CARCINOMA CERVIX

CARCINOMA CERVIX
1,25,000 new patients in India every year
Incidence varies from 15 48 / 100,000 women
Carcinoma cervix is preventable
Health education
Screening programmes

Risk factors for Carcinoma cervix

Early age at intercourse

Repeated / Frequent births
Multiple sexual partners
HPV infections (Type 16 & 18 highly oncogenic)
Low socio-economic status
Smoking

CARCINOMA CERVIX
Site
Ectocervix 80%
Endocervix 20%

Gross lesion

Occult
Proliferative : Friable growth
Ulcerative : Erodes the cervix to form an irregular crater
Infiltrative : Expands the cervix

Histopathology
Squamous cell carcinoma (80-90%)
Large cell keratinizing
Large cell non-keratinizing
Small cell

Adenocarcinoma (10-20%)

Endocervical
Clear cell
Adeno-squamous
Adeno-acanthoma

CARCINOMA CERVIX : SPREAD

Direct
Vagina
Uterus
Parametrium

Lymphatic
Primary nodes
Obturator
Internal & External Iliac
Sacral
Secondary nodes
Common Iliac
Para-aortic
Inguinal

Haematogenous
Lungs
Liver
Bone

CARCINOMA CERVIX : STAGING

Staging is clinical
Investigations permitted

Cystoscopy / Proctoscopy
Intra-venous Urography
X-ray chest
Imaging studies (USG / CT / MRI)

Preinvasive carcinoma
Stage 0 : Carcinoma in situ
Not to be included in therapeutic statistics

CARCINOMA CERVIX : STAGING OF

INVASIVE DISEASE
Stage I

: Carcinoma confined to the cervix

(Extension to the corpus should be disregarded)

Stage Ia : Invasive carcinoma diagnosed only by

microscopy
Stage Ia1: Minimal microscopic stromal invasion, maximum depth
3mm from basement membrane
Stage Ia2: Microscopic stromal invasion > 3mm from basement
membrane, but less than 5mm. Maximum horizontal
spread < 7mm. Larger lesions should be staged Ib

Stage Ib : Invasive carcinoma confined to the cervix,

greater than Ia2 whether seen clinically or not
Stage Ib1 : Preclinical lesions greater than Ia2 or clinical lesions not
exceeding 4cm in size
Stage Ib2 : Clinical lesions > 4 cm in size

CARCINOMA CERVIX : STAGING OF

INVASIVE DISEASE

Stage II : The carcinoma extends beyond the

cervix and uterus but not to the lateral pelvic wall
or to the lower 1/3 of the vagina
Stage IIa: No obvious parametrial involvement
Stage IIb: Obvious parametrial involvement

CARCINOMA CERVIX : STAGING OF

INVASIVE DISEASE

Stage III : The carcinoma extends to the lateral

pelvic wall, or to the lower 1/3 of the vagina, or
causes Hydronephrosis or non-functioning Kidney
Stage IIIa: The carcinoma involves the lower 1/3
of the vagina. No extention to the lateral pelvic
wall
Stage IIIb: The carcinoma extends to the lateral
pelvic wall, or causes Hydronephrosis or non
functioning kidney

CARCINOMA CERVIX : STAGING OF

INVASIVE DISEASE

Stage IV : The carcinoma extends beyond the true

pelvis or has clinically involved the mucosa of the
bladder or rectum (biopsy proven)
A bullous edema of the bladder / rectal mucosa as
such, does not permit a case to be allotted to
Stage IV
Stage IVa: Spread of carcinoma to adjacent
organs
Stage IVb: Spread of carcinoma to distant organs

Diagnosis of carcinoma cervix

Preclinical (Stage Ia & some patients of Stage Ib1
with absence of obvious growth)
Asymptomatic
Detected on screening

If microinvasion is detected on targeted biopsy or

endocervical curettage, a conization of the cervix
is mandatory to exclude the presence of invasive
carcinoma

Diagnosis of carcinoma cervix

Clinical (Stage Ib1 onwards)
Early symptoms
Abnormal bleeding
Post coital
Inter-menstrual
Post-menopausal

Abnormal discharge
Blood stained
Dirty
Foul smelling

Late symptoms
Pelvic pain
Urinary symptoms
Rectal symptoms

Diagnosis of carcinoma cervix

Signs

Abnormal area / growth on cervix

Induration
Friability
Bleeding on touch
Fixity

Confirmation of diagnosis
Diagnosis is confirmed by Histopathological
examination of the biopsy sample

Differential diagnosis

Fibroid polyp
Chronic inversion of the uterus
Cervical Tuberculosis
Cervical ectopic pregnancy

Complications

Pyometra
Haemorrhage
Pyelonephritis
Vesico-vaginal fistula
Uraemia
Recto-vaginal fistula

Prognosis

Staging
Histologic type
Differentiation
Tumor volume
Lymph node involvement

Cause of death
Uraemia
Haemorrhage
Sepsis

Prevention of Carcinoma cervix

Health education

Avoid early marriage

Avoid early intercourse
Avoid promiscuity
Proper hygiene
Use of barrier contraception

