280 Textbook of iyneoloqy

CARCINOMA CERVIX
MAGNITUDE OF THE PROBLEM

. Incidene otcevical cancer is steadily declining in the

dvropelwod.
. lpsmeat has reduced the incidence ofcervical cancer
b neatly N0% and death by 70%.
" lIseotlNvacciar is expected to reduce the incidence
turther.
enical cancer is an entirely preventable discase as
the different screening, diagnostic and therapeutic
procedures are cffcctive.
At present throughout the globe, there arc ncarlyI
million women cach vear haing cervical cancer.
Cancer cenix is the most common cancer in women
of the developing countries where screening (acilities Fig. 24.5: Ulcerative type of cervical malignancy with a
are inadequate. friable growth on the posterior lip. Radical hysterectomy done.
Uterine arteries are ligated at origin (see p. 290)
Incidence
In most of the developing countries, carcinoma of the
breast and ceris are the leading sites of malignancies in
female and are major public health problems.
In India. welve population-based cancer registries
(PBCRS) showed cancer breast was the most common
followed by cancer of the cervix (1CMR-2004). Amongst
female cancers, relative proportion of cancer breast varied
between 21 and 24% whereas that of cancer cervix was
berween 14 and 24%. In India, an overall incidence of
23.5 100,000 has been observed (WHO 2008).
Major factors affecting the prevalence of carcinoma
cervix in a population are economicfactor, sexualbehavior
and degree of effective mass screening.
EPIDEMIOLOGY

This has been discussed in CIN (see p. 262). In India, the

prevalence is more amongst the comparatively youngerage
group. Carcinoma cervix is rare in Women wno are seXuaiy Fig. 24.6: Histology of squamous cell carcinoma of the cervix
(small cell type), Keratin pearls within the nests of malignant cels
De active (nuns, virginal women). Male circumcision is are seen
only partially protective against cericalcarcinogenesis.
| GROSS PATHOLOGY Poorly differertiated. These arise from the ectocervix.The
sources of the squamous epithelium which turn into
The site of the lesion is predominantly in the ectocervix malignancy are--squamocolumnar junction, squamous
(80%) and the rest (20%) are in the endocervix metaplasia of the columnar epithelium.
Naked Eye Squamous cell carcinoma (Fig. 24.6) is further
Exophytic: These arise from the ectocervix and form subdivided histologically into three groups: () large
friable masses almost filling up the upper vagina in late cell keratinizing, (iüi) large cell nonkeratinizing and
cases. (ii) small cell type. Patients with small çell type have
Uwlcerativ: The lesion excavates the cervix and often got poor prognosis compared to the large cell types.
involves the vaginal fornices (Fig. 24.5). Adenocarcinoma (20-25%) develops from he
Infiltrative: These are found in endocervical growth. endoceryical canal, either from the lining epithelium
They cause expansion of the cervix, so that it becomes or from the glands.
barrel-shaped. Currendy increased number of cervical adeno
carcinomas are observed specially in the younge
Histopathology age group. The majority (80%) of them are purely
The most common variety is squamous cell carcinoma endocervical type. The remainders are endone
(75-R0%) either well-differentiated or moderately or trioid, clear cell, adeenosquamous or a mixed type.
 Adenoma-mal
tiated ignum is an
extremcly well differen
ladenocarcinoma with favorable
Neurocndocrine
Chapter 24 " Genital Malignancy
The fallacles are- -difftcult to Assess the lyrnph
Z81

mas andi tumors pognosis.

