In the name of God

Cervical Cancer Dr.T allameh MD

Cervical cancer

• Annually 500000 new cases

• 4/100000= lowest in Israel,

83.2/100000= highest in Brazil

• USA breast, lung, colorectum, endometrium, ovary, cervix

• Average age = 52.2 years old

• Peaks at 35-39 & 60-64 years

Cervical cytologyCervical cytologySingle negative pap-smear Single negative pap-smear 45% 45%

decrease in riskdecrease in risk9 negative pap-smears 9 negative pap-smears 99% 99%

decrease in riskdecrease in riskFirst pap-smear at 18 years or sexual First pap-smear at 18 years or sexual

activityactivityEvery 3 years repeated and if more Every 3 years repeated and if more

than one risk factor, every year than one risk factor, every year Screening till 65 years old ( 25% of Screening till 65 years old ( 25% of

cancers and 41% mortality in this cancers and 41% mortality in this age)age)

History History Commonest symptom = AUB or dischargeCommonest symptom = AUB or discharge Postcoital spotting, intermenstrual bleeding, Postcoital spotting, intermenstrual bleeding,

menorrhagia, postmenopausal spottingmenorrhagia, postmenopausal spotting Chronic bleeding Chronic bleeding fatigue & anemia fatigue & anemia Frequent serosanguineous or yellowish discharge Frequent serosanguineous or yellowish discharge Advanced lesion or necrosis Advanced lesion or necrosis Foul odor discharge Foul odor discharge Locally advance disease or trauma Locally advance disease or trauma pelvic pain pelvic pain Advanced stage Advanced stage sciatic pain, back pain, sciatic pain, back pain,

hydronephrosishydronephrosis Advanced stage ( bladder Advanced stage ( bladder hematuria, rectum hematuria, rectum

hematochezia) hematochezia)

Physical examination Normal general ph/ex Visible lesion on the cervix Early lesion focally indurated,

ulcerated, slightly elevated and granular area bleeding

Large lesion Exophytic: polypoid or papillary Endophytic : bimanual exam

Inguinal and supraclavicular fossa for distant metastasis

Differential diagnosis

Other genital cancers ( endometrial ) Cervical leiomyoma Severe erosive cervicitis Complication of pregnancy Rarely cervical ectopic pregnancy

Diagnostic evaluationDiagnostic evaluationClinical evaluationClinical evaluationCareful inspection and palpation of cervix and Careful inspection and palpation of cervix and vagina (EUA) vagina (EUA) Colposcopic evaluation + ECC + directed cervical Colposcopic evaluation + ECC + directed cervical biopsybiopsyCervical conization or punch biopsyCervical conization or punch biopsyConization ifConization if

unsatisfactory colposcopyunsatisfactory colposcopy Positive ECC Positive ECC Lack of correlation in cervical cytology, colposcopy, biopsyLack of correlation in cervical cytology, colposcopy, biopsy Cervical microinvasiveCervical microinvasive Cervical biopsy + ECC = adenocarcinoma in situ for R/O of Cervical biopsy + ECC = adenocarcinoma in situ for R/O of

invasive adenocarcinomainvasive adenocarcinoma

IVP, CX-RayIVP, CX-Ray

Prognostic factorsPrognostic factors Clinical stage Clinical stage 5-year survival5-year survival

Stage IA = 97%, Stage IA = 97%, Stage IB = 85%, 5-year Stage IB = 85%, 5-year

survivalsurvival Stage II = 60%Stage II = 60% Stage III = 45%Stage III = 45% Stage IV = 18%Stage IV = 18% All stagesAll stages

75.2% if node 75.2% if node negativenegative

45.6% if pelvic node 45.6% if pelvic node positivepositive

15.4% if para-aortic 15.4% if para-aortic node positivenode positive

Size & depth of tumorSize & depth of tumor Histologic differentiation Histologic differentiation

( 75% well, 63.7% ( 75% well, 63.7% moderate & 51.4% poorly moderate & 51.4% poorly differentiated )differentiated )

SurgerySurgery

Type I Type I standard standard extrfascial TAHextrfascial TAH

Type II Type II modified modified radical radical hysterectomyhysterectomy

Type III Type III hysterectomyhysterectomy

Lymph adenectomy Lymph adenectomy ( II,III )( II,III )

Radiation therapyRadiation therapyExternal beam = whole External beam = whole pelvis lateral pelvis lateral prametriumprametriumBrachytherapy Brachytherapy central diseasecentral disease

Internal uterine tandem Internal uterine tandem with colpostats with colpostats

Interstitial needle Interstitial needle implantsimplants

Vaginal sylinderVaginal sylinder

Point A, 2cm lateral and Point A, 2cm lateral and 2 cm higher than 2 cm higher than external os ( 7500-8500 external os ( 7500-8500 cGY )cGY )Point B, 3cm lateral to Point B, 3cm lateral to point A ( sidewall of point A ( sidewall of pelvis )( 4500-6500 cGY)pelvis )( 4500-6500 cGY)

Acute complicationsAcute complications• Blood loss Blood loss average average

81%81%• Uterovaginal fistula Uterovaginal fistula

1-2%1-2%• Vesicovaginal fistula Vesicovaginal fistula

1-2%1-2%• Pulmonary embolus Pulmonary embolus

1-2%1-2%• Small bowel obstruction Small bowel obstruction

1-2% 1-2%• Hemorrhagic cystitis Hemorrhagic cystitis

3%3%• Proctosigmoiditis Proctosigmoiditis 8% 8%• Febrile morbidity Febrile morbidity 25- 25-

50%50%• 10% pulmonry10% pulmonry• 7% Pelvic cellulitis7% Pelvic cellulitis• 6% UTI6% UTI• 5% wound 5% wound

infection, pelvic infection, pelvic abscess, phlebitisabscess, phlebitis

Subacute & chronic complications

Subacute– Postoperative bladder dysfunction– Lymphocyst formation

Chronic – Vaginal stenosis (most common=70%) – Bladder hypotonia– Ureteral stricture

Chemotherapy Extrapelvic metastasisRecurrent disease ( not candidate for surgery or radiation )Cisplatin

Complete response is 24%Partial response is 16%

Neodjuant chemotherapy (Before surgery) improved survival & better resectionChemoradiation advanced cervical cancer ( sensitization of cervical cancer cell to irradiation)

Follow-up Persistent if detected within 6 months Failed primary treatment recurrence 50% in first year, 80% in first two years Pelvic examination and lymph node evaluation

( supraclavicular ) every 3 months for 2 years, every 6 months for following 3 years)

Cytologic smear every examination Any palpable mass, FNA under CT CX-Ray annually