CANCER CERVIX

India accounts for about one-fourth of the new

cases of cervical cancer disease in the world
2

New Cervical Cancer Cases

India ~23%

India: ~122,844
India - 27%

Rest of World - 77%

World: ~
527,624
India ~23% of new
Cervical Cancer cases in world
TRICHY
WHO/ICO OBGCentre
Information MEET on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India.
Report 2015. [Accessed on 13tth Apr,2015]. Available at www. who. int/ hpvcentre
 India accounts for about one-fourth of
the cervical cancer deaths in the world
3

Approx. 184 women die every day

Cervical Cancer
67,477 Approx. 8 women die every hour

Deaths/Yr
(25%) Every 7 minutes a women dies

TRICHY
WHO/ICO OBGCentre
Information MEET on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2014. [Accessed
on 11 h Feb,2014]. Available at www. who. int/ hpvcentre
 Within India, the burden of cervical cancer is
especially high in rural 4and urban Tamil Nadu
Average annual age adjusted Incidence Rates per 100,000 population, Females – Cervix Uteri*

25
22
21
20 19 19 19 19
18

15 15
15 14 14 14
12
11 11
10 9 9 9
8
6
5

* ASR Dindigul (2003-2006)1; ASR Chennai (2006-2008)2

TRICHY
1. Swa minathan ROBG MEET
et al. Ca ncer Epidemiology 33 (2009): 325-331 2. Na ti onal Ca ncer Registry Programme. Three-Year Report of Population Based Ca ncer Registries. 2006-2008. Fi rst Report of 20
PBCRs i n India. Indian Council of Medical Research. Ava ilable a t www.pbcrindia.org
 The burden of cervical cancer in India is
projected to increase by >85% by 2025
5

INCIDENCE MORTALITY
Projected burden in 2025 is estimated by applying 2010 population forecasts for India and assuming that
current mortality rates of cervical cancer are constant over time.
TRICHY OBG MEET
WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in I ndia. Summary Report 2010.
[Accessed on 5th July,2010]. Available at www. who. int/ hpvcentre
WHO Recommends a Comprehensive and
Coordinated Strategy To Prevent and Control
Cervical Cancer

PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION

HPV vaccination for girls 9-13 Screening for women > 30 years All women as needed
years and treatment as needed Treatment of invasive cancer at any
age

Adapted from Dr Nathalie Broutet. WHO strategies and responses to cervical cancer burden. World Health Organization. Reproduc tive Health and
TRICHY OBG MEET 6
Research Department. Regional Workshop on Cervical Cancer, Bangkok Thailand 27 -30 November 2012
 MACROSCOPIC FEATURES

 Exophytic
Irregular (Cauliflower growth)
Vascular
Fungating
 Endophytic
Barrel Shaped
Stony hard
 Ulcerative
Large ulcers
Indurated
 MICROSCOPIC

SQUAMOUS CELL CA- 80-85%

ADENOCARCINOMA
 endocervical
 endometroid
 Minimal deviation
 Papillary villoglandular
 Serous
 Clear cell
 Mesonephric
MIXED CERVICAL TUMOURS
 Adenosquamous
 Glassy cell
NEUROEDOCRINE TUMOURS
 Large cell
 Small cell

OTHERS
 Sarcomas
 lymphomas
 GRADING

 GRADE 1 ,2 and 3
 Association between histological grading and
prognosis is not clear
 SPREAD

 DIRECT EXTENSION-parametrium,pelvic side

wall,uterine corpus,vagina,bladder,rectum
 LYMPHATIC SPREAD-
PRIMARY NODES
paracervical,parametrial,internal iliac,external
iliac,obturator,sacral
SECONDARY NODES
comman iliac,para-aortic,inguinal,left
supraclavicular
HEMATOGENOUS-Liver,lungs and bones
 CLINICAL FEATURES

 HISTORY
Age(35-65yrs)
Multipara
Abnormal uterine bleeding,
Vaginal discharge
Pain due to involvement of uterosacral ligament
Pedal edema
Urinary symptoms like dysuria,hematuria
Bowel symptoms like diarrhoea,rectal bleeding
Age at first intercourse,STDs,immunosupression,
COC Use,Multiple sex partners
 EXAMINATION

 GENERAL: Anemia,cachexia,pedal
edema,supraclavicular node,inguinal nodes
 P/A: Palpable mass
 P/S: Growth in cervix
 P/V: Friable,bleeds on touch,extension
 P/R: Parametrial infilteration, rectal mucosa
 COMPLICATIONS

