1. CERVICAL CANCER
DR /Omar Hashim

2. ANATOMY OF CERVIX
The cervix is the lower 1/3 of the uterus, it is the
narrower part of the uterus (neck of uterus) .it is
rounded and directed downward and posteriorly
.
Portio is the portion of the cervix that protrudes
into the vagina (about 1cm long and covered by
vaginal epithelium .

5. EPIDEMIOLOGY AND ETIOLOGY
Ca cervix is the fifth most common cancer in the
women worldwide . In USA new case 11,270 and
deaths n 4,070 (in2010) .
The incidence is ↓ due to screening and human
papilloma virus (HPV) vaccines in the past 4th
decades .but still in some area in developing
countries ca cervix is the most common cancer
and leading cause of death .
Risk factors ;- early age of sexual intercourse/ high
number of lifetime sexual intercourse /exposure to
to sexually transmitted diseases (HPV)
(AIDS)/smoking / oral contraceptive/DES exposure
in utero

6. PATHOLOGY
80% of ca cervix is squamous cell carcinoma
(SCC) usually originate at the squamocolumnar
junction and progress from mild,moderate,and
sever dysplasia to carcinoma insitu, to invasive
carcinoma .
10%--20% of ca cervix is adenocarcinoma .
Usually arise in high endocervical region and
originate from endocervical gland .
While SCC have ↓ in USA the incidence of
Adenocarcinoma ↑

8. LYMPH DRAIN & LYMPH SPREAD
*Lateral trunk ;-
Upper branch → upper internal iliac LNs
Middle branch→obturator LNs
Lowest branch→gluteal ,common iliac, presacral
LNs
*posterior trunk ;-
Superior rectal LNs
Sup-aortic LNs (sacralpromontory)
*anterior trunk ;-
Distal external iliac

9. INVOLVEMENT OF LNS GROUP( IN%) BY
STAGE
Lymph nodes group stage
1 11 111
Pelvic LNs 15% 30% 50%
Para-aortic LNs 5% 20% 30%

10. DIAGNOSIS
CILNICAL PRESENTATION ;-
Abnormal vaginal bleeding > 80% .
Vaginal discharge .
Late symptoms include symptoms of pelvic organ
compression or extension e.g ;-
Sciatic pain /lower extremity edema
Hydronephrosis /pelvic pain /rectal symptoms
Urinary obstruction

11. INVESTIGATION
investigation description
Tissue diagnosis Pap smear –ve not excluded .
biopsy by endocervical curettage
lab work CBC to assess HB & CBC and
differential
Count in anticipation chemotherapy
Serum chemistries to assess renal
function
Imaging studies CXR or chest
CT /abdominoplevic CT or
MRI which is better in delineation .
Or PET which is higher in senitivity in
staging LNs or METs

12. DIAGNOSIS AND PRETHERAPY EVALUATION
Ca cervix suspected
complete history and physical
examination
Physical exam focus;-
Procedure ;-
pelvic and Lab ;CBC /blood
colposcopy
rectovaginal chem/urinalysis
Papsmear if no
exam/cervical portio Radiology;-
bleeding
/tumor extension to CXR/Ctor MRI of abd-
Biopsy
vagina /abd-ex &pelvis OR PET
Cold knife conization
/supraclavicular LNs

13. con→
Exam under anesthesia
Cystoscopy,proctoscopy
Ureteral
staging FIGO
→radical hysterectomy vs definite
radiation chemotherapy

14. STAGING
Generally staging depend on history and
examination and radiologic and laboratory
workup . The most common used staging
system is Federation Gynecology and
Obstetrics (FIGO) Is based on clinical examation
. FIGO permits minimal information from plain
radiograph and does not incorporate
information on LNs involve-
Ment .despite not altering stage categories ,cross
sectional imaging (CT/MRI/PET) and invasive
surgical staging provide important additional
information on the extent of loco regional nodal
involvement and distant disease status

15. FIGO &TNM STAGING OF CA CERVIX
FIGO TNM Description
- Tx 1ry Tumor not assessed
- T0 No evidence of 1ry tumor
-a Tis Carcinoma in situ
1 T1 Ca cervix confined to uterus
1A T1a Invasive carcinoma (diag-microscopy) stromal
invasion depth 5.0 mm & wide 7.0mm
1B T1b Visible lesion confined to the cervix or mic->7
11 T2 Ca cervix invades out uterus but not pelv-wal
11A T2 a Tumor without parametrial invasion
11B T2b Tumor with parametrial invasion
111 T3 Tumor→plevic wall /lower1/3vagina/affet kid-
111A T3a tumor →Lower 1/3 of vagina/ no plevic wall
111B T3b Tumor→plevic wall or cause hydronephrosis
1v T4 Bladder or rectal invasion
1vA T4a Invade of mucosa of bladder or rectal

