CERVICAL CARCINOMA

ANATOMYParts of Uterus1.Body/Corpus2.Isthmus3.cervix-a)supra-vaginal part b)vaginal part

Ligaments1.Broad ligament2.Round ligament3.Uterosacral ligament

LYMPHATICSLYMPH NODES AROUND UTERINE CERVIX1.Uppermost-Hypogastric LN2.Obturator LN & External illiac LN3.Inferior & superior gluteal, Common illiac,Presacral and Subaortic LN4.Anterior branch-Internal illiac LN5.Posterior branch-superificial rectal LN

COMMON ROUTES OF LYMPHATIC SPREADObturator LN or Hypogastric LN or External illiac LN

Common illiac LN or para-aortic LN

ANATOMIC SITES OF FIRST METASTASIS

HISTOLOGY

• Squamocolumner junction

• Transformation zone

RISK FACTORSEarly coitusMultiple sexual partnersEarly childbirthMulti-parity with poor birth spacingPartner with penile cancer

Poor personal hygeinePoor socioeconomic status

Smoking,alcohol,drugs

Immunosuppression(eg.transplant recipients)Infections-STDs,HIV,HSV2,CondylomataHPV(16,18,31,33,45…)Pre-invasive lesions

HPV-an essential criteria for CA Cervix

HPV infection & proliferation

Molecular biology of HPV infection

HPV vaccination•GARDASIL-Quadrivalent(VLPs for HPV 6,11,16,18)•CERVERIX-Bivalent(VLPs for HPV16,18)Efficacy 100% for seronegative or seropositive but with negative HPV DNA

•ACS GUIDELINESReccomended for girls @ 11 to 12 years(9-18years)Cervical Screening programme to remain unaffected

PRE-INVASIVE LESIONS of CERVIX

COMPARISON B/W VARIOUS CLASSIFICATION SYSTEMS

Pre-invasive to invasive% of CIN REACH INVASIVE STAGE IN YEAR

4% 1 Y

11% 3 Y

22% 5 Y

30% 10 Y

screening ACS NCCN ACOG

Start Within 3 years of 1st sexual activity, no later than 21 year

Age 21 year

Upto 30 Y

Conventional Pap-annuallyLiquid Pap-2yearly

Every 2 years

>30Y Every 2-3 years after 3 consecutive normal pap smears

Every 2-3 years after 3 consecutive normal pap smearsOr every 3 years when cytology + HPV Test

Every 3 years after 3 consecutive normal pap smears

Stop Age 70 years after 3 consecutive normal Paps & no abnormal results within 10 years

Age 70 years after 3 consecutive normal Paps & no abnormal results within 10 years

Age 65-70 years after 3 consecutive normal Paps & no abnormal results within 10 years

Post hystere ctomy

none none None.except H/O CIN2-CIN3

HPV DNA

>30 years,every 3 years with cytology

DIAGNOSIS• Clinical features Mostly asymptomatic Post coital bleeding Post menopausal bleeding On Inspection- cervicitis/erosion - bleeds on touch

• investigations Pap smear test Liquid based cytology DNA study Colposcopy Cone biopsy

CONVENTIONAL PAP GIVING WAY TO LIQUID PAP

HYBRID CAPTURE TEST FOR HPV DNA

COLPOSCOPY & BIOPSY

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Conization• Removes a cone-

shaped piece of tissue

• Often allows for diagnosis and treatment

• Performed with local anesthesia in the office or under general anesthesia in the operating room

CONE BIOPSY

TREATMENT

LOCAL DESTRUCTION LOCAL EXCISION RADICAL TREATMENT

CeauterisationCryo-surgeryLaser ablation

ConisationLLETZLEEPNETZ

TrachelectomyHysterectomy with removal of vaginal cuff

Local excision methods

RADICAL SURGICAL TREATMENT

INVASIVE CERVICLE CANCER

PATHOLOGY•Invasive squamous carcinomaSmall cellLarge cellKeratinisingNon-keratinising

Rare varientsPapillaryVerrucoussarcomatoid

Adenocarcinoma •Adenocarcinoma in situ•Invasive adenocarcinomaMucinousMinimal deviation adenocarcinomaGlassy cell adenocarcinomaAdenoid basal adenocarcinomaAdenoid cystic adenocarcinoma

Serous

Other types

• Neuroendocrine tumors-Anaplastic small cell tumors

• Rare neoplasms Metastasis-from colon , breast Sarcomas - Embryonal Rhabdomyosarcoma,

Leiomyosarcoma,Adenosarcoma Lymphoma melanoma

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CLINICAL FEATURES 1. BLEEDING --- postmenopausal, metrorrhagia, menorrhagia, post coital bleeding.

2. PAIN in the pelvis or hypogastrium

3. URINARY Symptoms

4. RECTAL Symptoms

5. DISTANT SITE SPECIFIC METASTATIC MANIFESTATIONSa. LYMPHATIC SPREAD --- to supraclavicular LN, para-aortic lymphadenopathy (non

specific abdominal symptoms)b. HEMATOGENOUS SPREAD---- to lungs (cough, respiratory distress, in 21% of patients

in metastatic setting) ---- bone pain

INTERNAL EXAMINATION (EXAMINATION UNDER ANAESTHESIA – ADVISED)1. INSPECTION --- Cauliflower like growth --- exophytic nature Bleeding from the growth Serosanguineous vaginal discharge2. PALPATION ----1) uterus ---- size, shape, position2) cervix ---- bulky3) growth might obliterate the vaginal fornices 4) friable growth, ulcerated , which bleeds to touch ---- blood

present on finger tips5) parametrium – nodular thickening extending upto the

lateral pelvic wall (by per –rectal examination)

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CLINICAL FEATURES -EXAMINATION - DIAGNOSIS

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STAGING --- FIGO STAGING

1) FIGO staging was based on anatomical compartmental spread of cervical cancer.

2) No inclusion of lymph nodal status

3) LVI not included because pathologists do not agree on status on presence of LVI

4) MRI, CT and PET Scan – not included in formal staging.

FIGO STAGING OF CA CERVIX

Staging & survival

IMAGING STUDIES

CT scan Detects para-aortic metastasis(Sp-100%)

MRI scan Assessment of extracervical tumor extension Assessment of local tumor control Early prediction of tumor regression Can differentiate reccurant tumors from fibrosis

FDG PET scan detects para-aortic metastasis(Sn-72% & Sp-92%) Detects metabolically active recurrence or residual