Initial Evaluation, testing, pre-op evaluation and staging of Carcinoma Cervix

1. CARCINOMA CERVIX
INTRODUCTION AND EVALUATION
Student: Surg Lt Cdr Ankur Shah
Moderator: Lt Col Tony Jose

2. ●
References:
– Berek's and Novak's Gynaecology, 15th
ed
– William's Gynaecology, 2nd
ed
– DiSaia, Creasman Clinical Gynaecologic Oncology,
7th
ed
– Berek and Hacker's Gynaecologic Oncology, 5th
ed
– WHO Weekly Epidemiological Record, No 15 dated
10 April 2009

3. Introduction
●
Latin - “neck”, entry to womb
●
Anatomy
– 2-4 cm in length
– Cervical canal – antomical external os to internal os
– Histologic internal os – transition from endocervical
to endometrial glands
●
Histology
– Exocervix – stratified squamous epithelium
●
Basal, parabasal, intermediate and superficial layers
– Endocervix – cylindrical epithelium, arranged in
branching folds

6. ●
Squamocolumnar junction
– Embryogenesis – upward migration of squamous
epi from vaginal plate replacing mullerian epi.
– Low vaginal pH stimulates squamous metaplasia
– Location of SCJ varies with age & hormonal status
●
Everts outwards during adolescence, pregnancy & OCP
use
●
Regresses into endocervix with menopause, low
estrogen states

8. ●
Transformation zone
– Adjacent to SCJ
– Most active zone of squamous metaplasia – prone
to carcinogenic effects
●
Risk factor for Cervical cancer
– Metaplasia, most active during adolescence and
pregnancy

10. Pre-invasive Lesions
●
Squamous epi lesions, considered to be
precursors, but lack features of invasive Ca
●
Cervical cytology – major tool to detect CIN
lesions early before onset of invasive Ca
●
Pap Smear

11. ●
Pap smear
– Conventional smear
●
Smear made directly on glass slide at time of sampling
– Liquid based Cytology
●
Cells collected in liquid transport medium, further
processed to produce a monoloayer of cells on slide
●
Advantage of LBC
– Most of the collected material available for sampling
– Abnormal cells, which are few, obscured, clustered
on conventional Pap are easily visible

13. ●
Before a Pap Smear, ensure:
– Avoid menstruation
– Abstain from intercourse, douching, use of vaginal
tampons, or contraceptive creams for min of 24-48
hrs
– Avoid touching the cervix before Pap smear
– Discharge from cervix may be removed with a swab
without touching the cervix

14. PAP Smear Classification
●
The Class System (I to IV)
●
The CIN System
– Based on degree of cellular abnormalities
●
The Bethesda System

15. ●
Bethesda (2001) reporting of Pap Smear:
– Specimen type – conventional, LBC
– Specimen adequacy – satisfactory, unsatisfactory
– General Categorisation:
●
Negative for intra-epithelial lesion
●
Epithelial cell abnormality
●
Other findings that may indicate increased risk
– Interpretation of results

18. Epidemiology & Risk Factors
●
'Preventable' disease
●
Third most frequently diagnosed carcinoma in
women
●
370,000 cases diagnosed annually
– 78% in developing countries
– Lack of screening

19. ●
Risk factors
– HPV Infection
– Cigarette smoking
– Parity
– Oral Contraceptive use
– Early sexual activity, Multiple partners
– STDs
– Chronic Immunosuppression

20. ●
HPV Infection
– The initiating event in cervical dysplasia and
carcinogenesis
– DNA virus
– More than 100 subtypes
●
Low risk – 6, 11 – cause genital warts, rarely asso with
cancer
●
High risk – 16, 18, 45, 31 – asso with 95% of cervical
cancers
●
HPV 16 predominant subtype – 40-70% of invasive
cervical cancer
– Spread through sexual contact
●
Gains access to the basal layer of the cervical epithelium,
which becomes the viral reservoir

22. HPV and Ca Cervix

23. ●
Vaccination against HPV
– Recombinant vaccine
●
Prepared from purified structural proteins
– Two types of vaccine
●
Quadravalent – against HPV 6, 11, 16, 18
●
Bivalent – against HPV 16, 18
– Recommended age
●
Before initiation of sexual intercourse
●
Age between 9 – 26 yrs
●
Routine vaccination for girls aged 10-14 yrs
●
Catch-up vaccination for adolescent girls and older
women

24. ●
Dosage schedule
– Quadravalent vaccine – 3 doses 0, 2, 6 months
– Bivalent vaccine – 3 doses 0, 1, 6 months
●
Quadravalent vaccine approved for use in
males for prevention of anogenital warts
●
Duration of protection:
– Quadravalent – 5 yrs
– Bivalent – 6.4 yrs

25. Clinical Picture
●
Asymptomatic
●
Vaginal Bleeding
– Post coital
– Intermenstrual spotting
– Irregular or Postmenopausal bleeding
●
Discharge P/V
●
Pain referred to flanks
●
Dysuria, hematuria, rectal bleeding
●
Massive Haemorrhage, uraemia

26. Evaluation
●
Clinical Examination
– Per speculum
– Per rectal examination
– Presence of lymph nodes
– Colposcopy
– Cervical Biopsy

27. ●
Colposcopy
– Examination of cervical, vaginal or vulval epithelia
for identification and evaluation of suspected
malignant or pre-malignant changes
– Biopsy an integral part of the procedure
– Indications
●
In response to abnormal Pap Smear
●
Clinically suspicious cervical lesion
●
Abnormal/unexplained bleeding P/V
●
Persistent vaginal discharge