18. CON→
FIGO TNM DESCRIPTION
1VB T4b Mets-peril-/supraclavicular
LNs/lunge...
3/4 Nx Reg-LNs not assess
3/4 N0 No regional LNs mets
3/4 N1 Regional LNs mets-
3/4 Mo N o distant mets
3/4 M1 Distant met(peri-/supraclavicularLN or
mediastinal LNs

19. Stage111 enhancement of lift internal iliac lymph nodes

20. Lymph nodes enhancement in cervical cancer

21. PROGNOSIS
Ca cervix is curable when diagnosis early ,these lead
to improve out come in countries with access heath
care and cytological screening .
In more advanced disease, tumor recure 1/3 of PTs-.
The outcome is improved significantly with the
Introduction of of concurrent chemotherapy in stage
1B2_ 1v A . Neuroendocrine carcinoma of the cervix
has ↑mets rate ,poor prognosis and spread in
pattern similar to that of small cell cancer .
Low HB associated with ↓local control and survival
rates specially during RT. Hypoxia also associated
with poor out come

22. stage Local control Disease –free treatment
survival
1A—1B 93-95% 92% Surgery/Radiatio
n
1B All 94% All 81-85% Radiation
4-5cm 90% 4-5cm 86% therapy
>5cm 82% >5cm 67%
11A 94– 96% 70– 85% Radiation
therapy
1B-11 87% 74%
Radiation/chemo
therapy
111—1v 71% 40—50% Radiation
/chemotherapy
1vB -- 0% Palliative
chemotherapy
no Radiation

23. TREATMENT
 In stage 1A , non bulky 1B ,and early stage 11A , The
1ry treatment is surgery with hysterectomy and 1ry
radiation result in similar outcome
 Stage 1B1 radiation alone a choice or radical
hysterectomy .
 Stage ≥1B2 radiation with concurrent cisplatin
based chemotherapy .
 Treatment modalities ;-
surgery ;-
Modified radical hysterectomy ;- in which remove
done to the uterus ,cardinal ligament , partially the
uterosacral ligament ,pelvic LNs .
Survival > 95% /preserving ovarian function
/avoidance of radiation complication

24.  Radical hysterectomy ;-
 For stage 1A2 with LVS1 IB1 , non bulky 1B2 –
11A. In which remove done to the uterus
.cardinal ligament & upper 1/3 of the vagina
/pelvic LNs .
 Survival 80—90% .
 Radiation ;- used to as definitive treatment for
stage 1—11A inside of surgery .
 Definitive treatment for stage 11B– 1VA with
concurrent chemotherapy .
 For bulky disease >5—6cm should complete in
7weeks .stage 1B-11A .
 Postoperative pelvic radiation for involved LNs
+ve SM (EBRT integrated with brachytherapy )
.RT

25. Diagnosis of ca cervix
Clinical and radiological staging
Stage 1A– B1 Stage 1B– 11A Stage 11B– 1vA
RH/pelvicL
Ndissect- RH pelv
ERBT+BT/
±PALN LN disse-
CH
sam- PA samp
OR or
↑ ↑
ERBT +BT
ERBT+BT risk/LV/de risk/SM/LN
/CH
pth inve- /param-
Post op- RA- Post op radia-
Concu-chem-
Follow up

26. CHEMOTHERAPY
AS part of definitive treatment with concurrent with RT
for locally advanced cervical cancer.
Stage 1B1 concurrent CH not validated. Adjuvant
CH following concurrent RT/CH may↓ overall
recurrence rate used for palliation for local, regional
or systemic disease.
We use weekly cisplatin during 5weeks with pelvic
EBRT with or without CH during BT.
3-weekly cisplatin/5-FU is also validated level
Evidence. No benefit to cisplatin to other CH.
5-FU alone is not recommended .

27. Tow randomized trial defined the 1)utilizing of the adjuvant
radiation ,and 2)adjuvant radiation with concurrent
chemotherapy after hysterectomy
Eligibility criteria arm 1 arm2
LVS1 stromal tumor
Pelvic RT 46GY in 23 Observation
+ve deep1/3 any size fr . 50.4 GY in 28 fr
.
+ve middle1/3 ≥2cm N=140
n= 137
+ ve superficial1/3 ≥5cm
-ve deepormidlle ≥ 4cm

28. In the first trial show 46% reducation in risk of
recurrence favoring RT arm (p=0.0007) . Deferent in
overall survival

29. The 2nd trial 109 evaluated addition of concurrent
CH. Taking stage 1A,1B, or 11A (LN +ve /paramet-
+ve /SM +ve). Pts treated with RH then randomized
To RT alone versus RT with 4 cycles of cisplatin/5
FU. Overall survival was significantly improve.
Analysis show particular benefit for large tumor,
Multiple LNs.
HR for overall survival was 1.96 (p=0.007) favoring
RT/concurrent CH. OS for 4 yrs 71% with R and
81% for with RT/CH.

