Anatomy of The Cervix

The distal
* cervix is the
cylindrical portion of the uterus

* It is divided into the eetooesuix and endocesvix .

The the
portico vaginalis
has that into
* cervix -

part projects vagina

* The is the above
portico supra vaginalis past
The
*
past seen when a
speculum is
passed is the patio vaginalis .

* Has external that into the called external

an
opening opens vagina ,
os

* Has an internal
opening that
opens into the uterus called internal os .

>
simple columnar
epithelium
E-

Endo cervical and :

.

III.
◦

fusiform in
shape
It is luminal cavity that forms between internal and external
•

a
passage os .

It lined the
is
by endocerñxl simple columnar epithelium ) which
•

secretes mucous .

Eto cervix

covered keratinized stratified squamous

by non
epithelium
-
-

;¥o•

-
Can be native or metaplastic .
Metaplasia : A
change from one
specialized cell type to the other .

Usually occurs as a
response to
injury or irritation .

Dysplasia Abnormal changes shape usually

: lesions
in cell size and
organization seen in
pre cancerous
. -
.

Hypertrophy : An increase in the size of cells .

Hyperplasia : Increase in number of cells .

Neoplasm Abnormal that

benign
'

growth of cells can be or

malignant .

Sfuamo -

columnar Junction ( 84¥)

Its the junction between the

squamous epithelium and the columnar
epithelium . ie the
point where
they meet .

The position of the set is variable and is as a result of continuous remodelling due to

1. uterine
growth
cervical
enlargement
2.

3- Hormonal status

4.
Age
•
At birth and pre menarchal : located at 1 close to the external os
age very
- .

the
•
•

During reproductive age i.

At variable distances from the external os

•
Post-menopausal period : Hot visible
,
recedes into the endocenix .

•
There can be eversion onto the end ◦cervix
of the SCJ
along with large portions of
the columnar epithelium
whih is
referred to as ectropion .

Ectropion is
exposed to acidic vaginal environment which leads to formation of metaplasia epithelium
•

squamous

klhen the
ectropion becomes meth
plastic ,
a new sci is
formed in addition to the old SG -

The area between the old SCJ and new KJ is called the transformation zone .
(T2 )

◦
The T2 can either be wide or narrow
depending on

1.
Age
2-
Purity
3-
Exposure to female hormones

4- Infections
 Clinical Relevance .

HPV infections usually affect the transformation zone

•

Helps in
screening purposes ieg Visual
.

inspection with acetic acid

cervical cancer

Refers to
malignancy of the
'

cervix .

Risk Factors

The main risk

factor is HPV

HPV -

related risk Factors .

.
Non HPV
-
related Risk Factors .

Early coitatehe Low status

-
-

.
socio-economic .

Multiple sexual
partners Oral
-

contraceptive
-

use .

A
high smoking
-

risk partner
-

A
history Family
-

STIs
history
-

of .

Early age at first birth .

-

Partners with uncircumcised

penis .

History vaginal
-

vulvar
of or
squamous epithelial neoplasm .

HPV of cervical
development
*
is central to the cancer .

* HPV can be detected in 99.72 of all cervical cancer cases .

* More than 40 HPV have been identified

subtypes of of which 15 are
oncogenic .

* HPV can increase the risk

of anal cancer, throat cancer .

* HPV also causes warts -

 HPV
Oncogenic strains
of

16,18 , 31,3 ] , 35,39

,
45 , 51 , -52 ,
56,58 59,68 , , 69,82

Subtypes 16,418 are seen in ≥ 703 of all cervical cancer cases .

Pathophysiology
1- HPV infection of the methpkstic squamous cells
of the cervical
transformation zone

Time from infection to disease be

can
long 15
•

as as
years
.

2.
The HPV infection persists if nothing is done .

3.
Progression of a clone of epithelial cells
from persistent vital infection to
pre
-
cancerous lesion .

4. Development of the cervical cancer and evasion of the basement membrane .

Classification

1- Gross anatomical types

Endophytic
-

Exophytic
-

Endophytic
cervix indurated
appears enlarged and
smooth
,

Exophytic
Cauliflower
-

appearance .

Appears fingerling cauliflower growth and

*
as a be ulcerated
may
.

2-
Histopathological types .

Squamous cell carcinoma -1 most common

,
752 of cases )

Adenocarcinoma .

