Cervical

Cancer
ANN MARGRETTE A. MADRID, MD
BMC OBGYN
 Introduction
● 3rd worldwide
● 2nd in the Philippines
● 2nd most frequent among women between 15
and 44 years of age
● About 2/3 of cervical cancer in the Philippines
are diagnosed in an advanced stage

SGOP 2019
 Introduction
● lower incidence and mortality
● significant cause of cancer morbidity and
mortality
● 604,000 new cases
● 342,000 deaths
● 84% of cases form resource limited countries

UPTODATE 2021
 Introduction
● Human papillomavirus (99.7%)
- HPV 16 and 18 (71%)
- HPV 31, 33, 45, 52 and 58 (19%)
● Squamous cell (70%)
● Adenocarcinoma (25%)

UPTODATE 2021
 ANATOMY OF THE CERVIX

● narrow inferior segment of

the uterus which projects into
the vaginal vault.
● It is a fibromuscular organ
lined by mucous membrane
and measures 3 cm in length
and 2.5cm in diameter

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 SHAPES OF THE EXTERNAL OS

NULLIPAROUS MULTIPAROUS MENOPAUSE

 ANATOMY OF THE CERVIX

● ENDOCERVIX
- extends from the isthmus
(internal os) to the ectocervix
and contains the endocervical
canal
- mucous secreting columnar
epithelium

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 ANATOMY OF THE CERVIX

● luminal surface of the

endocervical canal and crypts
is lined with a single layer of
columnar cells
● lining is made up of tall
cylindrical cells arranged in a
“picket “formation

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 ANATOMY OF THE CERVIX

● ECTOCERVIX
- extends from the squamo-
columnar junction to the vaginal
fornices
- covered by non keratinizing
stratified squamous epithelium

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 ANATOMY OF THE CERVIX

● SQUAMOCOLUMNAR
JUNCTION
- located at the point where the
columnar epithelium and the
squamous epithelium meet
● abrupt transition between squamous
and columnar epithelium
● Location is variable

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 ANATOMY OF
THE CERVIX

● TRANSFORMATION ZONE
- incorporates the area of
metaplastic change in the cervix
- cells of the transformation zone
are extremely susceptible to
carcinogens and most cancers
arise in the TZ

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 LOCATION OF SQUAMOCOLUMNAR
JUCNTION
BEFORE PUBERTY

● original
squamocolumnar
junction is located at,
or very close to, the
external os

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 LOCATION OF SQUAMOCOLUMNAR
JUCNTION
ADOLESCENT

● eversion of the columnar

epithelium of the lower
part of the endocervical
canal on to the
ectocervix

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 LOCATION OF SQUAMOCOLUMNAR
JUCNTION
MENOPAUSE

● new squamocolumnar
junction progressively
moves on the ectocervix
towards the external os
● postmenopausal women,
the new squamocolumnar
junction is often invisible
on visual examination

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

HOW TO DESCRIBE THE CERVIX
PATHOGENESIS
DISEASE PROGRESSION

WHO: AN INTRODUCTION TO THE ANATOMY OF UTERINE CERVIX

 Risk factors

● Early coitarche ● Low socioeconomic status

● Multiple sexual partners ● Oral contraceptive use
● High risk sexual partner ● Cigarette smoking
● History of STI ● Uncircumcised partner
● early age at first birth
● Immunosuppression

UPTODATE 2021
 2ND
Most common female cancer in the
Philippines

UP-PGH WEBINAR 2020

 PHILIPPINE STATISTICS 2018
35.6million – women at risk for cervical cancer (>15yo)

7,190 new cervical cancer per year

2nd leading cause of female cancer in the Philippines

2nd most common female cancer in women 15-44yo

4,088 – cervical cancer deaths per year

3rd leading cause of female cancer death

3rd leading cause of cancer deaths in women 15-44yo

UP-PGH WEBINAR 2020
 SYMPTOMS

44% Localized disease

36% Regional disease

16%
Distant metastasis

UP-PGH WEBINAR 2020

 SYMPTOMS
Asymptomatic during early stage

Irregular vaginal bleeding

Post coital bleeding

Pelvic or lower back pain

Bowel or urinary symptoms

UP-PGH WEBINAR 2020
 diagnosis

PHYSICAL
EXAMINATION

● Pelvic examination
● Speculum exam
● Rectovaginal exam

UPTODATE 2021
 CERVICAL
CYTOLOGY

● Papsmear
● Principal method for
cervical cancer
screening

UPTODATE 2021
 CERVICAL BIOPSY AND
COLPOSCOPY

● Cervical biopsy
- sample at area that looks most
suspicious and avoid grossly necrotic
areas
● Colposcopy
- w/o visible lesion but symptomatic or
abnormal cytology
● Conization or LEEP
- Suspected malignancy but not found in
directed biopsy