(highly aggressive), node involvement on clinical examination whic.h
lyyphonas are rare sarco-
tumors of the cervix. Adversely affects the prognosis, There is also difficulty in
MODE OF SPREAD iferentiation of inlammatory and malignant induration
of the parametrium.
Direct Extension Staglng of cervical cancer ls hased principally on
cllnlcal examinatlon, Pelvic examination (speculum,
lhe gromth spreads directly to the
thevagina andtothe body ofthe adjacent
bimanual and roctal examination) should be done under
the parametrium,
structures,
uterus. It extends laterallyto anestlhesia. The routine supplementary investigations
len, the tumor cells paracervical
surround
and paravaginal tissues.
and compreSs the ureter,
include X-ray chest, intravenous pyelography, cysoscopy.
may spread backwards along the It and proctoscopy. In cases of suspected pelvic inflammation,
uterosacral ligament,
imohe the rectum or forwards to involve the base of to a coursc of antibiotic should be given prior to clinical staging.
ladder. specially in endocervical growth. the Final staging cannot be changed once therapy has
begun. If any doubt exists as to which stage should be
Lymphatic assigned, the lower stage should be chosen.
CTscan, MRI, positron emission tomography (PET),
The primary group involved are-parametrial nodes. lymphangiography (see p. 98) can detectinvolvement o
internal iliac nodes, obturator, external iliac nodes, rectal the pelvic or periaortic lymph nodes and parametrium.
and sacral nodes. The seccondary nodes involved are MRI is helpful to detect parametrial extension and to
common iliac group, the inguinal nodes, and paraaortic define the tumor volume. But these findings do not change
nodes (Table 24.6). FIGO stage of disease (Table 24.7).
Sentinel ymph node (SLN) is the first node that
drains a primary tumor. In most cases (85%) there is a PROGNOSIS
single sentinel lymph node (seep. 501). This node can be The prognosis depends on the following:
detected by intraoperative lymphatic mapping injecting " Stage of the lesion at the initial therapy is the most
methylene blue dye into the tumor or lymphoscintigraphy important factor in the outcome of the treatment.
using technetium 99. Endocervical tumor is diagnosed late and grows faster.
Depth of tumor invasion when <l cm, less Iymph
Hematogenous nodes are involved and improved survival is observed.
Blood borme metastasis is late and usually by veins rather
than the arteries.Lungs, liver or bone are usually involved. TABLE 24.7: STAGING PROCEDURES ALLOWED BY FIGO

Direct Implantation " Inspection of cervix and vagina

on the
Direct implantation of the cancer cells at operation . Pelvic examination (vaginal, rectovaginal) under anesthesia
very
vault of the vagina or abdominal or perineal woundis
are. PROCEDURE USED DETECTION
squamous
The risk of ovarian metastases in stage I 1.7% for O Lymph node palpation Enlargement and site
cervix is 0.5% and it is
Cell carcinoma of the
o Colposcopy (see p. 266) (see above)
adenocarcinoma.
o Hysteroscopy (see p. 510) Extension and depth
|STAGING o Cystoscopy (see p. 103) of tumor spread
to determine the prognosis, oBiopsy (see p. 487)
ne purp0ses of staging are treatment and to compare the
O lormulate the line of oEndocervical curettage
results of one to the other. (see p. 295)

NODES IN DIFFERENT
aConization (see p. 487)
TABLE 24.6: INVOLVEMENT OF LYMPH
STAGES (APPROXIMATE)
Paraaortic nodes (%) o Chest X-ray
Pelvic nodes (%) Pulmonary metastasis
Stage a Skeletal X-ray Bone metastasis
a Intravenous urogram/USG
la, (<3 mm) 0-0.5 Hydronephrosis
<1 O Barlum enema
la, (3-5 mm) 5 Large bowel involvement
2 n Proctoscopy
16 Rectal involvement
15
30 Ultrasonography, lymphangiography, CT and MRI, PET,
44
30 radlonucleotide scanning
optlonal and not to be studies, laparoscopy/laparotomy are
40 used for FIGO staging.
IV 55
282 Textbook of Gynecology
Tumor size ho than 4Cm is associated with more (ontd

Iymph node metastasis and joon suvival. Stage-IVB Spread to distant organs
Well diffeentiatet syuamous cell carcinonna grows lesions even
slowt and metastases late than the anaplastic type. " All macroscoplcally visible carcinomas. with superhcial
invasion are allotted to stage IB Invasion is
" Toung age is suallk associated with poorly differen to a measured stromal invasion with a
maximal o
depth limited
7.0 mm. Depth ofof50 mm
tiated squamous cell carinoma or
adenocarcinonma and a horizontal extension of not >
and is pnngnostically poor. should not be > 5.0 mm taken from the base of the eoithet irvaion
Iimph node imolvement (pevic and paraaortic) of the original tissue-superhcial or glandular. The da
of invasion should always be reported in mm, even in
rduces the sunival rate by 50%. cases with "early (minimal) stromal invasion" (~1.0 mm). Thethose
HPV ositie younger patients have better prognosis. involvement of vascular, lymphatic spaces should not change
lhe clinical staging as recommended by IGO is the stage allotment.
tabulatcd helow (2009) and shown in ligure 21.7. **On rectal examination, there is no cancer-free space behwese
the tumor and the pelvic wall. Alcases with hydronephrosis or
FIGO STAGING OF CARCINOMA OF THE CERVIX (2009)
non-functioning kidney are included, unless they are known to
be due to another cause.
Invasive Carcinona
Stage
Stage The carcinoma is strictly confined to the cervix SURGICAL STAGING OF CANCER CERVIX
(extension to the corpus would be disregarded)

