1. Cervical cancer

2. Introduction
Cancer of the cervix is the most common female genital cancer in developing countries every year about 500,000 women , acquire the disease and 75% are from frame developing countries.
About 300,000 women also die from the disease annually and of these 75% are from developing countries

4. Finland which has an advanced population based screening program has one of the lowest rates in the world.

5. Incidence
4-6 % of female genital cancers.

6. Age
40-50 years old

7. Risk factors and aetiology
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of
Coitus at young age: <16 years old increased risk by 50%
Number of sexual partners: 6 sexual partners or more increase risk by 14.2 folds.
Smoking
Smoking for> 12 years increase the risk by 12.7 folds.
Male related risk factors:
number of the partners previous sexual relationships is relevant .
cervical cancer risk increased if partners has penile cancer (circumcision)
Previous wife with cervical cancer.
Previous CIN
Poor uptake of screening program.
Long term use of the contraceptive pill increase the risk due to increasing exposure to seminal fluids.
Barrier method decrease the risk (condan)
Immuno suppresion risk increased with immuno suppressed renal transplant patients and in HIV positive women.
HPV (Human papilloma virus ) infection mainly 16,18
the main aetiological is infection with subtypes of HPV (16,18)
Low socioecomic class of

10. Type of patient: Multiparous. Low socioeconomic class. Poor hygiene.
Prostitutes.
Low incidence in Muslims and Jews.

11. Predisposing factors:
Cervical dysplasia.
(Cervical intraepithelial neoplasia)
CIN III / CARCINOMA IN SITU
THE LESION PROCEEDS THE INVASION BY YEARS

17. Symptoms: Early symptoms Late symptoms - None.
- Thin, watery, blood tinged vaginal discharge frequently goes unrecognized by the patient.
- Abnormal vaginal bleeding
Intermenstrual
Postcoital
Perimenopausal
Postmenopausal
- Blood stained foul vaginal discharge.
- Pain, leg oedema.
- Urinary and rectal symptoms
dysuria
haematuria
rectal bleeding
constipation
haemorrhoids
- Uraemia

18. Pathology type
Squamous cell carcinoma- 90%.
Adenocarcinoma- 10%.

19. Types of growth
Exophytic: is like cauliflower filling up the vaginal vualt.
Endophytic: it appears as hard mass with a good deal of induration.
Ulcerative: an ulcer in the cervix.

20. DIAGNOSIS 1- History. Many women are a symptomatic .
Presented with abnormal routine cx smear
Complain of abnormal vaginal bleeding
I M bleeding
post coital bleeding
perimenopausal bleeding
postmenopausal bleeding
blood stain vaginal discharge

21. 2- Examination:
Mainly vaginal examination using cuscu’s speculem nothing is found in early stage .
Mass ,ulcerating fungating in the cervix
P/V P/R is very helful.

22. Cytology
Histology
calposcopy

24. Preoperative evaluation
Review her history.
General examination:
Anaemia.
Lymphadenopathy-Supraclavicular LN.
Renal area.
Liver or any palpable mass.
Oedema.
Laboratory tests:
CBC, LFT, RFT, Urine analysis.
Tumour markers.
Chest X- ray, abdominal X- ray, IVU.
CAT, MRI, if necessary.
Ultrasound.
Lymphography, if necessary.

25. Staging Best to follow FIGO system. Examination under anaesthesia.
Bimanual palpation.
P/V, P/R.
Cervical biopsy, uterine biopsy.
Cystoscopy, Proctoscopy, if necessary.

27. STAGES OF CANCER CERVIX
Once cancer cervix is found (diagnosed), more tests will be done to find out if the cancer cells have spread to other parts of the body. This testing is called staging.
TO PLAN TREATMENT, A DOCTOR NEEDS TO KNOW THE STAGE OF THE DISEASE.

33. SPREAD: Direct Lymphatic Dissemination (late) - Uteruq. - Vagina.
- Parametrium.
- Bladder and rectum.
A- primary node:
parametrial.
Paracervical.
Vesicovaginal.
Rectovaginal.
Hypogastric.
Obturator and external iliac
B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Inguinal.
- parametrial spread causes obstruction of the ureters, many deaths occur due to uraemia.
- Obstruction to the cervical canal results in pyometria.

34. DIFFERENTIAL DIAGNOSIS
Cervical ectropion.
Cervical tuberculosis.
Cervical syphilis, Schistosomiasis, and Choriocarcinoma are rare causes.

