1. Stage II Stage II - Invasive cancer with tumor extending beyond the cervix and/or the upper two-thirds of the vagina, but not onto the pelvic wall. –Stage IIA - Tumor has spread beyond the cervix to the upper part of the vagina. –Stage IIB - Tumor has spread to the tissue next to the cervix - perimetrium. 1

2. Stage III Stage III - Invasive cancer with tumor spreading to the lower third of the vagina or onto the pelvic wall; tumor may be blocking the flow of urine from the kidneys to the bladder. –Stage IIIA - Tumor has spread to the lower third of the vagina. –Stage IIIB - Tumor has spread to the pelvic wall and/or blocks the flow of urine from the kidneys to the bladder. 2

3. Stage IV Stage IV - Invasive cancer with tumor spreading to other parts of the body. This is the most advanced stage of cervical cancer. –Stage IVA - Tumor has spread to organs located near the cervix, such as the bladder or rectum. –Stage IVB - Tumor has spread to parts of the body far from the cervix. 3

4. Metastases - via lymph vessels Most common way stage I – 13-20% stage II – 30-33% stage III – 40-60% In stages II and III to surrounding tissues. 4

5. Primary spread group 1.Parametrial nodes axe the small lymph nodes, traversing the parametria 2.Paracervical or ureteral nodes are located above the uterine artery where it crosses the ureter 3.Obturator: surrounding the obturator vessels and nerves 4.Internal iliac nodes course along the hypogastric (internal iliac) vein near its junction with externaliliac groups 5.Sacral nodes 5

6. Secondary spread group Common lilac nodes Inguinal nodes consist of the deep and superficial femoral lymph nodes Para-aortic nodes 6

7. Metastases – via veins liver bones lungs bowels brain skin cervical cancer Usually occur late. prognosis is very bad here. 7

8. 5 year survival rates: Stage I : 80-90% Stage II : 75% Stage III : 35% Stage IV : 10-15% Prognosis is stage dependent 8

9. Stage 1 - 32 months Stage 2 - 24 months Stage 3 - 11 months Stage 4 - 5 months Prognosis - if not treated 9

10. Clinical symptoms 10

11. 1-st Clinical symptom ? Patients with early-stage cervical cancer are relatively asymptomatic. At the microscopic stage of disease, most cervical cancers produce no signs or symptoms. 11

12. In early stage there are often no symptoms other than an abnormal Pap smear. 12

13. First clinical symptoms of cervical cancer are the sign of advanced disease !!! 13

14. And these are not an early symptoms but first clinical symptoms. Try to remember that!! First clinical symptoms are not accompanied by any suffering. Late symptoms are followed by pain and suffering. 14

15. First Clinical symptoms As the carcinoma grows, symptoms such as abnormal bleeding and vaginal discharge may occur Postcoital bleeding may be the first symptom in sexually active women. 15

16. Other clinical symptoms Larger tumors may cause size-related symptoms: urinary frequency or retention, rectal pressure, constipation, neurologic symptoms (eg, sciatic pain due to local extension), lower extremity pain, and swelling. Anemia – patients report feeling weak or dizzy. Urinary or fecal incontinence prompts patients to seek care. 16

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18. Physical examination The most common sign of cervical cancer is a grossly visible lesion upon vaginal speculum examination 18

19. Attention ! An exophytic or ulcerative lesion may be obvious during the clinical examination, but an endocervical lesion may have normal-appearing ectocervical mucosa in the presence of a firm & enlarged cervix. 19

20. TREATMENT 20

21. TREATMENT Surgery Radiation therapy Chemotherapy Strategies and proportion of methods depend on stage and advancement of cancer. 21

22. Surgical treatment 1.protective operation (conization, amputation of cervics), 2.simple amputation of uterus’ trunk (hysterectomy) without adnexes, 3.radical hysterectomy with selective removal of lymph nodes +/– additional treatment 22

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24. brachytherapy (intravaginal and intrauterinal,) radiotherapy (teletherapy in coop. with brahytherapy), Radical surgery followed by radio- chemotherapy, radiotherapy combined with chemotherapy. Radio and chemo therapy 24

25. CIN III - preinvasive cancer Cervical conization – removal of the part of the cervix containing the preinvasive cancer ( HSIL / CIN III). Followed by abrasion of cervix’s canal = diagnosis and treatment * cancer in canal => amputation 25

26. Contradictions for protective operations - conization – tumors and inflammation of adnexes, – myomas uteri, – high grade disfigurement of vaginal part of cervix after delivery, – little and tiny cervix, – cancer in canal (abrasion). 26

27. Microinvasive ca. stage IA1 – treatment is analogical to preinvasive cancer. But…. Microinvasive ca. Stage IA2 – surgical treatment ± complementary radiotherapy. Surgery - radical hysterectomy with selective LN removal 27

28. Invasive cancer IB1 (< 4 cm) – Invasive cancer IB2 (> 4 cm) – Invasive cancer IIA * surgery ± radiotherapy. * sampling – biopsy of paraaortic LN 28

29. RADICAL HYSTERECTOMY Radical abdominal hysterectomy (Wertheim – Meigs) is indicated for patients with stage IA2-IIA of cervical cancer, who are medically fit enough to tolerate an aggressive surgical approach and wish to avoid the long-term adverse effects of radiation therapy. 29

30. RADICAL HYSTERECTOMY Contraindications: patients who are medically infirm and those who refuse surgical treatment. 1/3 -2/3 of surgical patients require transfusion, radiation therapy should be considered for patients whose religious or personal beliefs prohibit blood product transfusion. As with any other surgery, careful preoperative risk assessment must be performed. 30

31. Invasive cancer IIB Invasive cancer IIIA Invasive cancer IIIB Invasive cancer IVA radiotherapy. Invasive cancer IVB – NO TREATMENT STANDARDS 31

32. Radio&chemotherapy 30-50% reduction of risk of death in comparison to radiotherapy only. Should be placed in standards of treatment for stages : Ib, II, III and IVa. 32

33. Nice To Know: The number of new cervical cancer diagnoses and the number of cervical cancer deaths decline each year. Experts believe these statistics would decline even more rapidly if regular Pap tests were given to all women who are or have been sexually active or have reached the age of 18. 33

34. Remember! It can be curable when detected early with a Pap smear. 34

35. Pap smears guidelines recommended for all women: –beginning at age 25 (18 US) or, –when becomes sexually active (max 3y after). If normal + no risk factors – repeat every 3 years Highr risk groups – every year HIV+,HPV+, immunosupression, HSIL – repat within 12 months 35

36. Cervical Cancer in Pregnancy Aproximately 1/1000 – 10 000 1-3% of all CC Mean age 32-34 years 36

37. Cervical Cancer in Pregnancy Influence of pregnancy is controversial –Suppression of cellular resistance –High oestrogen levels However the progress of dysplasia, preinvasive and microinvasive cancer is not enhanced No influence on prognosis and survival rate 37

38. Cervical Cancer in Pregnancy identical screening 50% - preinvasive and Figo I 81-87% squamous 7-15% adenocarcinoma 38

39. Cervical Cancer in Pregnancy Few cases = no guidlines Treatment depends on: Stage Hbd Having offsprings Individal’s decision 39

40. Cervical Cancer in Pregnancy Treatment may be delayed till foetus’ maturity –Early stages –DGN at the end of 2nd and 3rd trimester –Invasive IB <2cm without meta DGN in 1st trimester Tumor>4 cm => immediate treatment 40