Stage-iA Invasive carcinoma which can be diagnosed only There are often discrepancies between clinical staging
by microscopy with deepest invasion s S.0 mm and surgicopathological findings. Surgical staging can
and largest extension s 7.0 mm
minimize this by identifying the occult tumor spread and
Stage-iA1 Measured stromal invasion of s 3.0 mm in depth also the extrapelvic disease. Assessment of the pelvic
and horizontal extension of s 7.0 mm and paraaortic nodes are done by surgical approach.
Stage-IA2 Measured stromal invasion of > 3.0 mm and not > This is done either by extraperitoneal approach or by
5.0 mm with an extension of not > 7.0 mm laparoscopy.
Stage-IB Clinically visible lesions limited to the cervix uteri
DIAGNOSIS
or preclinical cancers greater than stage 1A*
Stage-1B1 Clinically visible lesion s 4.0 cm in greatest " Early carcinoma (Stage IA, IB, ILA)
dimension
Advanced carcinoma (Stage IB-IVB).
Stage-IB2 Clinically visible lesion > 4.0 cm in greatest
dimension Early Carcinoma
Cervical carcinoma invades beyond the uterus, but
Nomenclature: The concept of early carcinoma of the
Stage-1l
not to the pelvic wallor to the lower third of the cervix is not well-defined. Presumably, it should include
vagina those lesions which have got minimal morbidity and
Stage-IlA Without parametrial invasion
deaths with the best available therapy and a maximal
5-year survival rate (Table 24.8). With these criteria, the
Stage-1lA1 Clinically visible lesion s 4.0 cm in greatest following stages as per FIGO classification are includedin
dimension
the category of early carcinoma.
Stage-1A2 Clinically visible lesion > 4.0 cm in greatest Thus all these have got 5-year survival rates rangng
dimension
between 80-100%. Stage II reduces the 5-year survival
Stage-lIB With obvious parametrial invasion rate to as low as 55-70%. As such, it is inapproprlate to
Stage-ll The tumor extends to the pelvic wall and/or include any lesion extënding beyond Ithe cervix as early
involves lower third of the vagina and/or causes carcinoma:
hydronephrosis or nonfunctioning kidney* As the presentation of the case differs, these are
grouped as:
Stage-llA Tumor involves lower third of the vagina, with no " Preclinical " Clinical
extension to the pelvic wall
Stage-lB Extension to the pelvic wall and/or TABLE 24.8: EARLY CARCINOMA
hydronephrosis or nonfunctioning kidney
Stage S-year survival rate (%)
Stage-IV The carcinoma has extended beyond the true
pelvis or has involved (biopsy proven) the mucosa IA1 98.7
of the bladder or rectum. A bullous edema, as such, IA2 95.9
does not permit a case to be allotted to Stage IV IB1 90.4
Stage-IVA Spread of the growth to adjacent organs I82 79.8
Contd..
 Chapter 24 Genital Malignancy 283
IA
IA1 IA2 IB1 (s 4 cm)
I82( 4 cm)

IIA1
IIA2
(s 4 cm)
(>4 cm)

-Lateral
parametrium
VUpper bwo-thirds
vagina Medial
parametrium
Lower-third vagina

IIIA IIB

Ureteric
obstruction
causing
hydroureter
and
hydronephrotic
Upper two-thirds changes
vagina
Lateral
Lower-third vagina pelvic wall

IVB
IVA
-Aortic nodes
Uterus

Bladder
-Rectum

carcinomacervix according to FIG0 (see p 2gs)

