Cervical cancer

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Cervical cancer
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Introduction

• Cancer of the cervix is the most common female
  genital cancer in developing countries every year
  about 500,000 women , acquire the disease and 75
  are from frame developing countries.
• About 300,000 women also die from the disease
  annually and of these 75 are from developing
  countries

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• Finland which has an advanced population based
  screening program has one of the lowest rates in
  the world.

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Incidence

• 4-6 of female genital cancers.

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Age

• 40-50 years old

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Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology
Risk factors and aetiology

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

• Coitus at young age lt16 years old increased risk
  by 50
• Number of sexual partners 6 sexual partners or
  more increase risk by 14.2 folds.
• Smoking
• Smoking forgt 12 years increase the
  risk by 12.7 folds.
• Male related risk factors
• number of the partners previous
  sexual relationships is relevant .
• cervical cancer risk increased if
  partners has penile cancer (circumcision)
• Previous wife with cervical cancer.
• Previous CIN
• Poor uptake of screening program.
• Long term use of the contraceptive pill increase
  the risk due to increasing exposure to seminal
  fluids.
• Barrier method decrease the risk (condan)
• Immuno suppresion risk increased with immuno
  suppressed renal transplant patients and in HIV
  positive women.
• HPV (Human papilloma virus ) infection mainly
  16,18
• the main aetiological is
  infection with subtypes of HPV (16,18)
• Low socioecomic class of

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Type of patient

• Multiparous.
• Low socioeconomic class.
• Poor hygiene.
• Prostitutes.
• Low incidence in Muslims and Jews.

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Predisposing factors

• Cervical dysplasia.
• (Cervical intraepithelial neoplasia)
• CIN III / CARCINOMA IN SITU
• THE LESION PROCEEDS THE INVASION BY 10-12 YEARS

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Symptoms
Early symptoms Late symptoms
- None. - Thin, watery, blood tinged vaginal discharge frequently goes unrecognized by the patient. - Abnormal vaginal bleeding Intermenstrual Postcoital Perimenopausal Postmenopausal - Blood stained foul vaginal discharge. - Pain, leg oedema. - Urinary and rectal symptoms dysuria haematuria rectal bleeding constipation haemorrhoids - Uraemia
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Pathology type

• Squamous cell carcinoma- 90.
• Adenocarcinoma- 10.

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Types of growth

• Exophytic is like cauliflower filling up the
  vaginal vualt.
• Endophytic it appears as hard mass with a good
  deal of induration.
• Ulcerative an ulcer in the cervix.

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DIAGNOSIS

• 1- History.
• Many women are a symptomatic .
• Presented with abnormal routine cx smear
• Complain of abnormal vaginal bleeding
• I M bleeding
• post coital bleeding
• perimenopausal bleeding
• postmenopausal bleeding
• blood stain vaginal discharge

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• 2- Examination
• Mainly vaginal examination using cuscus speculem
  nothing is found in early stage .
• Mass ,ulcerating fungating in the cervix
• P/V P/R is very helful.

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Cytology
Histology
calposcopy
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Preoperative evaluation

• Review her history.
• General examination
• Anaemia.
• Lymphadenopathy-Supraclavicular LN.
• Renal area.
• Liver or any palpable mass.
• Oedema.
• Laboratory tests
• CBC, LFT, RFT, Urine analysis.
• Tumour markers.
• Chest X- ray, abdominal X- ray, IVU.
• CAT, MRI, if necessary.
• Ultrasound.
• Lymphography, if necessary.

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Staging

• Best to follow FIGO system.
• Examination under anaesthesia.
• Bimanual palpation.
• P/V, P/R.
• Cervical biopsy, uterine biopsy.
• Cystoscopy, Proctoscopy, if necessary.

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STAGES OF CANCER CERVIX

• Once cancer cervix is found (diagnosed), more
  tests will be done to find out if the cancer
  cells have spread to other parts of the body.
  This testing is called staging.
• TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE
  STAGE OF THE DISEASE.

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SPREAD
Direct Lymphatic Dissemination (late)
- Uteruq. - Vagina. - Parametrium. - Bladder and rectum. A- primary node parametrial. Paracervical. Vesicovaginal. Rectovaginal. Hypogastric. Obturator and external iliac B-Secondary nodes Common iliac Sacral Vaginal Paraaortic Inguinal. - parametrial spread causes obstruction of the ureters, many deaths occur due to uraemia. - Obstruction to the cervical canal results in pyometria.
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DIFFERENTIAL DIAGNOSIS

• Cervical ectropion.
• Cervical tuberculosis.
• Cervical syphilis, Schistosomiasis, and
  Choriocarcinoma are rare causes.