 Hemorrhage
 Frequent attacks for ureteric pain due to pyelitis and
pyelonephritis
 pyometra
 vesicovaginal fistula
 rectovaginal fistula
 Causes of death

 uremia is due to ureteric obstruction following

parametrial invovement.there is hydronephrosis and
hydroureter
 hemorrhage: vaginal bleeding from the growth may
be brisk or continous
 sepsis: localized pelvic or generalized peritonotis
may occur which is fatal
 cachexia: cumulative effect leads to cachectic
condition
 metastases to distant organs
 DIAGNOSIS

CERVICAL BIOPSY
COLPOSCOPIC
CONE
ENDOCERVICAL CURETTAGE
 Staging procedures allowed by FIGO

 Inspection of cervix and vagina

 pelvic examination

 Procedure used: Lymph node

palpation,coloposcopy,hysteroscopycy,cystoscopy,
biopsy,endocevical curettage,conization,

 Detection: enlargement and site, extension and depth of

tumour
 chest xray-pulmonary metastasis
 skeletal xray- bone metastasis
 usg- hydronephrosis
 barium enema-large bowel involvement
 proctoscopy-rectal involvement
 STAGING

 CLINICAL
 FIGO
I A:Microscopic disease(<5mm depth,<7mmwidth)
B: Macroscopic disease
II: Beyond uterus,not to pelvic wall,lower 1/3rd
vagina
III: Pelvic wall,lower vagina,hydronephrosis,
Non-functionong kidney
IV: Bladder,Rectum,other organs
 OTHER MODALITIES

 CT SCAN-
enlarged lymph nodes,liver,urinary tract and skeletal
metastasis
MRI
PARAMETRIAL INVASION
extension to uterine body and vagina
 INVESTIGATIONS

 CBC
 Blood Grouping
 RFT
 RBS
 Chest X-ray
 USG: enlarged uterus,barrel cervix,kidneys
 TREATMENT

 IA1: conization – for diagnosis and treatment

if free margins
simple hysterectomy:no LVSI
IA2:Modified radical hysterectomy
IB1: Radical Hyst +b/l pelvic lymphadenec/ChemRT
IB2: Radical Hyst+ b/l pelvic lymphadenec+RT
IIA: Radical Hyst+b/l pelvic lymphadenec/ChemRT
III-IV-ChemoRT
 SURGERY RADIOTHERAPY

 Ovaries preserved  Partially preserved with

transposition
 No vaginal narrowing  Vaginal stenosis

 More immediate  Few-

complications nausea,vomiting,diarrho
ea
 More-
 Few late complications
cystitis,proctitis,fistula,
stenosis
 Difficult with
comorbidities Indicated in co morbidities
 DECISION MAKING

 Age
 Menopausal status
 Stage
 Size<4cm
 Co-morbidities-obesity,HT,DM,IHD
 CHEMORT

 Chemotherapy
Cisplatin 40mg/m2 weekly X 4 wks
External RT
With chemotherapy
5 days a week X 5 weeks
Intracavitary Radiation
LDR-Cs-137(36-48 hrs)
HDR-Ir-192(once weekly X 2 wks)
POINT A-80-85 Gy
POINT B-55-65 Gy
 FOLLOW UP

 3 mthly X 3 yrs
 6 mthly X2 yrs
 Yrly thereafter
 advantages of surgery over radiotherapy

 spread of the disease can be determined more

through surgicopathological staging
 surgical staging and assessment of paraaortic and
pelvic lymphnode can predict survival rate
 preservation of ovarian function
 retention of more function and pliable vagina for
sexual function
 Disadvantages of surgery

 ureteric fistula
 vesicovaginal fistual
 bladder dysfunction
 cystitis,pyelonephritis and rectal dysfunction
 bladder dysfunction
 neuropathies due to nerve injury
 lymphocyst formation- tissue fluid,lymph,blood are
collected in the form of cyst following radical
hystrectomy
 Advantages of radiotherapy

 wider applicability in all stages of ca cervix

 survival rate 85%,comparable with that of surgery in
early stage
 less primary mortality and morbidity
 individualization of dose distribuations and
requriement possible
 Disadvantages of radiotherapy

 intestinal and urinary sticture

 fistual formation
 vaginal fibrosis
 stenosis causing dyspareunia,radiation
menopause,fibrosis of bowel and bladder
 Containdications of radiotherapy

 Associated PID- acute or

chronic,diabetes,IBD,pelvic kidney
 Associated myoma,prolapse,ovarian tumour,adnexal
mass
 young patient
 vaginal stenosis
 cases with adenocarcinoma or adenosquamous
carcinoma
 ADENO CA

 Endophytic growths
 Ballooned cervix
 Treated the same as squamous cancers