1. CARCINOMA OF THE UTERINE CERVIX BY: DR
CARCINOMA OF THE UTERINE CERVIX BY: DR. MALAK AL-HAKEEM Assistant Professor and Consultant Obstetric and Gynaecology

2. Presenting signs of cervical carcinoma The most frequent symptom is: 1
Presenting signs of cervical carcinoma The most frequent symptom is: A bloody discharge presenting as postcoital bleeding. 2. Intermenstrual bleeding or 3. Menorrhagia Symptoms of more advanced disease include: - backache - leg pain - leg edema or - hematuria

3. RISK FACTORS FOR CERVICAL CARCINOMA 1. First coitus at a young age 2
RISK FACTORS FOR CERVICAL CARCINOMA 1. First coitus at a young age 2. Multiple sexual partners 3. Lower socioeconomics status 4. Human papillomavirus (HPV) probably acts as a cofactor in cervical carcinogenesis

4. Diagnosis of cervical cancer made
Diagnosis of cervical cancer made? All cervical lesions should be biopsied, regardless of the Pap smear. Pap smear and colpocopically directed biopsies are used for microscopic (or occult) lesions. Cervical biopsy consistent with micro - invasion requires cone biopsy to rule out frankly invasive carcinoma.

5. What is the definition of microinvasion
What is the definition of microinvasion? How does it determine necessary treatment? Microinvasion is defined by the International Federation of Gynecology and Obstetrics (IFGO) as measurable microscopic lesions not exceeding 5 mm from the base of the epithelium or 7 mm of horizontal spread. The 1995 FIGO staging system further defines cervix cancer stage as measured invasion of stroma no greater than 3 mm in depth and no wider than 7 mm.

6. Patients may be treated with conservative surgery, i. e
Patients may be treated with conservative surgery, i.e., simple hysterectomy or, in selected cases, cone biopsy with free margins to preserve childbearing ability. What is the 1995 FIGO staging system for carcinoma of the cervix? Stage I: The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded).

7. Stage IA : Invasive cancer identified only microscopically. All gross lesions, even with superficial invasion, are stage IB cancers Invasion is limited to measured stromal invasion with maximal depth of 5.0 mm and maximal width of 7.0 mm.

8. Stage IAI: Measured invasion of stroma no. deeper than 3
Stage IAI: Measured invasion of stroma no deeper than 3.0 mm and no wider than mm. Stage IA2: Measured invasion of stroma deeper than mm but no deeper than 5.0 mm and no wider than 7.0 mm. Stage IB : Clinical lesions confined to the cervix or preclinical lesions larger than stage IA. Stage IBI : Clinical lesions no larger than 4.0 cm.

9. Stage II : The carcinoma extens beyond the cervix but
Stage II : The carcinoma extens beyond the cervix but has not extended to the pelvic wall. The carcinoma involves the vagina but not as far as the lower third. Stage IIA : No obvious parametrial involvement. Stage IIB : Obvious parametrial involvement. Stage III : The carcinoma has extended to the pelvic wall. Rectal examination reveals no cancer- free space between the tumor and pelvic wall. The tumor involves the lower third of the vagina. All cases with hydronephrosis or nonfunctioning kidney are included unless kidney disease is known to be due to other causes.

10. Stage IIIA : No extension to the pelvic wall
Stage IIIA : No extension to the pelvic wall. Stage IIIB : Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney Stage IV : The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Bullous edema does not assign a case to stage IV. Stage IVA : Spread of carcinoma to adjacent organs. Stage IVB : Spread to distant organs.

11. What is the prognosis for 5 year survival based on stage of disease
What is the prognosis for 5 year survival based on stage of disease? Stage I % Stage III % Stage II % Stage IV %

12. Which patients are candidates for primary surgical management
Which patients are candidates for primary surgical management? What is paraaortic nodes are positive on frozen section? Patients with stage I and Stage IIA cervical carcinoma are candidates for primary surgical treatment. Positive paraortic nodes prevent cure with radical hysterectomy; therefore, the procedure should be abandoned and the patient treated with pelvic radiation therapy with an extended paraortic field. Although no definitive data document improved survival, some gynecologic oncologists treat these patients with adjuvant chemotherapy as a radiation sensitizer.

13. How does radical hysterectomy differ from simple hysterectomy
How does radical hysterectomy differ from simple hysterectomy? Are the ovaries always removed at the time of radical hysterectomy? In radical hysterectomy, the uterine artery is ligated at its origin from the internal iliac artery, uterosacral ligaments are resected back toward the sacrum, cardinal ligaments are resected at the pelvic sidewall, and the upper one-third of the vagina is removed. Pelvic lymphadenectomy is routinely performed. Ovaries may be preserved with this procedure; this is one of the major advantages of surgery over radiation in young patients.