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TREATMENT

• Surgical.
• Radiotherapy.
• Radiotherapy Surgery.
• Radiotherapy and Chemotherapy followed by
  Surgery.
• Palliative treatment.

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The choice of treatment will depend on

• Fitness of the patients
• Age of the patients
• Stage of disease.
• Type of lesion
• Experience and the resources avalible.

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Surgical procedure

• The classic surgical procedure is the wertheims
  hystrectomy for stage Ib,IIa, and some cases of
  IIb in young and fat patient

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Werthemeims hystrectomy

• Total abdominal hystrectomy including the
  parametrium.
• Pelvic lymphadenectomy
• 3 cm vaginal cuff
• The original operation conserved the ovaries
  ,since squamouss cell carcinoma does not spread
  dirctly to the ovaries.
• Oophorectomy should be performed in cases of
  adenocarcinoma as there is 5-10 of ovarian
  metastosis

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Surgery offers several advantage

• It allows presentation of the ovaries
  (radiotherapy will destroythem).
• There is better chance of preserving sexual
  function.
• (vaginal stonosis occur in up 85 of irradiates.
• Psychological feeling of removing the disease
  from the body .
• More accute staging and prognsis

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COMPLICATIONS OF SURGERY

• Haemorrhage primary or secondary.
• Injury to the bladder, uerters.
• Bladder dysfunction.
• Fistula.
• Lymphocele.
• Shortening of the vagina.

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• INDICATIONS OF P/O XRT FOLLOWING WERTHEIMS
  HYSTERECTOMY (STAGE I , IIa)
• Positive pelvic lymph nodes.
• Tumour close to resection margins and/or
  parametrial extension.

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Radiotherapy

• Stage IIb and III
• Radical Radiotherapy
• External irradiation (Teletherapy).
• Intracavitary radiation (Brachytherapy).
• In some cases of stage IIa or b radio and
  chemotherapy to be given then followed by simple
  hysterectomy -------

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Palliative therapy

• For stage IV individualized therapy.
• Some suitable for palliative XRT ( usually
  intracavitary Caesium).
• Some suitable for extensive surgery.
• Some suitable for chemotherapy.
• Good nursing care.
• Analgesia-must be used in sufficient amount to
  ----- pain (Codein sulfate, Pethidine, Morphine,
  Diamorphine).
• Antiemetic if necessary.
• IV drip, entral, and parentral feeding.
• Urinary Catheterization.
• Other measures for symptom relief.

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PROGNOSIS

• Depends on
• Age of the patient.
• Fitness of the patient.
• Stage of the disease.
• Type of the tumour.
• Adequacy of treatment.

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• THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY
• Stage I -------80
• Stage II-------50-60
• Stage III-------30-40
• Stage IV-------4

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MANAGEMENT OF RECURRENT DISEASE

• 1. Local recurrence
• Radiation if not used.
• Pelvic exenturation.
• 2. Distant disease
• Chemotherapy.

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Follow up policy

• On completion of treatment all patients are given
  a vaginal dilator to use until vaginal mucosa
  healed, this prevents vaginal stenosis.
• Premenopausal patients commenced on HRT
• post hysterectomy-Extraderm skin patches 50 meg
  twice weekly.
• No hysterectomy- Cycloprogyn 1mg daily.
• The patient to be seen 1/12 post-treatment.
• 3 monthly for 2 years.
• 4 monthly for 3rd year.
• 6 monthly until 5years.
• Then yearly all her life.
• Patients with stage I and II disease treated with
  radical radiotherapy will be assessed by EUA
  approximately 3 months after completing treatment.

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Objective

• Cancer of the cervix is still quite common,
  reduction in incidence depends on the quality of
  the screening program.

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• The aetiology appears to be multifactorial the
  prime oncogenic agent is probably HPV-16,18.
• Clinical presentation is with inermenstrul,postcoi
  tal, postmenospausal bleeding or following
  abnormal cytology.
• Tumour spreads locally to involve the uterus
  bladder , vagina, parametrium, ureters, rectum
  and bone.

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• Spread also to the internal and external iliac ,
  obdurater and common iliac nodes then to para-
  aortic nodes.
• Blood borne metastasis spread to liver, lung and
  bone occur .
• Microinvasion squamous tumour carry a good
  prognosis allowing conservative treatment
  initially if required.

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• Early invasive squamous cell disease (stage
  Ib,IIa and in some cases of IIb) may be treated
  by either a wertheimes hysterectomy or
  radiotherapy as first line treatment.
• Advanced stage (IIb, III,IV) treated by radio or
  chemotherapy.

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• Glandular tumours (adenocarcinomas) are not
  detectable by screening are associated with skip
  lesions and require radical surgery.