1. 11/7/2017
CANCER OF THE CERVIX
Dr Yusuf Muhammad

3. WHY IS CANCER OF THE CERVIX SO IMPORTANT?
11/7/2017
WHY IS CANCER OF THE CERVIX SO IMPORTANT?
400,000 new cases are identified each year.
80% of the new cases occur in the developing countries
At least 200,000 women die of cancer of the cervix world wide
Now, cancer of the cervix is the 3rd common cancer world wide
In Korle-Bu teaching Hospital, a study in mid 1990s showed the commonest female genital tract cancer to be cancer of the cervix. It accounts for 58% of all female genital tract cancer.

4. WHO GETS CANCER OF THE CERVIX
11/7/2017
WHO GETS CANCER OF THE CERVIX
Although cancer of the cervix is reported in all ages, even at birth, it is not common before the age of 40 years. There after the risk rises progressively to reach a maximum at years and then diminishes. It is essentially a sexually transmitted disease.

5. WHAT FACTORS INCREASE THE CHANCE OF A WOMAN GETTING CACX?
11/7/2017
WHAT FACTORS INCREASE THE CHANCE OF A WOMAN GETTING CACX?
Sex
Multiple sexual partners
Sexually transmitted disease – Human papilloma virus infection; Herpes simplex virus infection.
High parity
Smoking
Immunosuppression –HIV infection, Steroid use.
The use of hormonal contraceptives
Social class.

6. SIGNS AND SYMPTONS Initially asympptomatic.
11/7/2017
SIGNS AND SYMPTONS
Initially asympptomatic.
Vaginal discharge – The discharge is at first creamy or white but subsequently resembles dirty brown water. It has a particularly offensive odour. The odour is due to infection of the dead cervical tissue
Irregular vaginal Bleeding.
Contact bleeding – Any cervix which bleeds when touched is suspect.
Any other symptoms usually occur so late that are to be regarded more as evidence of impending death; They include;

7. SIGNS AND SYMPTONS cont.
11/7/2017
SIGNS AND SYMPTONS cont.
Frequency of micturition
Dysuria
Urinary incontinence
Rectal pain
Oedema of legs
Loss of weight
Anorexia
Low back pain

9. NATURAL HISTORY OF CANCER OF THE CERVIX
11/7/2017
NATURAL HISTORY OF CANCER OF THE CERVIX
It starts as high-grade dysplasia, which may progress to cancer of the cervix over a period of up to 10 years.
Tobacco use may influence whether a woman with dysplasia is likely to develop cancer of the cervix

10. IS CANCER OF THE CERVIX PREVENTABLE ?
11/7/2017
IS CANCER OF THE CERVIX PREVENTABLE ?
The cervix is uniquely placed for screening as a means of preventing cancer of the cervix
It is easily accessible.
Cells are constantly being shed from it. These cells can be viewed under microscope to identify early pre-cancerous changes (dysplasia).
There is a long period of about 10 years between when precursor (pre-cancerous) lesion appears and when cancer occurs.

11. WHAT SCREENING TEST IS AVAILABLE?
11/7/2017
WHAT SCREENING TEST IS AVAILABLE?
A pap smear (named after its inventor Dr. George Papanicolou), also known, as cervical smear is a cytological test designed to detect abnormal cervical cells.
THE PROCEDURE: The procedure involves scrapping cells from the cervix and then fixing them on a glass slide. The slides are then sent to a cytology laboratory and evaluated by a trained cytologist.

12. 11/7/2017
DIAGNOSIS
Cervical Biopsy for microscopic examination

14. TREATMENT Surgery (Weatheim’s Hysterectomy) – Up to stage 2a
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TREATMENT
Surgery (Weatheim’s Hysterectomy) – Up to stage 2a
Radiotherapy
Combined

15. 11/7/2017
STAGING
Stage 0
The cancer is limited to the epithelium (carcinoma in situ)

16. 11/7/2017
Stage 1
The cancer is invasive but is strictly to the cervix or the uterus
1a – Pre-clinical invasion
1b- Clinically diagnoses

17. Stage 2 2a – Cervix + upper 2/3 of vagina
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Stage 2
2a – Cervix + upper 2/3 of vagina
2b-Cervix + parametra but not reaching the pelvic side wall

18. Stage 3 3a-Cervix + lower 1/3 of vagina 3b- Cervix + pelvic side wall
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Stage 3
3a-Cervix + lower 1/3 of vagina
3b- Cervix + pelvic side wall

19. 11/7/2017
Stage 4
Extra pelvis or
Pelvic bones or
Bladder or
Rectum

21. COMPONENTS OF WERTHEIM’S HYSTERECTOMY
11/7/2017
COMPONENTS OF WERTHEIM’S HYSTERECTOMY
Removal of uterus and appendages
The upper half of vagina
Broad ligament together with their cellular tissue
The lymph nodes around the iliac vessels and on the lateral pelvic walls