9-24.7: Diagrammatic representation of staging of

Incidental on histological examination of tissues

Preclinical
There may not pelvic finding
be any symptom nor any apparently
removed by biopsy, portio amputation or removal of
look the uterus.
Kaise any suspicion. The cervix may
following: During screening procedures.
The diagnosis is made bythe
healthy.
 Woogwall suspicious smear is subjected to cervical lesionmay not be visible due to bleeding treer
oloseopy followed by dirccted biopsy. In the abscnce of the friable lesion caused by digital examination.
olposcopy. Schiller's test directed biopsy is to be taken. Bimanual examination reveals the lesion isindurated
I1 a positive lesion is found, diagnostic conization has to friable, and bleeds to touch. Cervix is freely mobile.
be done and subjccted to serial sections. Depending upon Rectal examination reveals the parametrium abso.
the degree of ncoplastic changes and/or its invasion to the lutely free.
adjacent stroma, the esions are diagnosed as follows: Confirmation of diagnosis is by biopsy
" Stage0 " Stage IA Stage lB Anclllary alds for confirmation of staging:
Stage 0 Cystoscopy
The neoplastic changes innolve whole thickness of the X-ray chest
cpithelium but the basement membranc remains intact. Intravenous pyclography
Proctoscopy.
Stage IA (microinvasive carcinoma) Allthese give usually a negative finding and as such, the
Microinvasive carcinoma is one which is predominantly clinical staging of IB is thereby confirmed.
intraepithclial carcinoma, except that there is disruption Oher investigations not to be used for FIGO staging
of the basement membrane. The neoplastic epithelium . MRI: Useful to measure tumor size, tumor extent.
invades the stroma in one or more places but limited up to bladder, rectum, parametrium, and lymph node
5 mm from the overlying basement membrane. As such, involvement.
the depth of invasion is measured by using a microscope CT is commonly used to detect nodal involvement and
with an ocular micrometer.
distant metastasis. However CT, MRI, PET are not to be
The malignant cells maintain their connection with the used for FIGO staging.
overlying intraepithelial neoplasm. The cords of malignant PET (see p. 101): FDG-PET is superior to CT or MRI
cells may become confluent or invade the lymphovascular for detection of node metastasis (size >5 mm). PET is
channels, irrespective of depth of penetration. used for planning the fheld of radiation, or planning
The mean age is 38-42 years. palliative chemotherapy.
In majority, the entity is asymptomatic. There may
be blood stained discharge, intermenstrual, postcoital or Advanced/Late Carcinoma
postmenopausal bleeding. The cervix may look abnormal All cases of carcinoma with stage IIand onwards are arbit
like erosion, eversion or cervicitis. rarily called advanced carcinoma considering the reduced
The diagnosis is made only on cone biopsy of the cervix. 5-year survival rate compared to earlier stages. In fact, in
Initial screening may be done with cytology, colposcopy, and India, this group comprises about 80% of the total cervical
directed biopsy along with endocervical curettage. carcinoma patients attending the hospitals for treatment.
The patient with microinvasive carcinoma may be
treated even with conservative surgery when there is no PATIENT PROFILE
risk of lymph node metastasis.
The patients are usually multiparous, in premenopausal
Stage lB age group. They have previous history of postcoital or
The invasion of the malignant cells to the underlying intermenstrual bleeding which they ignored.
sroma exceeds 5 mm.There is no clinical manifestation
and the cervix may look apparently normal. Symptoms
As previously mentioned, the duration of symptoms is not
Clinical proportionate to the stage of the disease. However, the
Stage IB (overt) following symptoms may be evident depending upon the
Symptoms extent of the lesion.
The duration of symptoms is not proportionate to the Irregular or continued vaginal beeding which may
stage of the disease. at times be brisk.
Menstrual abnormalities in the form of contact Offensive vaginal discharge.
bleeding or bleeding on straining (during Pelvic pain of varying degree: This may be either due
defecation), intermenstrual bleeding are very much to involvement of uterosacral ligament leading to
suspicious, specially over the age of 35. backache or deep seated pain due to involvement of
Excessive white discharge which may be at times sacral plexus.
obstruction of
offensive.
Leg edema is due to progressive
lymphatics and/or iliofemoral veins by the tumot.
micturiion,
Signs Bladder symptoms include frequency dueto
incontinence
Speculum examinationreveals dysuria, hematuria or even true
" Eitherared granular area which looks like an ectopy fistula formation. rectal
by diarrhea, fistula
Rectal involvement is evidenced rectovaginal
(erosion) extending from the external os or a nodular
growth or an ulcer. The lesion bleeds on friction. It pain, bleeding per rectum or even
should be done prior to bimanual examination. The (Fig. 24.7).
 285
Chapter 24 "Genital Malignarncy
Ureleral obstruction is due to
umor laterally. lhere may be progressive growth J llemorrhage: the vaginal bleeding from the grow
frequent attacks of leads to anemia and
nclonephritis due to ureteric obstruction/ may be brisk or continuous. This
ill health.
linately. the patient may be cachectic, anemic witlh J Sepsis: Localized pelvlc or generalized
peritonitis may
cdema lcgs. Utimately uremia develops, occur which may be fatal.
Sneculum examination reveals thá nature of the J Caclhexia: The cumulative
effect of the factors
growth.ulcerative fungating whiclh bleccs to touch.
or cancerous
mentioned leads to cachectic condition. The general
Bimanual examination reveals the induration and on
tissues have got depressant action
(Ntent of the growth to the vagina and to the sides. he metabolism.
commonly observed
induration of the bladder base may be felt
through the J Metastases to the distantorgans bone (16%) and
anterior fornix in advanced cases. are-lung (36%), Iymph nodes (30%),
Rectal examination is invaluable to note the abdominal cavity (7%). These may be fatal.
invokement of the parametrium and its extent in
MANAGEMENT OF CARCINOMA CERVIX
relation to the lateral pelvic wall. Nature of induraion
is to be noted carefully. If it is smooth, the possibility of " Preventive
inlammation has to be excluded and antibiotics has to be " Curative
given prior to final assessment for staging. In malignancy, Preventive
the induration is nodular. Incidental involvement of the
rectum has to be noted. Primary Prevention
factors and eliminating
For confirmation of diagnosis, biopsy is mandatory It involves identifying the causal effects. These are
exerting their
(see p. 487), If the lesion is small, wedge biopsy is taken or preventing those from
easy to enumerate, but difficult to implement in practice.
which should include a portion of the healthy tissue as
well. If it is big, a bit may be taken from a comparative " Identifying 'high-risk' female infection (see p. 264)
Women with high-risk HPV
noninfective area. There may be brisk hemorhage which Early age of first pregnancy
can be effectively controlled by plugging.
For staging of the disease--procedures (see above). High parity
Too many births/too frequent birth
Long-term use of COCs
DIFFERENTIAL DIAGNOSIS Low socioeconomic status

