CERVICAL CANCER

Cervical cancer is usually a squamous cell carcinoma; less often, it is an adenocarcinoma. The cause of most cervical cancers is human papillomavirus infection. Cervical neoplasia is often asymptomatic; the first symptom of cervical cancer is usually irregular, often postcoital vaginal bleeding. Diagnosis is by a cervical Papanicolaou test and biopsy. Staging is clinical, combined with imaging and pathology results when available. Treatment usually involves surgical resection for early-stage disease or radiation therapy plus chemotherapy for locally advanced disease. If the cancer has widely metastasized, chemotherapy is often used alone.

1. MohmmadRjab Seder
PALESTINE POLYTECHNIC UNIVERSITY
Faculty of Medicine and Health Sciences

2. The Cervix -Overview

3. Squamocolumnar Junction (SCJ)
The area between the original SCJ and the current SCJ is called as
“Transformation Zone” TZ

4. Cervix Histology

5. Cervical Cancer -Overview
oAlso called: invasive cervical carcinoma (ICC).
oCervical cancer is the third/fourth most common
cancer among women globally.
oClassified into:
oPremalignant/Precancer disease of the cervix.
oMalignantdisease of the cervix.
oMore than 95% of cervical CA is due to HPV.
oCervical CA can be curedif diagnosed at an
early stage and treated promptly.

6. Epidemiology
oAbout 90%of the new cases and deaths worldwide in
2020 occurred in low-and middle-income countries.
oAccording to PHC/MoH; there are only smallnumber of
diagnosed cervical CA in Palestine. (Health Annual Report
2021)

7. Worldwide -In 2022
604,000new cases
342,000deaths

8. In USA

9. Clinical Presentation
oCervical cancer often has no symptoms in its early stages.
oThe most common symptom as it develops is vaginal
bleeding.
oIrregular and/or abnormally heavy menstrual periods.
oPostcoital bleeding (PCB).
oPostmenopausal bleeding (PMB).
oOther symptoms:
oUrinary incontinence.
oLeg pain or swealing.
oBack pain.
oUnexplained weight loss.

10. Aetiologies and Risk Factors
Human papillomavirus (HPV) infection (95% of cases)
Having a family history of cervical cancer
Multiple sexual partners
Smoking (2x)
HIV (6x)
Immunosuppression
Co-infection with Chlamydia or HSV
Long-term use of OCPs
Having multiple full-term pregnancies (Multiparity)
Young age at first full-term pregnancy
A diet low in fruits and vegetables
Protective
Factors:
oIntrauterine device
(IUD) use.
oCondom use in
woman with
multiple sexual
partners.
NOTE

11. Human Papilloma Virus
oOncogenicviruses.
oThere are more than 100 different types of HPV classified
as low-riskor high-risktypes, depending on their ability to
cause cancer.
oHigh-risk types 16, 18, 31, 33, and 45 →cervical cancer.
oLow-risk types 6 and 11 →benign warts.
oTransmitted by sexual intercourse.
oHPV infection →premalignant →malignant (How??)

12. Pathophysiology
oHPV have two proteins known as E6and E7which turn off
some tumor suppressor genes, such as p53and Rb.
oMost women with HPV don’t get cervical cancer. But:
HPV + Coexisting Risk Factors →Cervical CA
oOncogenes:genesthathelpcellsgrow,divide,andstayalive.
oTumorsuppressorgenes:genesthathelpkeepcellgrowth
undercontrolormakecellsdieattherighttime.

14. Premalignant
Disease of the
CERVIX

15. Pre-cancers of the cervix
oCells in the TZ do not suddenly change into cancer.
oInstead, the normal cells of the cervix first gradually
develop abnormal changes that are called pre-
cancerous.
oSeveral terms are used to describe these pre-cancerous
changes, including:
oCervical intraepithelial neoplasia (CIN)
oSquamous intraepithelial lesion (SIL)
oDysplasia
What is the difference
between the terms SIL
and CIN???

16. Premalignant Malignant

17. Types of Cervical Cancer
oSquamous cell carcinoma
o70-80% of cervical cancers.
oDevelop from cells in the exocervix.
oAdenocarcinoma
o20% of cervical cancers.
oDevelop from glandular cells of the endocervix.
oAdenosquamous/mixed carcinomas
oLess commonly.
oHave features of both squamous cell carcinomas and
adenocarcinomas.
Other rare
types of cancer
also can
develop in the
cervix. Such as
small cell,
melanoma,
sarcomaand
lymphoma.
NOTE

18. Investigations and Diagnosis
oHPV testing
oCervical cytology
oPap smear
oLiquid-based cytology (LBC)
oCervical biopsy
oColposcopy
oMetastatic workup; pelvic examination, CXR, intravenous
pyelogram, cystoscopy, and sigmoidoscopy.

19. Pap Smear
oA procedure to test for
cervical cancer in women.
oUsed to screen for cervical
cancer.
oCost effective screening
method.