Adenosarcoma
-

-
Carlino sarcoma
-
Adenoid basal sceercinoma

Germ cell tumours

 Clinimal manifestations -

1-
Asymptomatic .

2-
Irregular or
heavy vaginal bleeding
Post coital
bleeding
3. -
.

4.
Vaginal discharge may
be watery ,
mucoid
, purulent ,
malodorous

5- Severe
pelvic or lower back
pain

6. Bowel and
urinary symptoms
7.
Cachexia

8- Severe anemia -

PE

Pelvic examination should be performed in

patient suggestive of cervical Ca
evey

Could have normal cervical

a
appearance

✓
visible
-
lesion
-

* If a lesion is seen ,
it should be biopsied except if it is a nabothian
cyst
.

Investigations
t.co/poswpy: Microscopic examination of the cervix

2.
cytological investigations
•

Papanikolaou smear : not contraindicated in

pregnancy
↳
patta is
preferred )

3-
Biopsy for histopathology

•
Cervical comizations

Supportive investigations

Imaging
-

Pelvic a- scan : to determine $ read

:p

Pelvic MM

Chest x-ray :
spread
•

•
Full blood count :↓Hb

Renal function test :

spread to the utters / bladder
hydro nephrosis → renal impairment Gost renal )
•

causing
- -
.
 Cervical Recommendation
Cancer
Screening .

• It doesn't depend on the

person's sexual history .

< 21 Ho
years screening
• -

21-29 :
cytology alone
for 3
•

years every years

-

65
30 :
cytology alone HPV
cytology every
°

+ 5
years every
3
years years
-

or

> 65 :
If all tests needed
•

years were
negative no
screening
-

staging of cervical cancer .

At =
Depth 3mm ✗ Width 7mm
µ, , ( [* , → F- micro -

invasion .

limited to the cervix

Lesion is
-

As =D 5mm * 7mm

M / ( phone
→ ✗
.

stage
→ D BA ≤ 4cm
I
by 7- clinical
=

no is used → c. CIB > → => lesion

4am
_

B.
.

÷ >

involvements
A- Cno parametric
PM -

Stage 11 → Bt ( parametric involvement ) -

It is a band of connective tissue and

supportive structures that provide support to the cervix and
help anchor it within the
pelvic cavity .

¢ ↳ 4114) to the lower third of

the
vagina
: cancer
spreads
.

VIP
-

stage → pay B) : pelvic side wall involvement /

causing hypno nephrosis
-

to
give out

( NA ) Bladder and bowel

^

BB :
-

BBM → stage N -
M ( WB ) : Distant metastasis -

Management of cervical cancer .

The
management is
dependent on

1.
Type
2.
stage
3 And associated complications

include
Management options

Surgery
1- .

i. Removal the
simple hysterectomy of the items including
-

cervix

Radical hysterectomy : Removal of the uterus ,

cervix
, parts of the
Vagina and
nearby structures including lymph nodes -

Traeheteetomy : Removal of the cervix whist

preserving the uterus .
Done for
people with
early stage and
fertility desires
 Pelvic exenteration : Removal
parts of the vagina bladder rectum and
uterus
surrounding structures
-

cervix
of
'

, , , ,

Radiation
2.
therapy
•

External beam radiation i.

High protons directed at the lesion from outside the body
energy
.

Bthehy therapy : Radio active substances

put inside the tumour to deliver irradiation to kill the cells
•
-

are or cancer .

Chemotherapy Drugs carboplatin , Paclitaxel

: include
3. used
cisplatin ,,

4.
Targeted therapy : Inhibit the
formation of new blood cells in the tumour .

eg
. Bevacizumab

5-
Immunotherapy : Eg Pembwlizumab

Neo
adjuvant therapy

chemotherapy given before surgery

to reduce tumour size

Adjuvant therapy : chemotherapy given after surgery

.

Prevention .

Primordial Prevention .

Legislation : Ban sexual workers Pelvic exentetation

Avoid
having unprotected
-

sex

primary
-

Vaccination

•
Cesvarix ,
16,18
Primary
•

Garda sit / 9-arda.si/ 9

Secondary

Tertiary
 Secondary

Screening
-

•
Pap -

smear

under acid
a.
Visual inspection acidic

☒ isual iodine
e.

inspection under bigot 's

Tertiary
Treatment of disease complications
to
prevent
.