The growth needs to be differentiated from: Poor maintenance of genital hygiene.

Sexual behavior
" Cervical tuberculosis (seep. 118)
Early sexual intercourse
" Syphilitic ulcer
Cervical ectopy (see p. 217) Multiple sexual partners
Previous wife died of cervical carcinoma.
Products of conception in incomplete abortion
Fibroid polyp (see p. 232). " Prophylactic HPV vaccine (see p. 269) is approved to
all school girls (12-18 years) and women (16-25 years).
COMPLICATIONS Two or three doses are usually to be given (bivalent
0-2-6 month or quadrivalent 0-1-6 month).
sooner or later, as
Ihe following complications may occur Use of condom during early intercourse, raising the
the lesion progresses. age of marriage and of first birth, limitation of family,
" Hemorrhage. maintenance of local hygiene, and effective therapy of
and
Frequent attacks of ureteric pain, due to pyelitis STIs are the positive steps in prevention.
Pyelonephritis and hydronephrosis. Removal of cervix during hysterectomy as a routine
Pyometra specially with endocervical variety. for benign lesion is a definite step in prevention of
Vesicovaginal fistula. rare stump carcinoma. The incidence may be as high as 1%.
Rectovaginal fistula: This is comparatively
pouch of Douglas.
Decause of the interposition of theeither Secondary Prevention
involved through the It involves identifying and treating the disease earlier
Ine rectum may be septum.
uterosacral ligament or through rectovaginal in the more treatable stage. This is done by
screening
procedures. The details have been described in Ch 9 and
CAUSES OF DEATH 23. The abnormal cervical pathology likely to
progress to
invasive carcinoma can be detected. Its effective
The patient may die of: obstruction following reduces dramatically the therapy
Oremia: This is due to ureteric and in areas where it has beenincidence invasiye carcinoma
of
parametrial involvement. There is hydroureter implemented. Even when the
invasive carcinoma is detected,
hydronephrosis. Infection supervenes, thereby further it is so
5-year survival rate could be achieved.early that a 85-100%
Compromising kidney functions.
 of Gynecology

