MALIGNANT LESIONS OF CERVIX

Revo
ANATOMY

The cervix (Latin for neck) is the inferior

part of the uterus protruding into the
vagina
The cervix measures 2.5-3 cm in
diameter and 3-5 cm in length.
the cervix projects into the vagina as the
portio vaginalis
CONTANATOMY

The lymphatic drainage of the cervix is first to the

parametrial nodes, then to the obturator, internal iliac, and
external iliac nodes. Secondary drainage is to the
presacral, common iliac, and para-aortic lymph nodes.
HISTOLOGY

Ectocervix ; stratified nonkeratinizing

squamous epithelium.
Endocervical canal ; columnar
epithelium with mucinous producing
glands
The area btn the two is the SCJ
Transformation zone (TZ) is the area
FOR squamous metaplasia.
 Squamous metaplasia occur
continuously throughout life but is
more in fetal development,
menarche, pregnancy, local
hormonal changes, trauma, chronic
irritation or infection
80 -85% of all cancer of cervix arise
from TZ .
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 CHRONOLOGY OF CANCER SERVICES IN
TANZANIA.
1888:First hospital built in Tanganyika by the Germany.
1968:Ministry of health request Prof.Ulrich Henschke to
assist Government of Tanzania to establish cancer
radiotherapy services at Muhimbili Medical Centre.
1972-1980:Radiotherapy facility was expanded with
introduction of remote after-loading intracavitary services.
Training of local man power started.

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 1982-1984:Cancer services started at Ocean road
hospital.The services provided were:
-Cancer chemotherapy
-Oncological imaging with:
X-rays
ulrasound
Nuclear medicine

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 -Public health cancer education
-Cancer research
-Cancer registry and documentation
1996:Establishment by act of parliament of
Ocean Road Cancer Institute.

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TABLE SHOWING TYPE AND NUMBER OF CANCERS SEEN AT ORCI IN
1995.

Tumor type Number of Percentage

patients
Uterine,cervix}carcino 877 53.7
ma
Kaposis Sarcoma 180 11
Head and neck 174 10.6
carcinoma (including
oesophagus Cancer)
Breast Carcinoma 131 8.0
Child hood tumors 129 7.9
Others 148 9.0
Total 1639 100 10
CANCERS ATTENDED IN 2004 AT ORCI
Type of Cancer Number Percentag
of cases e
Cancer of cervix 992 34.6
Kaposis Sarcoma 400 14
Oesophageal 232 8.1
Carcinoma
Carcinoma of 230 8.0
breast
Head and neck 223 7.8
tumour
Burkitts 109
11
3.8
Hodgkins NHL 92 3.2
Skin cancers 77 2.6
Carcinoma of the 58 2.1
bladder
leukemia 55 1.9
Conjuctive 48 1.6
cancers

others 350 12.2

total 2866 100

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PATHOGENESIS

CIN has a long natural history.

As it becomes invasive, the tumor breaks
through the basement membrane and
invade the cervical stroma.
 HPV has been associated with
malignant transformation of
epithelial lining of the female lower
genital tract.
HPV ; epitheliotropic double
stranded DNA virus.
99.7% CACX; HPV DNA
 HPV virus has the gene products
which cause immortalisation and
transformation of a cell into a
malignant cell line.
E6 transforming protein which
can bind the p 53.
E7 - major transforming protein
which binds the RB .
Histologic Types

Majority are squamous cell

carcinoma.
Others Adenocarcinoma,

endometroid carcinoma, clear cells

adenosarcoma, adenoid cystic
carcinoma and adenosquamous cell.
RISK FACTORS
-early age of sexual intercourse
-low social economic status
-Multiple sexual partners
-sexual transmitted infections
-human papilloma virus infection
-immunosuppression
-smoking
-uncircumcised males
-oral pills
- Too many pregnancies
 Pattern of Spread of Cacx:
Direct invasion into the cervical stroma,
corpus, vagina and parametrium.
lymphatics metastasis.

Blood-borne metastasis.

Intraperitoneal implantation.
STAGES OF CERVICAL CARCINOMA
Stages are defined by FIGO
(Federation Internationale de
Gynaecologie et dObstetrique) or
TNM by American Joint committee on
cancers(AJCC)
STAGING PROCEDURES

Physical examination:
Palpate lymph nodes
Examine vagina
Bimanual recto-vaginal examination
Radiological studies:
Intravenous pyelogram
Barium enema
CXR
 Procedures:
Biopsy
Conisation
Hysteroscopy
Colposcopy
Endocervical curretage
Cystoscopy
Proctoscopy
 Optional studies
CT Scan
Lymphangiography
Ultrasonography
MRI
radionucleotide scanning
laparascopy
 CLINICAL STAGES OF CANCER OF THE CERVIX
Stage 0. CIN. no stromal invasion
Stage I Cancer confined to the cervix
IA Invasive cancer detectable microscopically only
IA1 Invasion less than 3 mm and width less than 7 mm
IA2 Invasion more than 3 mm but less than 5 mm