14. What are the common complications of a radical hysterectomy
What are the common complications of a radical hysterectomy? The most common complication: - Is bladder dysfunction - Lymphocyst formation may occur - Risk of pulmonary embolus - Hemorrhage - Infection is increased - Ureteral fistula is also a complication of radical hysterectomy but has become less frequent as surgical techniques improve.

15. What is the alternative to surgical therapy for early – stage disease
What is the alternative to surgical therapy for early – stage disease? Is there a difference in cure rates? Primary radiation therapy can be used to treat early – stage carcinoma of the cervix with the same survival rates as surgery.

16. What is the theory on which radiation therapy for cervical cancer is based? The cervix is accessible to application of radiation techniques and is surrounded by normal tissue (cervix and vagina) that is highly radioresistant. Because of the anatomy of the cervix, intracavitary doses of 10,000 rads may be delivered to the tumor. The dose of radiation falls off by the inverse square of the distance from the source; the bowel and bladder are protected by packing.

17. Does postoperative radiation therapy in patients with positive pelvic nodes at the time of radical hysterectomy improve survival? No. Postoperative radiation therapy increases pelvic control but does not improved long – term survival.

18. What are the advantages and disadvantages of high dose – rate (hdr) brachytherapy vs. low dose rate (ldr) brachytherapy? The advantages of HDR brachytherapy include outpatient treatment, less anesthesia, less potential for displacement, and decreased personnel exposure. HDR brachytherapy delivers therapy with shorter exposure than the repair half-time of sublethal damage, which may increase the risk of complications. More insertions are required for HDR therapy because of the loss of the dose-rate effect. Preliminary studies of HDR vs LDR brachytherapy suggest nearly equal 5 – year efficacy without increased late tissue response. Initial expense for HDR equipment may prove to be a major limitation to this therapy.

19. What is the most common location of recurrence after radical hysterectomy? After radiation therapy? After radical hysterectomy, approximately one-third of recurrence are in the pelvic sidewall and approximately one-fourth in the central pelvis Recurrence after radiation therapy is in the parametrial area in 43% of cases; 27% of recurrence are in the cervix, uterus, or upper vagina.

20. What is the prognosis for a patient with persistent or recurrent cervical carcinoma? The I – year survival rate is %. What treatment options are available for patients with recurrent tumor? Patients with pelvic recurrence after radical hysterectomy may be treated with radiation therapy. Patients with central recurrence after radiation therapy are candidates for pelvic exenteration.

21. Which patients are candidates for pelvic exenteration
Which patients are candidates for pelvic exenteration? Pelvic exenteration for recurrent carcinoma of the cervix is indicated only when pelvic recurrence is centrally located. The triad of unilateral leg edema, sciatic pain, and ureteral obstruction indicates unresectable disease.

22. What are the obsolute contraindications for pelvic exenteration. 1
What are the obsolute contraindications for pelvic exenteration? Extrapelvic disease 2. Triad of unilateral leg edema, sciatica, and ureteral obstruction 3. Tumor – related pelvic sidewall fixation 4. Bilateral ureteral obstruction

23. Does chemotherapy have a role in treatment of recurrent cervical cancer? Chemotherapy has traditionally had low response rates and short duration. The prognosis for patients with unresectable recurrent disease is so poor that new combinations of chemotherapeutic agents are being evaluated. Cisplatin had been shown to be the best single agent against squamous cell carcinoma. The use of chemotherapeutic agents (cisplatin, 5-flourouracil, and hyroxyurea) as radiosensitizers is being evaluated for prolonged survival or increased cure rates inpatients with poor prognosis. The combinations of bleomycin, ifosfamide, and cisplatin has shown initially encouraging results in recurrent disease. The use of chemotherapy as neoadjuvant therapy has been considered but to date has shown no significant improvement over standard therapies.

24. Is the prognosis of adenocarcinoma of the cervix worse than the prognosis of squamous carcinoma? If so, should the two lesions be treated differently? Stage for stage there is no significant difference in survival of patients with adenocarcinoma vs. squamous cell carcinoma, but lesions tend to be initially bulky and more poorly differentiated. Local recurrence is more common in adenocarcinomas; as a result, many oncologists consider combined radiotherapy and surgery for these lesions.

25. Should the treatment of adenocarcinoma is situ and microinvasive adenocarcinoma differ from the standard treatment of the squamous counterparts? Adenocarcinoma in situ of the cervix can be a difficult pathologic diagnosis to make. Present data suggests that come biopsy with negative margins or simple hysterectomy is adequate therapy. The patient with adenocarcinoma in situ who elects to preserve her uterus should be followed closely, because the disease may be multifocal, with lesions above the negative margin. Pap smears tend to be less reliable in adenocarcinoma. Microinvasive adenocarcinoma of the endocervix is not well defined. There are essentially no data to support less than radical treatment of invasive adenocarcinoma.

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