22. PROGNOSIS The extent of growth at the time of treatment.
11/7/2017
PROGNOSIS
The extent of growth at the time of treatment.
Site – an endocervical growth is more dangerous than one which grows on the vaginal surface because it is diagnosed relatively late, and it spreads to the broad ligaments and to lymph nodes relatively early.
Naked eye appearance – The hypertrophic, florid, massive growth filling the upper vagina generally carries a bad prognosis – even if it does not appear to have spread much beyond the cervix.
Histological type – An adenocarcinoma is unfavorable because it is usually endocervical in site. Among the squamous cell growths the wall differentiated are to be preferred because they grow slowly and metastasize late.
Age – the younger the patient the more likely is the growth to be fulminating in type and the worse the outlook

23. HOW IMPORTANT IS PRE-TREATMENT ASSESSMENT?
11/7/2017
HOW IMPORTANT IS PRE-TREATMENT ASSESSMENT?
Preliminary examination under anaethesia is generally desirable in order to estimate the extent of the disease, the size of the uterus, vaginal fornices and to obtain material for histopathological study.
Anemia and malnutrition should be corrected, even at the expense of delaying treatment. A health blood picture improves the results of radiotherapy considerably, possibly because it means better oxygenation of malignant tissues.

24. 11/7/2017
RADIOTHERAPY
This is the treatment of choice and is applicable to all stages of the disease.
It aims at giving cancericidal dose of gamma – rays to all areas where there is growth or where there is likely to be growth.
Gamma-rays act by damaging the nuclear structures is actively dividing cells.
Radio sensitivity depends to a large extent on whether the tumour receives a good blood supply from its bed.
In favourable cases the tumour disappears within 6 weeks.
If the initial course of treatment is adequate, radiotherapy should never be used again even if the growth recurs. IT CAN ONLY DO HARM.

25. Radioactive material used
11/7/2017
Radioactive material used
Radium – The most commonly used
Cesium
Cobalt

26. COMPLICATIONS OF RADIOTHERAPY
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COMPLICATIONS OF RADIOTHERAPY
Major complications are caused by
overdose and by technical errors; but many
are unavoidable.

27. IMMEDIATE COMPLICATIONS
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IMMEDIATE COMPLICATIONS
Malaise, Anorexia, Vomiting, Pyrexia
Enteritis, Proctitis, Cystitis, Pyelonephritis, Cellulites, Peritonitis
Pyometra
Pelvic abscess
Vaginal and skin burns
Septicemia

28. MEDIUM TERM COMPLICATION
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MEDIUM TERM COMPLICATION
Vaginal and cervical atresia secondary to burns
Hydronephrosis secondary to ureteric stricture due to scaring in the broad ligament.

29. LONG TERM COMPLICATIONS
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LONG TERM COMPLICATIONS
A state of aseptic cellulites in which all the tissues become “frozen” 3 month after treatment.
Ischaemic rectal injury occurs in 10-15% cases and usually makes itself manifest 6-18 month after treatment
A similar reactions occur in the bladder in 5-10% cases and tend to appear even later than those in the rectum’. It presents as frequency, dysuria and haematuria.
Necrosis of the pelvic part of the ureter followed by fistula formation or by stricture.
Spontaneous fracture of the neck of the femur.

30. TREATMENT OF ABOVE LATE RADIATION REACTION
11/7/2017
TREATMENT OF ABOVE LATE RADIATION REACTION
The treatment of late radiation rectal reactions in the acute phase is by means of warm baths and suppositories containing analgesics and cortisone.
Bladder reactions can be treated by antispasmodics and a liberal fluid intake.

31. COMPLICATIONS OF WERTHEIM’S OPERATIONS
11/7/2017
COMPLICATIONS OF WERTHEIM’S OPERATIONS
IMMEDIATE COMPLICATIONS
Haemorrhage
Shock
Peritonitis
Ileus
Intestinal obstruction
Direct injury to pelvic structures, notably
Bladder
Ureters
Rectum

32. LATE COMPLICATIONS Fistula forms 7-14 days after the in 1-15%
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LATE COMPLICATIONS
Fistula forms 7-14 days after the in 1-15%
Atony of bladder, incomplete emptying, cystitis and pyelitis complicate 80% of operation, and there is generally a need for prolonged post-operative bladder drainage.
Stress incontinence
Recurrent cancer

33. COMBINED RADOTHERAPY AND HYSTERECTOMY
11/7/2017
COMBINED RADOTHERAPY AND HYSTERECTOMY
Here we are concern with combined therapy as a planned primary procedure, not with the resort to one when the other has failed of appears to be failing.
For this purpose various combinations are used; Radiotherapy may follow surgery. But ordinarily, however, the plan is to use radiotherapy initially and to proceed to wertheim’s hysterectomy 6 weeks later.