IB All others, any visible cancer

IB1 Cervix lesion less than 4 cm in diameter
IB2 Cervix lesion greater than 4 cm

Stage II Spread to adjacent structures

IIA Spread onto the upper 2/3 of vagina
IIB Spread laterally with obvious parametrial involvement but not yet onto the pelvic wall
Stage III More extensive but still within the pelvis
IIIA Extends to the lower third of the vagina
IIIB Extends onto the pelvic wall, obstructed ureter
Stage IV Distant spread or involvement of a pelvic organ
IVA Involves the inside of the bladder or rectum
IVB Distant metastases, i.e. lung, liver or bone
SYMPTOMS AND SIGNS
Abnormal vaginal bleeding (blood stained leukorheal
discharge,scant spotting or frank)
Leukorhea (sanguinours,purulent,odorous nonpruritic)
Postcoital,contact- bleeding
Pelvic pain
Incontinence,weakness,weight loss, anaemia
 Extension of the tumor in the cervix,
manifest as :
Ulceration

Exophytic tumor

Extensive infiltration of underlying

tissue including bladder and
rectum.
DIFFERENTIALS
Ectropion
Cervicitis
Condyloma
Cervical TB
Ulceration due to STI (GI,LGV,Chancroid
Cervical pregnancy
Metastases,actinomycosis,schistosomiasis
TREATMENT

Similar to any other type of malignancy:

Both the primary lesion and potential sites of spread should be
treated.
Therapeutic modalities:
Primary treatment with surgery
Radiotherapy
Chemotherapy
Radiotherapy can be used in all stages of disease.
Surgery is limited to patients with stage I and IIa
Radical hysterectomy (Meigs-Wertheim)
 In general Stage IA cancers can be treated by simple
hysterectomy or even in special cases by cone biopsy.
All other Stage I cancers are treated either by radical
surgery or radical radiation.
Some stage IIA cancers can also be considered for
surgery.
Otherwise, all stage II, III and IV cancers are treated with
radiation.
Occasionally ultra-radical surgery is done on some stage
IVA cancers..
 Surgery for stage IB and some IIA cancers requires
a radical hysterectomy and removal of the pelvic
lymph nodes.
Radical hysterectomy technique removes all the
supporting ligaments to the cervix which means that
the dissection is very close to the bladder and to
the rectum.
 Ultra-radical pelvic surgery for advanced or
recurrent cancer means that all the pelvic organs
are removed.
The uterus and cervix, vagina, bladder and rectum
are removed.
Sometimes a vagina can be reconstructed. If the
rectum can be reattached then there will be no
need for a colostomy
 External beam radiation therapy (teletherapy) usually requires a
treatment each day, five days a week, for about five weeks where
the entire pelvic area is irradiated by an x-ray beam usually
generated by a linear accelerator.
Brachytherapy (intracavitary) which means slow therapy is done
by placing a radioactive source inside the cervix and vagina and
left in place several hours or several days. This is focused on
radiating the tumor cells directly.
Often chemotherapy is also given to increase the effects of the
radiation
PROGNOSIS
Most early cancers are cured; most advanced cancers are
not.
FIVE YEAR SURVIVAL RATES FOR CERVICAL CANCER
Stage I 80%
Stage II 65%
Stage III 30%
Stage IV 15%
PREVENTION OF CERVICAL
CANCER
HPV is the most prevalent sexually
transmitted infection in the world. And,
unlike other STIs such as gonorrhea or
HIV/AIDS, the use of condoms and other
safe-sex practices may not be nearly as
effective in preventing this infection.

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 This is because the papilloma virus lives in the
skin (squamous) cells covering the pubic area
(vulva and shaft of the penis) as well as the
interior cells lining the vagina and cervix in
women, and urethra and anus in both sexes
Condoms do not cover the entire shaft of the
penis nor do they block contact with pubic skin.

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 Therefore, during intercourse, even with a
condom, skin cells containing HPV can come
in contact with a womans vulva or vagina,
enabling the virus ultimately to reach the
cervix.
In addition, the friction during sexual
intercourse is believed to cause tiny tears in
the vaginal wall, making transmission far more
likely.

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PRIMARY PREVENTION
Cervical cancer can be prevented by avoiding cigarette
smoking, long term use of combined oral contraceptives
and early sexual intercourse
The development of the vaccine for primary prevention of
HPV is a key step towards reducing Cervical cancer.
This vaccine is focusing on the induction of effective
humoral and cellular-immune responses that are
protective against HPV infection

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SECONDARY PREVENTION
This can be achieved by early detection and
treatment of cervical pre-cancerous lesions.
This can be done through screening for the
precancerous lesions among sexually active
women.

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SCREENING
Screening appears to be one of the most
preventive measures for cervical cancer,
unfortunately in developing countries it is
still difficult to do massive cervical screening

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QUALITIES OF A GOOD SCREENING TEST
Effective (sensitive)
Safe
Acceptable
Affordable
Available

To date, cervical cancer prevention efforts world wide have

focused on screening at-risk women using Pap smears or
Visual inspection with acetic acid (VIA/ VIAM), with Lugol`s
iodine (VILI) and treating precancerous lesions.

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Assignment
. Read on HPV vaccines.