Screening programs
Screening for pre-malignant lesions
Screening for early diagnosis

Investigations
For confirmation of diagnosis
Biopsy
From obvious growth or abnormal area
Directed biopsy in very early lesions
Cone biopsy

For staging of disease

Intravenous Urography
Abdominal Ultrasonography
Cystoscopy
Proctosigmoidoscopy
Examination under anaesthesia (EUA)
CT / MRI

Base line investigations of general condition

Treatment
Factors

Stage of disease
Age of patient
General condition / Associated problems
Tumor configuration

Modalities

Surgery
Radiotherapy
Combined
Chemo-radiation

Surgery for Carcinoma cervix

Curative surgery can be performed in Ca Cx upto
Stage IIa
Surgery is preferred in

Young patients
Patients with prolapse
Patients with uteri distorted by fibroids
Co-existing pelvic pathology

Stage Ia1 disease

Conization may be both diagnostic and therapeutic
Simple extra fascial hysterectomy

Surgery for Carcinoma cervix

Stage Ia2 IIa disease
Wertheims / Meigs hysterectomy
(Extended hysterectomy with pelvic lymphadenectomy)

Uterus including cervix

Adnexae (Ovaries spared in the young)
Wide resection of the parametrium
Removal of vaginal cuff
Dissection of peri-ureteral tissues
Pelvic lymphadenectomy

Stage IV a disease
Exenteration

Surgery for Carcinoma cervix

Advantages

Preservation of ovarian function

Preservation of vaginal function
Lesser long term morbidity
Complications correctable

Complications

Haemorrhage
Infection
Lymphocyst formation
Ureteric injury / fistula
Traumatic

Ischaemic
Bladder injury
Neurogenic bladder dysfunction

Radiotherapy for Carcinoma

cervix
Advantages
Applicable for all stages of disease
As effective as surgery in early stages
Lesser primary mortality and immediate morbidity as
compared to surgery
Preferred in patients unfit for surgery because of
medical conditions or extreme obesity

Techniques
Brachytherapy
Teletherapy

Brachytherapy
Radiation sources placed adjacent to the tumor by means
of intra-uterine tandems and vaginal colpostats
Inverse square law : The dose of radiation at any given
point is inversely proportional to the square of the distance
from the source of the radiation
The dose decreases rapidly as the distance from the
applicator increases
Personnel protected by afterloading techniques
Computerized dosimetry plots isodose curves by taking
into account tumor geometry and placement of radiation
sources
Brachytherapy helps in achieving central control of the
tumor

Brachytherapy
Point A
It is a paracervical area located 2 cm lateral to the cervical canal and
2 cm above the external os
It corresponds to the crossing of the ureters under the uterine artery
Adequate summated dose to point A to achieve central control of the
tumor is ~ 7500 8000 cGy

Point B
It is located 3 cm lateral to point A on the same horizontal plane
It corresponds to the site of the Obturator lymph nodes on the lateral
pelvic wall
The prescribed dose to point B is 4500 6000 cGy depending upon
the bulk of parametrial and side wall disease

Techniques of Brachytherapy
Low dose radiation (LDR)
Paris technique
One application

120 hrs

Manchester technique
Two applications

72 hrs each repeated after 7 days

Stockholm technique
Three applications :

24 hrs each at weekly intervals

High dose radiation (HDR)

Five fractions of 700 cGy each to Point A daily

Teletherapy
Radiation is directed towards tumor tissue from
external sources like Cobalt 60, Caesium 137 or
Linear accelerators
Usual dosage is 900 cGy / week in 5 fractions of
180 cGy each, given with or without central
shielding
Teletherapy is usually given by parallel opposing
fields or multiple external fields to decrease
damage to normal tissues

Complications of radiotherapy
Radiation damages adjacent normal pelvic tissues
in addition to malignant cells
Ideal radiation treatments aims to achieve a
delicate balance between complete tumor kill
without exceeding the tolerance dosage for
normal tissues
The dose limiting tissues within the pelvis are the
rectum, bladder and any loops of the small
intestine within the radiation field
The radiation dosage to the bladder and rectum
should be kept less than 6000 cGy

Complications of radiotherapy

Radiation effects may be immediate or delayed

Immediate effects are inflammation and ulceration
Delayed effects may appear after months or years
Delayed effects are due to ischaemic endarteritis.
These effects are progressive, irreversible and
dose dependant
Vagina, Bladder and Rectum are effected with
fibrosis, stricture, vasculitis and fistula formation

Combined surgery and

radiotherapy
Minimal role, except in bulky endophytic lesions
(Stage Ib2 and IIa)
Long term survival is not improved using
combined radiotherapy and surgery
Complications of combined radiotherapy and
surgery are higher

Chemo-radiation
Adjuvant chemotherapy
Cisplatin initially used as an adjuvant to
improve results with radiotherapy or shrink
tumor size before surgery
Radiotherapy is now combined with adjuvant
Cisplatin chemotherapy in a chemo-radiation
protocol

Results of therapy

Stage

5 year survival rate

85%

II

55%

III

38%

IV

15%