Transcript Slide 1

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 cytology
Single negative pap-smear  45%
decrease in risk
 9 negative pap-smears  99% decrease
in risk
 First pap-smear at 18 years or sexual
activity
 Every 3 years repeated and if more than
one risk factor, every year
 Screening till 65 years old ( 25% of
cancers and 41% mortality in this age)
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History
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Commonest symptom = AUB or discharge
Postcoital spotting, intermenstrual bleeding,
menorrhagia, postmenopausal spotting
Chronic bleeding  fatigue & anemia
Frequent serosanguineous or yellowish discharge
Advanced lesion or necrosis  Foul odor discharge
Locally advance disease or trauma  pelvic pain
Advanced stage  sciatic pain, back pain,
hydronephrosis
Advanced stage ( bladder  hematuria, rectum 
hematochezia)
Physical examination
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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
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Other genital cancers ( endometrial )
Cervical leiomyoma
Severe erosive cervicitis
Complication of pregnancy
Rarely cervical ectopic pregnancy
Diagnostic evaluation
Clinical evaluation
Careful inspection and palpation of cervix and
vagina (EUA)
Colposcopic evaluation + ECC + directed cervical
biopsy
Cervical conization or punch biopsy
Conization if
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unsatisfactory colposcopy
Positive ECC
Lack of correlation in cervical cytology, colposcopy, biopsy
Cervical microinvasive
Cervical biopsy + ECC = adenocarcinoma in situ for R/O of
invasive adenocarcinoma
IVP, CX-Ray
Prognostic factors
Clinical stage
 5-year survival
 Stage IA = 97%,
 Stage IB = 85%, 5-year
survival
 Stage II = 60%
 Stage III = 45%
 Stage IV = 18%
 All stages
 75.2% if node negative
 45.6% if pelvic node
positive
 15.4% if para-aortic
node positive
 Size & depth of tumor
 Histologic differentiation (
75% well, 63.7% moderate &
51.4% poorly differentiated )
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Surgery
Type I  standard
extrfascial TAH
Type II  modified
radical
hysterectomy
Type III 
hysterectomy
Lymph adenectomy
( II,III )
Radiation therapy
External beam = whole
pelvis lateral
prametrium
Brachytherapy 
central disease
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Internal uterine tandem
with colpostats
Interstitial needle
implants
Vaginal sylinder
Point A, 2cm lateral and
2 cm higher than
external os ( 7500-8500
cGY )
Point B, 3cm lateral to
point A ( sidewall of
pelvis )( 4500-6500 cGY)
Acute complications
• Blood loss  average 81%
• Uterovaginal fistula  1•
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2%
Vesicovaginal fistula  12%
Pulmonary embolus  12%
Small bowel obstruction 
1-2%
Hemorrhagic cystitis  3%
Proctosigmoiditis  8%
Febrile morbidity  2550%
• 10% pulmonry
• 7% Pelvic cellulitis
• 6% UTI
• 5% wound infection,
pelvic abscess,
phlebitis
Subacute & chronic complications
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Subacute
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Postoperative bladder dysfunction
Lymphocyst formation
Chronic
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Vaginal stenosis (most common=70%)
Bladder hypotonia
Ureteral stricture
Chemotherapy
Extrapelvic metastasis
Recurrent disease ( not candidate for
surgery or radiation )
Cisplatin
Complete response is 24%
Partial response is 16%
Neodjuant chemotherapy (Before
surgery)  improved survival & better
resection
Chemoradiation  advanced cervical
cancer ( sensitization of cervical cancer
cell to irradiation)
Follow-up
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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