Cervical Carcinoma: Causes, Symptoms, and Treatment

Anyone with a cervix is at risk for cervical carcinoma and it usually shows up in women over the age of 30. Long lasting infection with certain types of HPV is the main cause. 

Read this blog post to know more about cervical carcinoma for your Obstetrics and Gynaecology preparation.  

Cervical Carcinoma

• Most common cancer of women in India is Ca Breast, while the most common gynecological cancer of women in India is Ca cervix
• HPV infection is associated with around 99% of cervical cancer

Screening  

• It is done for asymptomatic women and is done by:
• Pap Smear: 
  • It is taken by Ayre’s spatula. It has a sensitivity of about 47 to 62%.
  • Screening has brought down the incidence of Ca Cervix by 75 – 80 % & incidence of death by Ca cervix by around 70%
  • Use of cytobrush and cytobroom has increased sensitivity upto 90%, by prevention of drying artefacts prevented. This method washes the smear in fixative and filters out cells.
  • A routine paps smear is taken with Ayre spatula, placed on a slide and fixed with 95% ethanol by immediately placing the slide in the Coplin jar. 
  • This method is also called as Liquid based cytology
• Site of taking paps smear
  • Cervical smear is taken from the Transformation zone or the are between old and new squamo-columnar junction. The endometrium is composed of columnar cells while vagina & ectocervix is made of squamous cells, the junction of the two is known as the squamocolumnar junction.
  • TZ is more prone to infection by HPV (and thus cancer) as the cells are continuously dividing here.

Etiology and risk factors

• HPV infection (Human Papilloma Virus)

• HIV 1 & 2
• HSV 1 & 2
• Commercial sex worker
• Women with many partners
• Partner with STD
• Multiparous 
• Immuno compromised
• Low socio Economic status
• Smokers 
• Early intercourse [<16 yrs]
  • TZ is Located at 1.7 to 2.3 cm from the external Os changes location with age group. Early intercourse increases no of years of exposure of TZ to HPV as TZ gets externalized earlier
• Post partum/puerperal time

Time to do Pap Smear

• Any woman > 21 yrs of age
• Any women 3 yrs after 1st sexual exposure (in India)
• From 21 to 29 years, sexually active women should have cytology every 3 years
• From 30-65 yrs: Co-TEST [PAP + HPV]: if negative then 5 yearly if only cytology done, then once in 3 years if cytology is negative
• After 65 yrs: No more PAP, if 3 cytology are negative or 2 Co-TEST are negative

Cervical Dysplasia

Classification of cervical dysplasia

Dysplasia classification	Bethesda classification
CIN I- < 1/3rd abnormal	Low Grade Lesion
CIN II- > 1/3rd to <2/3rd abnormal CIN III- > 2/3rd abnormal CIS- All cells are abnormal	High Grade Lesion

Management of CIN I

• CIN I   5 yrs   → CIN III   10 yrs   → Ca CERVIX, CIN I not a precursor of Ca cevix. In case of CIN I & CIN II, 65-80% will regress spontaneously, however high grade lesions are precursor of Ca Cervix
• CIN I can be followed up with 6 monthly PAP smear along with antivirals & antibiotics. HPV DNA must be done. 
• If CIN I persists for > 2 yrs, we must continue surveillance and an ablative or therapeutic procedure must be planned

Management of CIN II & CIN III (HSIL/ High Grade Intrepithelial Lesion)   

• First step is a colposcopy biopsy as the cervix is normal looking, so we need to use some agents and magnification

• Colposcopy biopsy procedure
  • Acetic acid application to coagulate the proteins of the rapidly dividing areas which appear Acetowhite. Biopsy is now taken from acetowhite areas
  • Schiller iodine [LUGOL IODINE] application stains the glycogen rich areas which appear Mahogany Brown, biopsy is now taken from unstained areas or lugol’s negative areas.
  • In the absence of availability of colposcopy VIAA (Visual Inspection under Acetic Acid) or VILI (Visual inspection under lugol’s iodine) may be done
• Results of Colposcopic Biopsy
  • Invasive cancer Cx: Rx by Radical hysterectomy
  • Biopsy proven CIN III is treated by LLETZ (Large Loop Excision of Transformation Zone) or LEEP (Loop Electro surgical Excision Procedure)