Downstaging Screening (WHO 1986)

Downstaging tor cevical
t0 correct anemia and malnutrition. "Ihis not only makes
cancer is dcfined as "ihe detection of the paticnt
the disease at an carlier stage when it is still
curable. Detection
sufficiently fit to withstand surgery but rise in
Is done lby nurses and other
paramedical health workers using a hemoglobin percentage improves the tissue oxYgenation
simple seculum forvisual inspection ofthe cervis: needed for effective ionizing effect of irradiation.
Ihe downstaging screening" is an
siggested by W0 as an alternativeexperimental approach
to regular cytologic TREATMENT MODALITIES OF CARCINOMA
seTeening. In the developing countries, where cffective mass CERVIX
sereening cannot be extended and the majority of cases of
carcinoma cerix are diagnosed at an advanced stage, 'down The types of trcatment employed for the invasive
staging screcning' offers at least an carly detection of disease. carcinoma are as follows:
Compared to cytological screcning it is suboptimal. But Primary surgery
in places where prevalence of cancer is high and
cytological
screcning is not available. "downstaging screening" is uscful. The Primary radiotherapy
strategy is, however, not expected to lower the incldence of
cancer cervix, but it can certainly minimize the cancer death
Chemotherapy
Combination therapy.
through earty detection.
Downstaging procedure: A female primary health Surgery
The
care worker is trained for 2-3 weeks to perform types of surgery employed in invasive carcinoma are:
speculum
examination. They are trained to distinguish a normal Radical Hysterectomy (Fig. 24.8)
cervis from an abnormal one. John Clark (1898) first did the operation while working as a
Characters of a normal cervix: Pink in color, resident in Johns Hopkins Hospital. This operation is commonly
round in shape, smooth surface and does not bleed on done abdominally and is known by different names (Wertheim
touch. Whereas an abnormal cervix has the of Viena-1898, Okabayashi of Japan-1921, Meigs of
following USA-1944).
characters: Reddish,red or white area of patch, growth or Extensive vaginal operation was subsequently developed to
ulcer on the surface and bleeds on touch. minimize the mortality and morbidity from abdominal approach.
Once the abnormality is suspected, the case is referred to Pelvic lymph nodes are removed by bilateral
a center where diagnosis and treatment of
extraperitoneal
approach. This operation is also popularly known by different
premalignant and names (Schauta of Viena-1902, Mitra of India-1957). There
malignant lesions are done.
have been several modifications of the techniques of
radical
Curative hysterectomy and bilateral pelvic lymphadenectomy at present.
Ideally, the management of the patient with cervical The surgery includes (see Fig. 38.67) removal of the
cancer is a team approach. Both the gynecologist and uterus, tubes and ovaries of both the sides (ovaries may be
radiooncologist should review the patient along with the spared in young women), upper half of vagina, parametrium
biopsy report and the plan outlay be individualized. Due (most of cardinal and uterosacral ligaments), and the
consideration should be given to: draining primary cervical Iymph nodes (parametrial,
General condition of the patient obturator, internal and external iliac groups, and sometimes
Stage of the disease common iliac. Sacral group is not removed). Paraaortic
Facilities available-surgical and radiotherapy lymph node evaluation is done. Any enlarged paraaortic
Wish of the patient to be judiciously complied with. lymph node is sampled and sent for frozen secion biopsy.
Radiation therapy is to be considered if lymph nodes are
Pretreatment Evaluation found involved. Generally, negative sentinel lymph nodes
Irrespective of the treatment modalities (surgery or
radiotherapy) the following evaluations are to be made
apart from those already done (Table 24.7) for staging
purposes.

