1. Cervical Cancer

2. Assoc. Professor of Gynecologic Oncology Tata Memorial Hospital
Amita Maheshwari
Assoc. Professor of Gynecologic Oncology
Tata Memorial Hospital

3. Cervical Cancer: Epidemiology
Globally cervical cancer is the second most cancer among women
5,00,000 new cases & 2,75,000 deaths/year
10% of all cancer related deaths in women
The most common cancer in women in India
~1,32,000 new cases / year and deaths / year
Every 7 minutes a woman dies of cervical cancer

4. Staging of cervical cancer
FIGO (2008) Staging For Cervical Cancer: Clinical staging using examination under anesthesia, standard basic radiology including X-ray chest.
Value of modern radiological investigations:
CT scan:- R-P lymph nodes.
High specificity and low sensitivity.
MRI:- Equal to CT scan for R-P evaluation.
More accurate for assessment of cervical tumor and surrounding tissue.
PET scan:- More accurate to detect LN metastases.

5. FIGO Staging
Stage I Carcinoma confined to cervix Stage IA1 Stromal invasion upto 3mm in depth &  7mm in width. Stage IA2 Stromal invasion 3-5 mm in depth &  7mm in width. Stage IB Clinical lesions confined to the cervix or pre-clinical lesions >stage IA2 Stage IB1 Lesions  4 cm Stage IB2 Lesions > 4 cm
FIGO 2008

6. FIGO Staging…. FIGO stage Definition
Stage IIA Involvement of upper 2/3rd of vagina
Stage IIA1 Lesions  4 cm
Stage IIA2 Lesions > 4 cm
Stage II B Involvement of medial parametrium
Stage IIIA Involvement of lower 1/3rd of vagina
Stage IIIB Involvement of para upto LPW/HN
Stage IVA Bladder &/or bowel involvement
Stage IVB Distant metastasis

7. Basic Principles of Management of Cervical Cancer
All stages of cervical cancer can be treated by radiation therapy
Concurrent chemo-radiation is superior to radiation alone
FIGO stages I-IIA cervical cancer are amenable to primary surgical treatment
Adjuvant Rx may be required after Sx

8. Surgical Management of Ca-Cervix
St.-IA1
Class-I
Simple
Hysterectomy
Radical
Trachelectomy
Radical Cone
St.-IA2
Class-II
Modified Rad.
Hyst.+BPLND
Radical
Trachelectomy
St.IB1
Class-III
Rad. Hyst. +
BPLND
Radical
Trachelectomy
(< 2 cm)
St.IB2/IIA
Class-III
Rad. Hyst. +BPLND

9. Five classes of hysterectomy (Piver, 1974)
Extent of Surgery
Five classes of hysterectomy (Piver, 1974)
Class Type of Surgical margins Indications
Hysterectomy
I Extrafascial No vagina, parametia FIGO stage IA1
no ureteric mobilization without LVSI
II Modified Mid portion of uterosacral FIGO stage IA2,
Radical & cardinal ligaments, IA1 with LVSI
1-2 cm of vagina
III Radical All uterosacral & cardinal FIGO stage IB-IIA
ligaments,
1/3rd of vagina,

10. Extent of Hysterectomy
Class-I
Class-II
Class-III

11. Five classes of hysterectomy (Piver, 1974) cont..
Extent of Surgery
Five classes of hysterectomy (Piver, 1974) cont..
Class Type of Surgical margins Indications
Hysterectomy
IV Radical ureter completely dissected Recurrent disease
from cervico-vesical ligament
superior vesicle art. sacrificed
3/4th of vagina, ,
V Radical Resection includes portion Recurrent disease of distal ureter and bladder

12. Pelvic LN Metastasis in Early Cervical Ca
Stage IA1 <0.5% Stage IA2 8% (0-13%) Stage IB 12-20% Stage IIA 20-38%

13. Post-operative Morbidity
Febrile morbidity
Bladder dysfunction
Fistulae – VVF, UVF
Ureteric stenosis
Neuropathies
Thrombo-embolism
Lymphocele
Lower limb edema
GI complications

14. Prognostic Factors & Adjuvant Rx
Lymph node metastases
Parametrial involvement
Positive surgical margins
Deep stromal invasion
Lymph-vascular space invasion (LVSI)
Tumor size > 4 cm

15. Adjuvant Treatment after RH
Risk factors
Risk category
Adjuvant Rx
Nil
Low Risk
None
Deep stromal invasion
Tumor >4 cm
LVSI +ve
Intermediate Risk
Adjuvant pelvic RT*
Lymph node +ve
Cut margin +ve
Parametrium +ve
High Risk
Adjuvant Concurrent CT + RT **
any two
any one
*Sedlis et al. Gynecol Oncol.1999
**Peters et al. J Clin Oncol.2000

