Wedge biopsy: A wedge is resected from the suspected
area. This is usually carried out to confirm the diagnosis
before embarking upon the treatment.

26. Cone Biopsy
 Cone Biopsy: In this type
of biopsy, whole of the
squamo-columnar
junction along with the
columnar epithelium of
the cervix is excised in
one piece. This is carried
out with a scalpel under
general anaesthesia.
Haemostasis is secured
with electro-coagulation
or catgut sutures.

28. TREATMENT
Assessment and Preparation:
 General Health
 Assessment of the disease
 Investigations: routine investigation;
 Hb estimation
 Blood grouping and cross matching
 Blood urea and serum creatinine
 Urine for culture and sensitivity
 chest X-ray
 MRI
 IVU & Bone Scan

29. Radiotherapy: It's a treatment of choice especially
where facilities are available and for those patients
who are not fit to undergo operative treatment.
Techniques:
1. intracavitary irradiation
2. External irradiation
3. Combination
4. interstitial irradiation
Surgical Treatment:
Surgery for microinvasion: simple hysterectomy
Radical procedures:
1. Uterus alongwith fallopian tubes
2. Cervix along with a cuff of vagina

31. 3. Parametrial tissue along with parametrial lymphatics and
lymph nodes
4. Pelvic lymph nodes
5. Evaluation of paraortic glands
Techniques:
Abdominal operation:
Wertheim's Hysterectomy
Vaginal operation:
Shauta's or Mitras Hysterectomy
Chemotherapy: This is called neoadjuvant therapy. These
drugs are used in advanced diseases. These drugs are
Cisplatin, Vinblastine, Bleomycin, Methotrexate, 5FU and
Mitomycin C.

32. Combined Treatment: In some centers radiotherapy and surgery are
combined for the treatment of invasive carcinoma of cervix.
Palliative Treatment: Aim is to enhance the betterment of the patient
symptomatically. Cisplatin, Bleomycin, Vincristine are used for
palliative therapy.

34. SURVIVAL RATE IN RELATION TO STAGING
OF CERVICAL CANCER

36. JADE GOODY

37. JADE GOODY
+ CA cervix

39. Thanks