Serum Marker (see p. 43 1)

Commonly used serum tumor mnarkers are: Squamous
cell carcinoma antigen (SCCA), cancer antigen 125
(CA-125), and carcinoma embryonic antigen (CEA).
Elevated levels of SCCA correlate with tumor size, stage,
Stromal invasion, and lyraph node status. This antigen
is not specific. However it has been used as a means
to monitor treatment response and to predict tumor
recurrence.
9
Pretreatment Preparations
Irrespective of the methods of treatment, general health of Fig. 24.8: Exophytic type of cervical squamous cell carcinonma
the patient must be improved. Due attentieAis to be paid radical hysterectomy done
 Mallgnancy 287
Chapter 24 " Genital
may alllow omission of lymphadenectomy of the nodal injurles (femoral,
Neuropaghles due to nerve illoinguinal,
basin. lateral
Limitation
obturator, sciatic, genitofemoral,
nerves).
femoral cutancous, and pudendal frequent
is jdeally limited to early stage disease. Radical formation is a complication.
Lymphocyst collected to form
hysterectomy could be done by blood are
abdominal or vaginal
Ote or by laparoscopic, robotic assisted method, TISsue luid, lymph and hysterectomy. Lymphocyst is
he cyst following radical Rarely, it may be of large
depending upon the patient's fitness and surgeon's best diagnosed by ultrasound. or venous obstruction.
experience. ureteral
Size to cause pain and retroperitoneal space
Adequate suction drainage of the preventive measure.
Advantages of Surgery Over Radiotherapy postoperatively Is an inportant
" Spread of the disease can be determined more
Majorlty resolvespontaneously. Sometimes, it may drain
thoroughly by surgicopathological staging. aspiration is needed when
Sungical staging (laparotomy or laparoscopy) and through vagina. Rarely, needle
the size is large or it produces symptoms.
assessment of paraaortic and pelvic nodes, can predict
the survival rate accurately. Pelvic Exenteration after
+ Preservation of ovarian function, if desired, specially in ultraradical surgery is named
Ihis type of in a very selective
a young Woman. Brunschwig. This procedure is done
Ovaries may be transposed out of the radiation field if cases only:
Stage IVA disease. without
radiation is considered in the postoperative period. carcinoma (biopsy proven)
Retention of more functional and pliable vagina for Central pelvic recurrent
established by PET/CT Scan.
any metastasis as
sexual function. Completely resectable tumor mass.
sciatic pain or unilateral leg
Psvchologic benefit to the patient in that her cancer Absence of ureteral obstruction,
bearing organ has been removed. edema (triad of symptoms).
physically adjusted to
Special indications: As previously mentioned, there is Woman should be psychologically and
no superiority of surgery over radiotherapy when the cope with urinary and fecal stomas.
patients are placed in ideal circumstances. But, there are Contraindications of pelvic exenteration are extra
distant metastasis to liver,
conditions where radiotherapy is contraindicated and pelvic spread of disease with
only the surgical treatment has to be provided. lungs or bones.
Contraindication of Radiotherapy Types consists of radical hysterectomy,
" Associated PID-acute or chronic, diabetes, " Anterior exenteration: It implantation of ureters
removal of urinary bladder, and
inflammatory bowel disease, pelvic kidney. an artificial bladder made
either in the sigmoid colon or into
(procidentia), ovarian
" Associated myoma, prolapse mass. from an ileal loop (ileal bladder). hysterectomy,
tumor or genital fistula, adnexal Posterior exenteration: It consists of radical
ovarian function). removal of rectum and a permanent colostomy. anterior and
" Young patient (to preserve radiation source is of
Vaginal stenosis-placement of Complete or total: It consists of combination
exenteration with a permanent colostomy and an
inadequate. posterior
adenosquamous carci ileal bladder.
Cases with adenocarcinoma or is about
noma--surgery is preferred. The operative mortality of such type of operation
10-20% and witha 5-year survival rate of about 50%.

