1. In the name of God Cervical Cancer Dr.T allameh MD

2. Cervical cancer Annually 500000 new cases 4/100000= lowest in Israel, 83.2/100000= highest in Brazil USA  breast, lung, colorectum, endometrium, ovary, cervix Average age = 52.2 years old Peaks at 35-39 & 60-64 years

4. Cervical cytology Single negative pap-smear  45% decrease in risk Single negative pap-smear  45% decrease in risk 9 negative pap-smears  99% decrease in risk 9 negative pap-smears  99% decrease in risk First pap-smear at 18 years or sexual activity First pap-smear at 18 years or sexual activity Every 3 years repeated and if more than one risk factor, every year Every 3 years repeated and if more than one risk factor, every year Screening till 65 years old ( 25% of cancers and 41% mortality in this age) Screening till 65 years old ( 25% of cancers and 41% mortality in this age)

6. History Commonest symptom = AUB or discharge Commonest symptom = AUB or discharge Postcoital spotting, intermenstrual bleeding, menorrhagia, postmenopausal spotting Postcoital spotting, intermenstrual bleeding, menorrhagia, postmenopausal spotting Chronic bleeding  fatigue & anemia Chronic bleeding  fatigue & anemia Frequent serosanguineous or yellowish discharge Frequent serosanguineous or yellowish discharge Advanced lesion or necrosis  Foul odor discharge Advanced lesion or necrosis  Foul odor discharge Locally advance disease or trauma  pelvic pain Locally advance disease or trauma  pelvic pain Advanced stage  sciatic pain, back pain, hydronephrosis Advanced stage  sciatic pain, back pain, hydronephrosis Advanced stage ( bladder  hematuria, rectum  hematochezia) Advanced stage ( bladder  hematuria, rectum  hematochezia)

7. Physical examination Normal general ph/ex Visible lesion on the cervix Early lesion  focally indurated, ulcerated, slightly elevated and granular area  bleeding Large lesion  Exophytic: polypoid or papillary Endophytic : bimanual exam Inguinal and supraclavicular fossa for distant metastasis

8. Differential diagnosis Other genital cancers ( endometrial ) Cervical leiomyoma Severe erosive cervicitis Complication of pregnancy Rarely cervical ectopic pregnancy

9. Diagnostic evaluation Clinical evaluation Careful inspection and palpation of cervix and vagina (EUA) Colposcopic evaluation + ECC + directed cervical biopsy Cervical conization or punch biopsy Conization if unsatisfactory colposcopy unsatisfactory colposcopy Positive ECC Positive ECC Lack of correlation in cervical cytology, colposcopy, biopsy Lack of correlation in cervical cytology, colposcopy, biopsy Cervical microinvasive Cervical microinvasive Cervical biopsy + ECC = adenocarcinoma in situ for R/O of invasive adenocarcinoma Cervical biopsy + ECC = adenocarcinoma in situ for R/O of invasive adenocarcinoma IVP, CX-Ray

15. Prognostic factors Clinical stage Clinical stage 5-year survival 5-year survival Stage IA = 97%, Stage IA = 97%, Stage IB = 85%, 5-year survival Stage IB = 85%, 5-year survival Stage II = 60% Stage II = 60% Stage III = 45% Stage III = 45% Stage IV = 18% Stage IV = 18% All stages All stages 75.2% if node negative 75.2% if node negative 45.6% if pelvic node positive 45.6% if pelvic node positive 15.4% if para-aortic node positive 15.4% if para-aortic node positive Size & depth of tumor Size & depth of tumor Histologic differentiation ( 75% well, 63.7% moderate & 51.4% poorly differentiated ) Histologic differentiation ( 75% well, 63.7% moderate & 51.4% poorly differentiated )

17. Surgery Type I  standard extrfascial TAH Type II  modified radical hysterectomy Type III  hysterectomy Lymph adenectomy ( II,III )

22. Radiation therapy External beam = whole pelvis lateral prametrium Brachytherapy  central disease Internal uterine tandem with colpostats Internal uterine tandem with colpostats Interstitial needle implants Interstitial needle implants Vaginal sylinder Vaginal sylinder Point A, 2cm lateral and 2 cm higher than external os ( 7500-8500 cGY ) Point B, 3cm lateral to point A ( sidewall of pelvis )( 4500-6500 cGY)

23. Acute complications Blood loss  average 81% Blood loss  average 81% Uterovaginal fistula  1- 2% Uterovaginal fistula  1- 2% Vesicovaginal fistula  1- 2% Vesicovaginal fistula  1- 2% Pulmonary embolus  1- 2% Pulmonary embolus  1- 2% Small bowel obstruction  1-2% Small bowel obstruction  1-2% Hemorrhagic cystitis  3% Hemorrhagic cystitis  3% Proctosigmoiditis  8% Proctosigmoiditis  8% Febrile morbidity  25- 50% Febrile morbidity  25- 50% 10% pulmonry 10% pulmonry 7% Pelvic cellulitis 7% Pelvic cellulitis 6% UTI 6% UTI 5% wound infection, pelvic abscess, phlebitis 5% wound infection, pelvic abscess, phlebitis

24. Subacute & chronic complications Subacute – Postoperative bladder dysfunction – Lymphocyst formation Chronic – Vaginal stenosis (most common=70%) – Bladder hypotonia – Ureteral stricture

25. Chemotherapy Extrapelvic metastasis Recurrent disease ( not candidate for surgery or radiation ) Cisplatin Complete response is 24% Partial response is 16% Neodjuant chemotherapy (Before surgery)  improved survival & better resection Chemoradiation  advanced cervical cancer ( sensitization of cervical cancer cell to irradiation)

26. Follow-up Persistent if detected within 6 months Failed primary treatment  recurrence 50% in first year, 80% in first two years Pelvic examination and lymph node evaluation ( supraclavicular ) every 3 months for 2 years, every 6 months for following 3 years) Cytologic smear every examination Any palpable mass, FNA under CT CX-Ray annually