UPTODATE 2021
 DIAGNOSIS

LIVER /RENAL IMAGING

ENDOSCOPY
FUNCTION TEST
 Cystoscopy  SGPT/SGOT  IVP – Hydronephrosis
 Proctoscopy  BUN/Crea  CXR, Bone scan –
metastasis
 Barium Enema

UPTODATE 2021
 COLPOSCOPIC
PROCEDURE
● Gross visualization
● Green or blue filter
● Application of 3-5% acetic acid
● Application of Lugol or
Schiller;s solution
● Upper 1/3 of vagina examined
esp lateral fornices
 PET/CT + MRI • best combination in developed countries
d
MRI • best for determining size

Ultrasound • good diagnostic accuracy in EXPERT hands

• more accurate than CT and MRI for detection of

PET/CT
node metastasis

KUB, IVP, CT, MRI • hydronephrosis

Cystoscopy/Proctoscopy • bladder and rectum involvement

with Biopsy
UP-PGH WEBINAR 2020
 2018 FIGO STAGING (Pathologic staging)
● Radical surgery – complete lymphadenectomy or lymph
node sampling may be done
● Surgico-pathologic assessment of lymph node requires
advanced surgical skills, conventional or minimally
invasive
● Pathologic confirmation is the gold standard but imaging
can be used to determine extent of disease

UP-PGH WEBINAR 2020

Stage 1 (confined to
the cervix)
● IA Invasive carcinoma diagnosed
only by microscopy with
maximum depth of invasion
<5mm
● IA1 measured stromal
invasion <3mm in depth
● IA2 measured stromal
invasion ≥ 3mm and
<5mm depth
Stage 1 (confined to
the cervix)
● IB Invasive carcinoma with
deepest invasion >/= 5 mm,
lesion limited to the cervix, uteri
- IB 1 >/=5 mm stromal invasion
and <2 cm in greatest dimension
- IB2 2 to <4 cm
- IB3 >/=4 CM

SGOP 2019
Stage II (clinically visible
lesions beyond the
uterus)
● IIA – WITHOUT parametrial
invasion
● IIA < 4cm
● IIA2 ≥ 4cm
● IIB with OBVIOUS parametrial
invasion

SGOP 2019
Stage III (extension to the pelvic
wall, lower 1/3 of the vagina,
hyDronephrosis)
• IIIA Tumor involves lower L1/3, with
no extension to the pelvic wall
● IIIB extension to the pelvic wall and/or
hydronephrosis or non-functioning
kidney
● IIIC – involvement of pelvic and/or
paraaortic lymph nodes, irrespective of
tumor size and extent
● IIIC1 pelvic lymph nodes only
● IIC2 para aortic

SGOP 2019
Stage IV (Carcinoma has extended
beyond the true pelvis or has
involved the mucosa

• IVA Spread to adjacent pelvic

organs
• IVB Spread to distant organs

SGOP 2019
 General recommendations for staging
● The use of any specific imaging technique, lymph node biopsy or
surgical assessment of tumor extent is not mandatory

• Clinical evaluation, imaging or pathologic

Size of tumor measurement

• Any imaging technique and or pathologic

Lymph node metastasis assessment methods available
● Methods of imaging may include UTZ, CT, MRI, PET/CT if available
but not mandatory
● Choice of imaging depends upon availability and affordability. Non-
availability of imaging should not be a reason for treatment delay
UP-PGH WEBINAR 2020
 General recommendations for staging
● Method used for imaging and the pathologic technique should be
recorded
● It is recognized that there are limitations in low middle income
countries
● Best available technology should be used for assessment and lowest
appropriate stage should be assigned – WHEN IN DOUBT ASSIGN
THE LOWER STAGE
● Clinical staging with use of other facilities is permissible. THE
METHOD OF ASSIGNING STAGE SHOULD BE RECORDED

UP-PGH WEBINAR 2020

 General recommendations for staging
● In operated patients, histopathology report will provide the
information on size and extent of lesion
● Ovarian involvement does not change the stage
● LVSI (lymphovascular space invasion) dose not change the
stage
● Involvement of corpus does not affect the stage