Other Options

• Conization: not usually done 
  • Problem with conization: It leads to a short cervix which causes cervical incompetence leading to recurrent abortions. It may cause stenosis of cervix which may lead to infertility
  • Can be done if colposcopic Biopsy is inconclusive 
• Surgical Conization (If > 35 yrs)
• Hysterectomy (If > 40 yrs)
• Cryocautery 
• Laser ablation: However requires training & experience 

Symptoms of CA Cervix

• Abnormal bleeding
• Post coital bleeding, is most common, (Note: in newly married couple post coital bleeding can be due to a post coital tear most commonly located in Posterior Vaginal fornix)
• Foul smelling discharge
• Pyometra: Dirty vaginal discharge
• Post-menopausal bleeding
• Cancer cachexia
• Cancer pain
• Uremic symptoms 

Mx of Post Coital Bleeding 

• Do a local examination, rule out any lesion, take biopsy if any obvious growth is seen. If the cervix appears normal, do Colposcopic Biopsy (not a paps smear)

Indications for colposcopy biopsy

• CIN III [cervical intra epithelial neoplasia]
• CIS [carcinoma in situ]
• AIS (Adeno Ca) / endocervical curettage + → Hysterectomy
• VIN III: Superficial excision/ laser ablation  

Staging

Clinical Staging Done with

• P/ Speculum examination
• P/ Vaginal examination
• P/ Rectal examination [for parametrium]
• Cystoscopy [for bladder]
• Procto sigmoidoscopy
• Imaging: USG, CT, MRI, PET CT

Stage 

• I - Limited to Cervix
  • IA - Microscopic Cancer
    • A₁ - < 3 mm depth        Transverse → ⊗ Removed from staging 
    • A₂ - 3-5 mm depth Spread < 7 mm 
  • IB - Clinical/ macroscopic
    • B1 - < 2 cm: can consider fertility preservation
    • B2 - 2 – 4 cm
    • B3 - > 4 cm

Stage 

• IIA - Upper Vagina Involved (II A₁ → < 4 cm; II A₂ →> 4 cm)
• IIB - Parametrial involvement but short of pelvic side wall

Stage 

• IIIA - Lower 1/3^rd vaginal involvement
• IIIB - Parametrial involvement till the pelvic side wall [Hydronephrosis +] 

Stage

• III C₁ - Pelvic lymphnodes involved
• C₂        - Para Aortic lymphnodes

Stage 

• IVA - Bladder & Bowel Involvement 
• IVB - Distant Metastasis

Treatment protocol

• For all stages: Radiotherapy is good 
  • Stage I – IIA₁: Radical Hysterectomy
  • Stage ≥ IIA₂: Chemo Radiation

Management of Ca cervix 

IA1	<3 mm NO LVSI	Conization or Extra fascial Hysterectomy
	<3 mm with LVSI	Radical Trachelectomy Or Radical Hysterectomy + Pelvic LAD Or SLN (External Illiac (MC)> obturator)
IA2	≥3 mm <5 mm	Same
IB1	≥5 mm <2 cm	Same
IB2	≥2 cm <4 cm	Radical Hysterectomy + Pelvic LAD
IB3	≥4 cm	Chemoradiation
IIA1	<4 cm + upper vagina	Radical Hysterectomy + Pelvic LAD or Chemoradiation
IIA2	≥4 cm + upper vagina	Chemoradiation

Maximum Radiation Given At:

Point A

• 2 cm above & 2 cm lateral to external os
• Here ureter is under the uterine artery

• Parametrium seen here
• Upto 7500 to 8000 RADs given here

Point B

• 3 cm lateral to point A: this point corresponds to Obturator lymph nodes at the pelvic side walls. Obturator LN is the Sentinel group of LN. Upto 6000 RADs given here