20. Pap Smear –Video

21. Pap Smear

22. Liquid-based cytology (LBC)
oLBC is better than a Pap test.
oProduce a thin layer of cells on the slide.

23. LBC
Abnormal cervical cytology shows squamous cells at
different stages of maturity (dyskaryosis)

24. Colposcopy
oUsed for both diagnosis and treatment.
oMagnification: 5-20 fold.
oThe application of acetic acid and
iodine solutions highlights abnormal
areas of the cervix can be biopsied.
oAcetic acid causes nucleoproteins
within cells to coagulate temporarily;
therefore, areas of increased cell
turnover, including CIN, appear white.
Cervix with acetic acid

25. Colposcopy -Video

26. Colposcopy –Video

27. Cervical Biopsy
oRemove tissue from the cervix to test for abnormal cells or
precancerous conditions.
oGold standard for diagnosis.

28. Pelvic Examination
Checking vulva, vagina, cervix,
ovaries, uterus, rectum and pelvis
for any abnormalities.
Pelvic exam findings
oFriablecervix
oErosions
oCervicalmass
oBleeding
oFixed adnexa

29. A progressive cervical adenocarcinoma:
The image shows a rapidly progressingmassprotruding from thecervix.

30. Cystoscopy

31. Prevention

32. Treatment of Premalignant Disease of
the Cervix
oAim of treatment: eradicate CIN.
oLow-grade CIN:
o60% regresses spontaneously.
oCold coagulation.
oCone biopsy (Conization).
oHigh-grade CIN:
oTreatment + excision or ablation.
oDiathermy (thermal ablation).
oCold coagulation.
oCone biopsy (Conization).

33. Cold Coagulation.
oProcedure to treat women with abnormal cells on their
cervix, by destroying the abnormal cells with a heated
probe.

34. Conization
oA procedure in which a
cone-shaped piece of
abnormal tissue is removed
from the cervix.

35. Diathermy
oAKA: cervical cautery.

36. Malignant
Disease of the
CERVIX

37. Cancer is diagnosed when CIN breaks the
basement membrane.

38. Clinical Presentation
oCervical cancer often has no symptoms in its early stages.
oThe most common symptom as it develops is vaginal
bleeding.
oIrregular and/or abnormally heavy menstrual periods.
oPostcoital bleeding (PCB).
oPostmenopausal bleeding (PMB).
oOther symptoms:
oUrinary incontinence.
oLeg pain or swealing.
oBack pain.
oUnexplained weight loss.

39. Pathophysiology
oCervical tumours are locally infiltrative in the pelvic area,
but also spread via lymphatics.
oIn the late stages, spread via blood vessels.
oThe tumour can grow through the cervix to reach the
parametria, bladder, vagina and rectum.
oMetastases can occur, therefore, in pelvic(iliac and
obturator) and para-aortic nodes and, in the later stages,
liverand lungs.

40. Types of Cervical Cancer
oSquamous cell carcinoma
o70-80% of cervical cancers.
oDevelop from cells in the exocervix.
oAdenocarcinoma
o20% of cervical cancers.
oDevelop from glandular cells of the endocervix.
oAdenosquamous/mixed carcinomas
oLess commonly.
oHave features of both squamous cell carcinomas and
adenocarcinomas.
Other rare
types of cancer
also can
develop in the
cervix. Such as
small cell,
melanoma,
sarcomaand
lymphoma.
NOTE

41. Staging
Clinical Staging may be done through:
oClinical examination
oCervical biopsy (Assess malignancy and tumour type)
oEndoscopy
oHysteroscopy
oCystoscopy
oProctoscopy
oImaging studies
oIntravenous pyelogram (IVP): to evaluate for urinary tract obstruction
oCT
oCXR (exclude lung metastases)
oMRI (Assess local spread)
oPET

42. Staging
and
prognosis
of cervical
cancer
(By FIGO)

44. Staging -Video

45. Management
Depends on the stage.
oPreclinical lesions; stage IA
oClinical invasive cervical carcinoma: stages IB-IV
oSurgery
oRadiotherapy
oPalliative care

46. Preclinical lesions; stage IA
oLocal excision.
oTotal simple hysterectomy.
oModified radical hysterectomy: surgery to remove the
uterus, cervix, upper part of the vagina, and nearby
ligaments and tissues.

47. Clinical invasive cervical carcinoma:
stages IB
oRadical hysterectomy.
oBilateral pelvic node dissection (Wertheim’s hysterectomy).
oRadical trachelectomy (surgical removal of the cervix and
upper part of the vagina).

48. Clinical invasive cervical carcinoma:
stages II-IV
oChemoradiation = Radiotherapy + chemotherapy.
oRadiotherapy:
oExternal beam radiotherapy.
oInternal radiotherapy (brachytherapy).

49. BrachytherapyExternal beam radiotherapy

50. References
oKenny, L., & Bickerstaff, H. (Eds.). (2017). Gynaecology by ten teachers, 20th edition (20th ed.). CRC Press.
oKaplan Medical. (2018). USMLE Step 2 CK Lecture Notes 2019: 5-book set. Kaplan Publishing.
oAmerican Cancer Society. Retrieved September 18, 2022, from https://www.cancer.org/search.html?q=cervix.
oWorld Health Organization. (2022, February 22). Cervical Cancer. https://www.who.int/news-room/fact-
sheets/detail/cervical-cancer#:~:text=Cervical%20cancer%20is%20the%20fourth,%2Dincome%20countries%20(1) .

51. Thank You