35. TREATMENT Surgical. Radiotherapy. Radiotherapy & Surgery.
Radiotherapy and Chemotherapy followed by Surgery.
Palliative treatment.

36. The choice of treatment will depend on
Fitness of the patients
Age of the patients
Stage of disease.
Type of lesion
Experience and the resources avalible.

37. Surgical procedure
The classic surgical procedure is the wertheim’s hystrectomy for stage Ib,IIa, and some cases of IIb in young and fat patient

39. Werthemeim’s hystrectomy
Total abdominal hystrectomy including the parametrium.
Pelvic lymphadenectomy
3 cm vaginal cuff
The original operation conserved the ovaries ,since squamouss cell carcinoma does not spread dirctly to the ovaries.
Oophorectomy should be performed in cases of adenocarcinoma as there is 5-10% of ovarian metastosis

40. Surgery offers several advantage
It allows presentation of the ovaries (radiotherapy will destroythem).
There is better chance of preserving sexual function.
(vaginal stonosis occur in up 85% of irradiates.
Psychological feeling of removing the disease from the body .
More accute staging and prognsis

41. COMPLICATIONS OF SURGERY
Haemorrhage: primary or secondary.
Injury to the bladder, uerters.
Bladder dysfunction.
Fistula.
Lymphocele.
Shortening of the vagina.

42. INDICATIONS OF P/O XRT FOLLOWING WERTHEIM’S HYSTERECTOMY (STAGE I , IIa):
Positive pelvic lymph nodes.
Tumour close to resection margins and/or parametrial extension.

43. Radiotherapy Stage IIb and III Radical Radiotherapy
External irradiation (Teletherapy).
Intracavitary radiation (Brachytherapy).
In some cases of stage IIa or b radio and chemotherapy to be given then followed by simple hysterectomy

44. Palliative therapy For stage IV – individualized therapy.
Some suitable for palliative XRT ( usually intracavitary Caesium).
Some suitable for extensive surgery.
Some suitable for chemotherapy.
Good nursing care.
Analgesia-must be used in sufficient amount to pain (Codein sulfate, Pethidine, Morphine, Diamorphine).
Antiemetic if necessary.
IV drip, entral, and parentral feeding.
Urinary Catheterization.
Other measures for symptom relief.

45. PROGNOSIS Depends on: Age of the patient. Fitness of the patient.
Stage of the disease.
Type of the tumour.
Adequacy of treatment.

46. THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY:
Stage I %
Stage II %
Stage III %
Stage IV %

47. MANAGEMENT OF RECURRENT DISEASE
1. Local recurrence:
Radiation – if not used.
Pelvic exenturation.
2. Distant disease
Chemotherapy.

48. Follow up policy
On completion of treatment all patients are given a vaginal dilator to use until vaginal mucosa healed, this prevents vaginal stenosis.
Premenopausal patients commenced on HRT:
post hysterectomy-Extraderm skin patches 50 meg twice weekly.
No hysterectomy- Cycloprogyn 1mg daily.
The patient to be seen 1/12 post-treatment.
3 monthly for 2 years.
4 monthly for 3rd year.
6 monthly until 5years.
Then yearly all her life.
Patients with stage I and II disease treated with radical radiotherapy will be assessed by EUA approximately 3 months after completing treatment.

49. Objective
Cancer of the cervix is still quite common, reduction in incidence depends on the quality of the screening program.

50. The aetiology appears to be multifactorial the prime oncogenic agent is probably [HPV-16,18].
Clinical presentation is with inermenstrul,postcoital, postmenospausal bleeding or following abnormal cytology.
Tumour spreads locally to involve the uterus bladder , vagina, parametrium, ureters, rectum and bone.

51. Spread also to the internal and external iliac , obdurater and common iliac nodes then to para- aortic nodes.
Blood borne metastasis spread to liver, lung and bone occur .
Microinvasion squamous tumour carry a good prognosis allowing conservative treatment initially if required.

52. Early invasive squamous cell disease (stage Ib,IIa and in some cases of IIb) may be treated by either a wertheimes hysterectomy or radiotherapy as first line treatment.
Advanced stage (IIb, III,IV) treated by radio or chemotherapy.

53. Glandular tumours (adenocarcinomas) are not detectable by screening are associated with skip lesions and require radical surgery.