Histopathological variants

• Squamous cell carcinoma: most common
• Large cell Keratinising variant [mc]
• Large cell Non Keratinising variant
• Small cell variant
• Adenocarcinoma: Also related to HPV; similar treatment

Vaccines

HPV

Cervarix Bivalent 16, 18 Gardasil Quadrivalent: 6, 11, 16, 18 Nano valent vaccine (Gardasil 9): 6, 11, 16, 18, 31, 33, 45, 52, 58

HPV Schedule 0 day 2 months 6 months

• Chance of prevention if given before exposure: upto 90%
• Chance of prevention if given after exposure: upto 40%
• Given after 9 yrs, upto 45 yrs (all women)
• All serotypes are not covered, so continue screening protocol 

Cervical Cancer in Pregnancy

• All pregnant women should get a pap smear. If malignant cells are positive, conization is done
• Conization done after 12 weeks has reduced the risk of abortion.
• If Ca Cx: Diagnosed
  • Stage IA: can allow pregnancy to go till term. At term plan a cesarean section along with radical hysterectomy and LAD
  • Stage IB:  wait till Fetal lung maturity: till 28 weeks or 32 weeks followed by cesarean section along with radical hysterectomy and LAD
  • Stage II – IV - Radiotherapy irrespective of gestation
    • If detected beyond 28 wks, do a cesarean followed by radiotherapy
    • If detected in first Trimester give radiotherapy, fetus will abort
    • If detected in second Trimester, try to check for viability and plan accordingly.

Previous year questions

Q. Which of the following is the most common cause of death in Carcinoma Cervix?   

• Uremia
• Metastasis
• Bleeding
• Sepsis 

Q. Steps of preparing a paps smear are?

• Vaginal wall retraction —scrape ectocervix — Thin smear — Fix the slide
• Scrape ectocervix —vaginal wall retraction —Thin smear — Fix the slide 
• Vaginal wall retraction — scrape ectocervix — Thick smear — Fix the slide
• Vaginal wall Retraction —scrape ectocervix — Thin smear

Q. Cervical cancer screening is must for?

• Women > 65 years of age
• Woman < 15 years of age
• Woman between 21-65 years of age
• All teenagers

Q. Which of the following procedures is done using following 

• Dilatation and curettage
• Cervical biopsy
• Pap smear
• Endometrial aspiration

Q. A 30 year old woman who is P2L2 underwent a screening PAP smear. The cytology report came out to be carcinoma in situ. What is the next step in management? (AIIMS 2020)

• Colposcopy biopsy
• Hysterectomy
• Follow up after 6 months
• Radiotherapy

Q. Young female, multigravida, presenting with post coital bleeding on examination shows a normal vagina with normal endometrial cavity on USG. Next step in management? 

• Pap smear
• Colposcopy Biopsy
• Cryotherapy
• Per vaginal examination

Q. A 25 year woman presents with h/o post coital bleeding. Speculum examination showed following appearance. What is the diagnosis? (FMGE 2020)

• Cervical fibroid
• Ca cervix
• Cervical polyp
• Nabothian cyst

Q. Which of the following types of HPV is least associated with cervical malignancy? 

• Type 16
• Type 31
• Type 33
• Type 42

Q. 16 year old girl, not sexually active, came for vaccination against cervical cancer. Which vaccine to be given? (AIIMS 2019)

• Gardasil
• Rubavac
• Biovac
• Tdap

CROSSWORD

Screening for cervical cancer is done by __	PAPS SMEAR
____ bleeding is the most common symptom of ca cervix	POST COITAL
The most common histological type of cervical cancer is ___cell	SQUAMOUS
The bivalent vaccine against ca cervix available in India is ___	CERVARIX

And that is it! That is everything you need to know about cervical carcinoma for your Obstetrics and Gynaecology preparation. For more interesting and informative posts like these, keep reading PrepLadder blogs!