16. Fertility Preserving Surgeries
Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomy
Types of surgery Stage of the disease
Conization Stage IA1 without LVSI
Conization with BPLND Stage IA1 with LVSI
Radical Trachelectomy with BPLND Stages IA2-IB1,
IA1 with LVSI
Trachelectomy Lymphadenectomy
Vaginal
Abdominal
Laparoscopic
Extra-peritoneal

17. Radical Trachelectomy
- Dargent et al (1994) described the technique.
Eligibility criteria:
Desire to preserve fertility.
Upto FIGO stages IB1( <2cm).
Limited endo-cervical involvement.
No evidence of pelvic lymph node metastasis.

18. Radical trachelectomy..
Pelvic lymphadenectomy
Frozen section
Negative Nodes
Radical trachelectomy
If resection margins positive / nodes positive
Radical hysterectomy
Cervical circlage suture to ↓ the risk of abortion.

19. Radical trachelectomy- Obstetric considerations
Contraception for 6-12 mths.
↑second trimester abortions, premature rupture of membrane, choriamnionitis, and preterm deliveries.
Delivery by elective classical caesarean section.

20. Radical Vaginal Trachelectomy- Global data
Authors Total No Pregnancies No. of Rec. Deaths births Shepherd Dargent Covens Roy Schneider Burnett Schlaerth TOTAL (4.4%) 5(1.2%)

21. Ovarian Preservation & Transposition
Risk of Ovarian Metastases in Early Cervical Ca:
SCC % (4/770)
Adenocarcinoma 1.7% (2/121)
Adeno-squamous (0/99)
Sutton et al. Am J Obstet Gynecol. 1992

22. Ovarian Transposition
Ovaries are detached from the uterus along with its
blood supply and transposed in an area away from the
radiation field, generally in the para-colic gutters
abovethe pelvic brim.
Drawbacks of Ovarian Transposition:-
25% risk of benign ovarian cysts.
50% ovarian failure.
Risk of occult metastasis

23. Role of Sentinel Node Mapping
First draining lymph node of an anatomical region
Helps in tailoring the extent of surgery.
Techniques: Peri-tumoral injection of blue dye and/or radioactive tracer.
Extensively used in melanoma, breast and vulvar Ca.
Still experimental in Cervical Cancer!

24. Role of minimally invasive surgery in the management of cervical cancer
Laparoscopic Radical Hysterectomy (LRH).
Laparoscopic Assisted Radical Vaginal
Hysterectomy (LARVH).
Laparoscopic surgical staging.

25. Chemo-Radiotherapy in Ca Cervix
Combination of CT and RT is superior to RT alone.
Chemotherapy: Cisplatin 40mg/m2/wk X 5-6 wks
Radiation therapy: Combination of TELETHERAPY & BRACHYTHERAPY
TELETHERAPY (EXTERNAL BEAM RADIATION THERAPY)
BRACHYTHERAPY (INTERNAL RADIATION)
INTRACAVITARY LDR
HDR
INTERSTITIAL LDR HDR

26. RECOMMENDED TOTAL RADIOTHERAPY DOSES
85-90
35-40 50
IIIB 85
45-50
IIB
75-80
30-35 45
IB/IIA
50-60 IA
TOTAL DOSE ‘A’
ICRT-LDR
POINT ‘A’
EXT. RT
PELVIS
Stage
RADIOTHERAPY TREATMENT TO BE COMPLETED WITHIN 8 WKS
IJROBP 1993,1995,

27. INTERSTITIAL BRACHYTHERAPY IN CERVIX
INDICATIONS:
Extensive Parametrial Disease
Narrow/distorted vagina
Post-hystercetomy Recc.
Distal Vaginal involvement
Persistent disease after radical radiotherapy (EXT + ICA)
Applicators:
Syed-Neblett Template (LDR)
Martinez Universal Perineal Interstitial Template (MUPIT-HDR)

28. Management of Ca-Cervix
EARLY
I-IIA
ADVANCED
IIB – IVA IVA-IVB / REC
SURGERY
PALLIATION
RADICAL RADIOTHERAPY +
CHEMOTHERAPY
RADIOTHERAPY
CHEMOTHERAPY

29. Conclusions All stages can be treated with RT
Concurrent CT-RT is superior to RT alone
Surgery is the treatment of choice for early-stage cervical cancer.
Adjuvant treatment is recommended in patients with poor prognostic factors.
Preservation of fertility is possible in selected patients.