30. Clinical stage 1A,1B ,11A + any of ;-
1- +ve LN S
2- +ve parametria
3- +ve SM
randomization
ARM1 ARM2
Plevic RT 49.3GY IN 29 fr Same RT +
Cisplatin /5fu96 hours infusion
n=116 Every 3weeks x4 cycles
n=127
GOG protocol 109 evaluated the addition of concurrent chemotherapy
Is of benefit .*HR overall survival was 1.96 (p=0.007) favoring concurrent
Chemo-overall survival was 4 yrs 71% with RT .and 81% with RT+CHEMO-

31. Trial FIGO Number Compari- Follow up HR ↑ in
stage Of pts son survival
GOG85 11B-1VA 368 PF veru- 8.7 yrs 0.7 10%
HU
RTOG 1B(>5cm) 388 PF veru- 43 0.59 15%
9001 -1vA none months
GOG 11B-1VA 526 P /HU 35 0.61 18%
120 11B-1VA 526 PFHU/H months 0.58 18%
U 35 month
GOG 1B(>5cm 369 P versus 36 0.54 9%
123 -1vA none months
NCI/cana 1B(>5cm 253 P versus 64 0.91 3%
da -1vA none months
meta 1B-1VA 3,452 cth/none 62 0.78 ¾%
analysis months
Level evidence for the benefit from 5 randomized trial evaluating radiation
With concurrent cisplatin base cth-

32. RT TECHNIQUES
Definitive RT ;-
The definitive RT for ca cervix require EBRT (with
Pelvic and parametrical and nodal boosts if approp-
Riate) and BT . Treatment must be individualized based
on the patient‘s tumor extend ,normal tissue anatomy
,tumor response characteristics during
The therapy
EBRT ;- the field include 1ry tumor /local extension
(parametria / uterosacral ligament, vagina) draining
Regional LNs,

33. Simulation, target volume delineation & field
arrangement ;-
3-dimensional image- guide is high recommended to
Improve the delineation of target structures and
Exclusion of normal tissues include bowel ,bladder
And bone marrow . By use of intravenous contrast
For CT can differentiate regional LNs from vessels
CT can not differentiate tumor from normal tissues
In side the uterus ,so we use the MRI which show
Us the tumor extend in the uterus,parametria,

34. 1ry tumor GTV ;-entire uterus and tumor extension to para-
Metria based on imagi & implanted markers
CTV ;-additional 0.7 to 1cm margin,3-cm margin to
lower extension
PTV 0.5 -1cm margin
LNs Gross involved lymph nodes
CTV;- gross involved LNs+ 1cm margin in
obturator,external and common iliac LNs in 111A
In distal half vagina inginal LNs. Post surgical clips
&post operative seroma add0.7-cm/1-2 cm anterior
to theS1-S3
PTV ;-0.5 –cm margin
Target volume for definitive radiation therapy using Ctbased planing

35. The final PTV = 1ry tumor PTV +nodal PTV and because of
The viabilities in the aortic bifurcation 40% of common iliac LNs
are be higher to the L4-L5 interspace ,so in these case
The upper border can shifted up word by 1-3 vertebrae .
Contouring of normal structure include the rectum (up to the
recto sigmoid junction), bowel (large bowel &mesentery)
With in 5cm upper border of target, the bladder and femoral
Head .if 3D NOT available the field design should be guided
By bony landmark

36. field borders
AP/PA Superior; L4-L5 interspaced
Inferior ;- 3cm bellow the lowest tumor extend (determined by
Gold seed or bottom of obturator formen .
Lateral ;- 2cm lateral to the pelvic brim and include any surgical
clips with 1-1.5 cm margin
lateral superior;- same as AP/PA
inferior ;- same as AP/PPA .
Anterior ;- 1cm anterior to pubic pubic symphsis .
Posterior ;- at least anterior half of the sacrum

37. Dose and treatment delivery ;-
The EBRT prescribed dose to the range 45– 50.4 GY IN 1,8
GY.the BT boost 5.4—14.4 .
The total dose will be 50 in small stage 1B.and 55 GY in
moderately involved parametrial involved. And 60 GY for
Bulky parametrial .
IMRT ;- is used in the treatment of the ca cervix and show to
decrease the dose to the organ at risk (bowel,bladder
Acute gasterointestinsl toxicity and bone marrow dose

38. Regreesion of cervical cancer after 30 GY RT Compare lift and right