cervical carcinoma

Magnitude of the Problem: Carcinoma Cervix

Cervical cancer is a leading cause of cancer deaths in women globally. Over 527,600 new cases & 265,700 deaths annually, mostly in LMICs. In India, it's a major issue. Screening & vaccines aim to reduce this.

Pap smears reduce cervical cancer incidence by ~80\% & mortality by ~70\%. HPV vaccines are safe/effective, potentially reducing incidence by 90-100\%. Prevention relies on screening/therapeutics. Treated in preinvasive phase.

Incidence

In India, breast cancer is most common, followed by cervical cancer (ICMR - 2004). Breast cancer: 24-28\% of cases. Cervical cancer: 14-24\%. India's cervical cancer incidence: 23.5/100,000 (WHO - 2008).

Epidemiology

More prevalent in younger Indian women (~45 years). Rare in inactive women. Male circumcision offers partial protection.

Gross Pathology

Primary lesion: ectocervix (80\%), remaining in endocervix (20\%).

Naked Eye Exam

  • Exophytic: Ectocervix, masses, cauliflower-like.

  • Ulcerative: Excavates cervix.

  • Infiltrative: Endocervical, expands cervix.

Histopathology

Squamous cell carcinoma (80-85\%) is most common. Arises from ectocervix.

  • Squamous cell:

    • Large cell

    • Small cell

    • Verrucous

  • Adenocarcinomas (15-20\%):

    • Endocervical

    • Endometrioid

    • Clear cell

    • Adenoma malignum

    • Adenosquamous

    • Mixed

  • Others:

    • Large cell

    • Sarcomas

    • Neuroendocrine

    • Glassy cell

Mode of Spread

Direct Extension

Spreads to adjacent structures; vagina & uterus. Extends to parametrium/tissues. Tumor cells surround ureter.

Lymphatic

Primary nodes: parametrial, iliac, obturator, rectal, sacral. Secondary nodes: common iliac, inguinal, para-aortic. Sentinel lymph node (SLN) is first draining node.

Hematogenous

Late, via veins. Affects lungs, liver, bone.

Direct Implantation

Very rare.

Ovarian metastases risk: 0.5\% (squamous cell), 1.7\% (adenocarcinoma).

Staging

Determines prognosis/treatment. Based on exam. Give antibiotics before staging. Cannot change after therapy.

Assign lower stage if unsure. CT/MRI/PET detect node involvement. MRI detects tumor volume.

Imaging/pathology supplements findings. FIGO clinical staging used.

Prognosis

Poor indicators:

  • Tumor size, node involvement, LVSI.

  • Extra cervical spread.

  • Adenocarcinoma.

  • High SCA values.

  • HPV mRNA.

  • Node involvement reduces survival.

FIGO Staging (2018)

Assign lower staging if unsure. Imaging/pathology supplement. Note vascular/lymphatic involvement. Use 'r'/'p' notations.

Surgical Staging

Discrepancies exist. Assess nodes via laparoscopy.

Diagnosis

  • Early (IA, IB, IIA)

  • Advanced (IIB-IVB)

Stage unalterable after reports.

Histopathology Grades

  • GX: Cannot assess

  • G1: Well differentiated

  • G2: Moderately

  • G4: Undifferentiated

Early Carcinoma

Lesions with minimal morbidity/best survival; FIGO stages.

Preclinical

No symptoms. Diagnosis via screening/biopsy.

Stage IA

Intraepithelial with membrane disruption. Asymptomatic. Dx via biopsy; cytology/colposcopy.

Clinical: Stage IB

Symptoms not proportionate. Abnormal bleeding. Signs: granular area/growth.

Exam reveals lesion. Biopsy for confirmation.

Aids for Staging

Cystoscopy, X-ray, pyelography, proctoscopy, USG, CT/MRI/PET.

Advanced Carcinoma

Stage II B+ are advanced, ~80\%$$ of patients in India.

Patient Profile

Multiparous, premenopausal. History of bleeding. No screening.

Symptoms

Irregular bleeding, discharge, pain, edema, bladder/rectal issues, ureteral obstruction.

Signs

Exam reveals growth. Palpate for involvement. Biopsy needed. Sentinel node mapping.

Differential Diagnosis

  • Tuberculosis

  • Syphilis

  • Ectopy

  • Abortion

  • Fibroid

Complications

  • Hemorrhage

  • Ureteric pain

  • Pyometra

  • Fistula

Causes of Death

  • Uremia

  • Hemorrhage

  • Sepsis

  • Cachexia

  • Metastases

Management

  • Preventive

  • Curative

Preventive

Primary: Identify causes. Screening.

High-Risk Females

  • High-risk HPV

  • Early pregnancy

  • High parity

  • COCs

  • Low SES

  • Poor hygiene

Sexual Behavior

  • Early intercourse

  • Multiple partners

  • Prior wife died

  • HPV vaccine

Use condom, raise marriage age, limit family

Secondary: Early detection. Screening. Downstaging: detection at curable stage.

Curative

Team approach.

Pretreatment Evaluation

Serum Marker: SCCA/CA-125/CEA. Elevated SCCA correlates with stage.

Pretreatment: Improve health. Use stockings/antibiotics.

Modalities

  • Surgery

  • Radiation

  • Chemo

  • Combination

Surgery

Early-stage. Includes hysterectomy. Detects spread.

Limitation

Early-stage only.

Advantages

  • Staging

  • Ovarian function

  • Vagina function

  • Psychologic benefit

Special Indications

When radiation is contraindicated.

Contraindications

  • PID

  • Young patient

  • Adenocarcinoma

Complications

Comorbidities increase risk. Fistula, dysfunction.

Pelvic Exenteration

Selective cases.

Laparoscopic Hysterectomy

For early disease.

Primary Radiotherapy

For advanced disease.

Advantages

  • Wider use

  • Comparable survival

  • Less mortality

Principles

EBRT & brachytherapy.

Disadvantages

Strictures, fistula.

Dose

Points A & B used.

Cases