28. ●
ASCCP Guidelines for colposcopy
– Negative for intraepithelial abnormality – routine
cytological screening
– ASC-H, LSIL, HSIL – colposcopy and biopsy
– ASC-US – Repeat cytology, Reflex testing for HPV.
If still abnormal – colposcopy
– AGC – colposcopy, endocervical and endometrial
evaluation
– AIS – excision biopsy

29. ●
Solutions:
– Normal saline
– Acetic acid, 3 – 5%
– Lugol's iodine (Schiller's solution)
●
Colposcopic Grading – Reid's Colposcopic
Index
– Peripheral margin
– Color
– Vascular patterns
– Lugol's staining

31. ●
Colposcopic Findings of Invasion
– Abnormal blood vessels
– Irregular surface contour
– Color

32. ●
Confirmation by Cervical Biopsy
– Punch biopsy
– LEEP
●
Outpatient procedure
●
Diagnosis and therapy at same time
●
Main side effect – secondary haemorrhage
●
Endocervical location and incomplete excision predictors
for treatment failure (40% recurrence rate)

33. ●
Conization
– Cold knife
– Laser
– Curative procedure, with low recurrence rate (0.6%)
– If cut margins free from cancer, then almost 100%
disease free follow-up
– Post-conization, surgical margins show disease
●
No further treatment necessary, only regular follow up

36. ●
Histologic Subtypes
– Squamous Cell
– Adenocarcinoma
●
Adenoma malignum
●
Villoglandular
– Adenosquamous Carcinoma
●
Glassy cell
●
Adenoid basal cell
●
Adenoid cystic
●
Sarcoma
●
Malignant Melanoma
●
Neuroendocrine carcinoma

37. ●
Tumour Spread:
– Direct Invasion
●
Vaginal mucosa – microinvasive spread
●
Myometrium of lower uterine segment
●
Adjacent structures and parametrium, lateral pelvic wall

38. ●
Lymphatic Spread
– Primary Group
●
Parametrial nodes
●
Paracervical/ureteral nodes
●
Obturator nodes
●
Hypogastric nodes
●
External iliac nodes
●
Sacral nodes
– Secondary Group
●
Common Iliac nodes
●
Inguinal nodes (deep and superficial)
●
Periaortic nodes

39. Staging Investigations
●
Physical Examination
– Lymphnode examination
– Per Vaginum
– Bimanual rectovaginal examination
●
Radiology
– IVP
– Barium Enema
– X Ray Chest
– Skeletal X Ray

40. ●
Procedures
– Biopsy, Conization
– Hysteroscopy
– Endocervical Curettage
– Cystoscopy, Proctoscopy
●
Optional Investigations
– CT Scan
– MRI
– USG
– Laparoscopy
– Radionuclide Scanning

41. Non-invasive diagnostic testing
●
CT Scan-
– Evaluation of lymphnodes, liver, urinary tract and
bony structures
– Can detect only changes in size of nodes, < 1cm
considered as positive
●
MRI-
– Valuable modality to determine tumour size, degree
of stromal invasion, vaginal/corpus extension,
parametrial involvement, lymph node status
– LN evaluation was comparable to CT Scan

42. ●
PET Scan
– Use of radionuclides, which decay with emission of
positrons
– Most commonly used is Fluoro-deoxy-glucose
– Tumour cells actively use glucose, detected on
scanning as area of increased glycolysis
– Delineates extent of disease more accurately, esp
nodes which are not enlarged and distant sites not
picked up by conventional radiology

43. Pre-Operative Evaluation
●
NICE guidelines for pre-op testing
●
Patients categorised based on
– Age
– Surgical grade (minor, intermediate, major, major+)
– ASA grade
●
Recommended investigations
– Blood counts
– Renal/Liver function tests
– Blood sugar levels
– Xray Chest
–

44. Staging
●
Clinically staged disease
●
In case of doubt, earlier stage should be
allotted
●
Stage must not be changed because of
subsequent findings on extended clinical
findings or surgical findings

45. FIGO Staging (2009)
●
Stage I – carcinoma confined to cervix
– IA: invasive carcinoma diagnosed microscopically.
Stromal invasion depth upto 5 mm and width less
than 7 mm
●
IA1 – stromal invasion <3mm depth and <7mm width
●
IA2 – stromal invasion 3-5 mm and <7mm width
– IB: clinically visible lesion confined to the cervix
●
IB1 – lesion <4 cm or less
●
IB2 – lesion >4 cm

47. ●
Stage II – carcinoma invading beyond uterus
but not to pelvic wall or lower 1/3 of vagina
– IIA – Tumour without parametrial invasion
●
IIA1 – lesion < 4 cm
●
IIA2 – lesion > 4 cm
– IIB – Tumour with parametrial invasion

49. ●
Stage III – tumour extending to lateral pelvic
wall/lower third of vagina/causing
hydronephrosis or non-functioning kidney
– IIIA – Tumour involves lower 1/3 of vagina, no
extension to pelvic wall
– IIIB – Tumour extends to pelvic wall or causing
hydronephrosis/non-functioning kidney

51. ●
Stage IV
– IVA – Tumour invades mucosa of bladder or rectum
or extends beyond true pelvis
– IVB – Distant metastasis

53. ●
All macroscopically visible lesions, even with
superficial invasion – allot stage Ib
●
Diagnosis of Ia1 and Ia2 should be based on
microscopic examination of tissue, preferably,
cone
●
Vascular space involvement does not alter the
stage of disease
●
Extension of disease to corpus uteri should be
disregarded since it cannot be assessed
clinically
●
Growth fixed to pelvic wall by short and

54. THANK YOU