UP-PGH WEBINAR 2020

 General recommendations for staging
● Patient is staged after all clinical, imaging and pathology
reports are available
● Cannot be altered later even at recurrence
● Enables selection and evaluation of best therapeutic
management
● Better estimate of prognosis

UP-PGH WEBINAR 2020

STAGE TREATMENT
Stage IA, IB1, IIA1 Radical Hysterectomy + Pelvic LN Dissection +/- Para-artic LN
Dissection
OR
Pelvic External Beam Radiation (EBRT) + Brachytherapy +/- concurrent
Platinum-containing chemotherapy
Stage IB3, IIA2-IVA Pelvic External Beam Radiation (EBRT) + Brachytherapy + concurrent
Platinum-containing chemotherapy + Brachytherapy
OR
Extended Field Radiotherapy (EFRT) + Brachytherapy + Concurrent
Platinum-containing chemotherapy

Stage IVB Chemotherapy, Individualized radiotherapy, Palliative Care

SGOP 2019
 Other consideration for early stage cervical
●
cancers
What is the probability that adjuvant chemoradiation would ne required after
surgical treatment with radical hysterectomy and lymphadenectomy?
● Prognostic factors which would require adjuvant concurrent chemoradiation
1. Tumor size >2cm
2. Greater than 1/3 stromal invasion
3. Positive lines of resection
4. Lymph node metastasis
5. LVSI

UP-PGH WEBINAR 2020

 WHEN TO ABANDON PLANNED
SURGERY
● Nodular parametria on internal exam under anesthesia
● Unable to open 6 pelvic spaces (Prevesical, paravesical,
prerectal, pararectal)
● Distant metastasis
● Non-resectable lymph nodes

UP-PGH WEBINAR 2020

 Metastatic cervical cancer
● not good candidates for local treatment
● (+) systemic chemotherapy
● 1st line chemo: platinum based combination +
bevacizumab

UP-PGH WEBINAR 2020

 Radiation treatment
EBRT

• Administered in fractions
• 180 cGy/day, 5 days/week
• To destroy the tissue without
causing permanent damage to
normal tissues
• Delivers uniform doses to the
entire pelvis, including the
regional pelvic lymph nodes

UP-PGH WEBINAR 2020

 Radiation treatment
Brachytherapy

● delivers its highest energy locally to

the cervix, surface of the vagina,
paravaginal and paracervical tissues
● The radioactive source is placed in a
body cavity such as rectum or uterus

UP-PGH WEBINAR 2020

 COMPLICATIONS OF RADIATION
ACUTE CHRONIC

● GI effects ● Rectal or vaginal stenosis

● Cystourethritis ● Small bowel obstruction
● UTI ● Malabsorption
● Skin erythema ● Chroninc systitis
● Radiation proctitis
● Fistula formation

UP-PGH WEBINAR 2020

 CHEMOTHERAPY
CHEMOTHERAPY NEOADJUVANT
CHEMOTHERAPY

● Cisplatin Chemotherapy before surgery

- Single most active drug in the Advantages:
treatment of cervical cancer - For reducing tumor volume
- Increasing resectability
- To control micrometastatic
disease

UP-PGH WEBINAR 2020

 Radiation complication
 Second primary cancer
 Vaginal or cervical ulcerations
 Hemorrhagic cystitis
 Proctosigmoiditis- diarrhea, GI bleeding, pain on
defecation
 Rectal ulcerations or fistulas
 Inelastic vaginal walls
 menopause
COMPREHENSIVE GYNECOLOGY 7TH EDITION
 FERTILITY SPARING TREATMENT
• Cervical cancer spreads laterally to the parametria, inferiorly to the
vagina and rarely superiorly to the uterus
• It is possible to maintain the fundus and adnexa in early stage cancers
confined to the cervix to maintain the possibility of future childbearing
• The possibility of FST abandonment if there are:
- Positive margins and/or nodal involvement
- Rare histologic subtype
- Neuroendocrine carcinomas
- Non-HPV related adenocarcinomas

COMPREHENSIVE GYNECOLOGY 7TH EDITION

 CERVICAL CANCER IN PREGNANCY
• The therapy is influenced by:
- Stage of the disease
- Time in pregnancy when the cancer is diagnosed
- Beliefs and desires of the woman

