Cervical Carcinoma: Causes, Symptoms, and Treatment
Mar 29, 2023
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.
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)
Important Information
16: MC
Elaborate E6, E7 onco-proteins at transformation zone
18: Most malignant
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
Important Information
HPV infection is self limiting (in most cases) in 9-15 months.
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
Important Information
First step after CIN III is seen on paps smear is confirmation of diagnosis by COLPOSCOPIC [Vagino Scopic] BIOPSY
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)
IIB - Parametrial involvement but short of pelvic side wall
Stage
IIIA - Lower 1/3rd vaginal involvement
IIIB - Parametrial involvement till the pelvic side wall [Hydronephrosis +]
Important Information
MC Stage of Ca cervix presentation in India → STAGE III B
Stage
III C1- Pelvic lymphnodes involved
C2 - Para Aortic lymphnodes
Stage
IVA - Bladder & Bowel Involvement
IVB - Distant Metastasis
Important Information
Cervix doesn't drain into inguinal lymph nodes
Cervical cancer involving endometrium does not change staging
Most commonly involved: anterior lip
Downstaging is done for planning m/m when clinical staging is doubtful
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
Important Information
Ureter crosses the uterine artery [bridge over water]
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
Important Information
New studies show that the most commonly involved group in cervical cancer is external iliac
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
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!
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