• If diagnosed in the first trimester or early second trimester, treatment

may be taken immediately
• For patient beyond the 20th week of gestation, therapy is often delayed
until fetal viability

COMPREHENSIVE GYNECOLOGY 7TH EDITION

 Follow up

• Every 3 months for the first 2 years, every 6 months from year 3 to 5 and
yearly thereafter
• Physical and pelvic examination at every visit
• Pap smear annually unless an abnormality is detected in papsmear
• PET/CT is repeated at 3 to 6 months post chemoradiation therapy
• Chest xray annually

COMPREHENSIVE GYNECOLOGY 7TH EDITION

 RECURRENCE
• Reappearance of tumor 6 months or more after therapy
• Most metastases occur in the pelvis–
- centrally in the vagina or cervix or laterally in the
pelvic wall
- Less frequently distally in the periaortic nodes,
liver, lung, bone
• Vaginal utz to document pelvic recurrence

COMPREHENSIVE GYNECOLOGY 7TH EDITION

 SCREENING AND PREVENTION
• Regular gynecologic exams and cytologic tests
• HPV vaccination
- Should not be given during pregnancy
- Does not eliminate the necessity to undergo the
recommended cervical cancer screening
- If the HPV vaccine series was interrupted for
pregnancy, the series should be resumed
postpartum with the next dose

COMPREHENSIVE GYNECOLOGY 7TH EDITION

 CERVICAL CA SCREENING GUIDELINES
FOR AVERAGE-RISK WOMEN
POPULATION 2012 Guidelines PSCPC 2012 Guidelines ACS-ASCCP-ASCP

Less than 21 No screening No screening

21-29 Conventional cytology every year Cytology alone every 3 years
OR
Liquid based cytology every 2 years

30-65 Conventional cytology every year Co-testing every 5 years

OR OR
Liquid based cytology every 2 years Cytology alone every 3 years

COMPREHENSIVE GYNECOLOGY 7TH EDITION

 CERVICAL CA SCREENING GUIDELINES
FOR AVERAGE-RISK WOMEN
POPULATION 2012 Guidelines PSCPC 2012 Guidelines ACS-ASCCP-ASCP

Above 65 Conventional cytology every year No screening if with:

OR -3 consecutive negative prior screening
Liquid based cytology every 2 results
years -2 consecutive negative co-test results within
OR the past 10 years
Co-testing every 5 years
The most recent test should be within the past
5 years

Women with a history of CIN2 or worse should

continue routine screening for at least 20
years
After No screening if without history of No screening if without history of CIN2+ or
hysterectomy CIN2+ or cervical cancer in the cervical cancer in the past 20
past 20
COMPREHENSIVE GYNECOLOGY 7TH EDITION
 Staging of patients who
underwent hysterectomy
of unsuspected cervical
cancer
“In some cases, hysterectomy is
performed in the presence of
unsuspected invasive cervical
carcinoma that is diagnosed later on
histopathology. Such cases
CANNOT be clinically staged or
CREDITS: This presentation template was created by
included in statistics
Slidesgo, including but
icons by Flaticon,
infographics & images by Freepik.
and have to be

reported separately”

UP-PGH WEBINAR 2020

 Incidentally diagnosed
cervical cancer after
hysterectomy
This should be a rare instance
especially if there is a good clinical
assessment and appropriate
diagnostic work-up

1. Radical parametrectomy and

CREDITS: This presentation template was created by
upper vaginectomy,
Slidesgo, including icons by Flaticon,lymph
infographics & images by Freepik.
and node
evaluation
2. Adjuvant chemotherapy
UP-PGH WEBINAR 2020
 Any urinary tract obstruction should be
corrected prior to cervical cancer treatment
● The presence of hydronephrosis conferred poorer progression-free and overall
survival
● Relieving the obstruction with either stents or percutaneous nephrostomy
improved survival
● Co-management with the nephrologist and the urologist
● Patients presenting with the uremia may even warrant hemodialysis before any
urinary diversion procedure
● There has to be some caution with chemotherapy administration because of
challenged kidney function status
UP-PGH WEBINAR 2020
 summary

● Initial symptoms of cervical cancer are non specific, high index of suspicion is
needed
● Papsmear is the standard screening tool for the development of cervical cancer
● For locally advanced cervical cancer, standard treatment is concurrent chemoRT
● For metastatic and/or recurrent cervical cancer, systemic chemotherapy is the
choice
THE BEST
PROTECTION IS
EARLY DETECTION

THANK YOU!