Disadvantages of(below).
Surgery Women " Laparoscopic radical hysterectomy (LRH) with pelvic and
with comorbidities aortic lymphadenectomy is done for early invasive disease
See complications (stage I, ILA). The specimen is removed vaginally. Vaginal cuff
(obesity, heart disease) are at risk for surgery. is closed by endostitch. Pelvic and aortic lymphadenectomy
complications
Postoperative is done.
as observed following
Major postoperative complications have been discussed
otal abdominal hysterectomy
complications
Primary Radiotherapy
include: ureteric Cancer
(See p. 493). Other of the cervix was the first cancer of an internal
(about 1%), vesicovaginal fistula (0.5%), bladder
stula rectal dysfunction. organ to be treated with ionizing radiation using
ystunction, cystitis pyelonephritis andlymphedema of one radium by Margaret Cleves in 1903. Primary therapy
nere may be lymphocyst in the pelvis, mortality (chemoradiation) is given in locally advanced (stage IIB
dyspareunia, and recurrence. The to IVA)disease (see below).
von the legs,
Tate of the procedure is less than 1%. External photon beam radiation and
a known compli
Bladder dysfunction (atony) is sympathetic and are the two main methods (see p. 419, 420). brachytherapy
cation. This is due to damage from of the Both external beam radiation therapy (EBRT) and
and the bladder and
Parasympathetic fibers to drainage brachytherapy are delivered. External beam radiation
for bladder
urethra. Continuous catheterization usually preceeds intracavitary therapy
Smaintained for a periodof 6-10 days. (brachytherapy).
288 Textbook of Gynecology
TABLE 24.9: BRACHYTHERAPY TECHNIQUES Duration
No. of application
Amount of radium placement
Technique 120 hours
One
Paris Intrauterine tandem 33.3 mg-one
Vaginal ovoid 13.3 mg-two or three 72 hours each at
Intrauterine tandem 30-50 mg Two
Manchester interval of 7 days
Vaginal colpostat 30-50 mg
24 hours each at
Intrauterine tandem 50 mg-one Three
Stockholm weekly interval
Vaginal plaque-65-80 mg

treatment period in
weeks or afterloaded special applicators. One
EBRT is commonly given in 25 fractions during 5 Paris technique is 96-200 hours as compared
to Stockholm
in duration
(40-50 Gy).
radiation technique where each application is 24-28 hours
Hormone replacement therapy following
menopausal (Table 24.10). Manchester system, which is a modification of the
or surgery can be used for women with Paris technique, delivers constant isodose at different depths,
smptoms following counseling (see p. 50). regardless of the size of the uterus and vagina.
In Stockholm technique (Fig. 24.9), large high intensity
Advantages of Primary Radiotherapy source with less exposure time is given, but the vaginal source
is
Wider applicability in all stages of carcinoma cervix. closer to the cervix.
Survival rate 85%, comparable with that of surgery in
These three basic techniques are followed all through
early stages. the world in the brachytherapy for carcinoma cervix. After
Less primary mortality and morbidity.
Individualization of dose distributions/requirement loading remote control technique (see p. 419) is used
possible. for calculated dose distribution and to prevent radiaion
hazard. Fletcher-Suit afterloading modification systerm is
Early Stages widely used these days.
Brachytherapy technique (Table 24.9) is employed (see Ch 31).
Small radioactive sources, mainly radium sulfate is mixed with Disadvantages of Radiotherapy
some inert powder and packed in small needles or tubes. These Intestinal and urinary strictures, fistula formation (2-6%),
are used for interstitial, intracavitary or surface applications. vaginal fibrosis andstenosis causing dyspareunia, radiation
Radiation sources for intracavitary radiation are radium (26Ra), menopause (see p. 52), fibrosis ofbowel and bladder. Ovarian
cesium (137Cs) or Cobalt (G0Co). The container is made up of
platinum, gold or alloy steel to absorb alpha and beta particles transposition (ovariopexy) well out of the range of pelic
and allowing the gamma rays to sterilize the cancer cells. In irradiation may be done to avoid radiation menopanse. For
carcinoma cervix, the tandems are inserted in the uterine cavity other complications of radiation (see p. 421).
and the ovoids and colpostats are placed in the vaginal vault Calculation of the dose (see p. 420): The radium dose
under anesthesia. Different methods of brachytherapy are in is conventionally calculated with respect to the amount of
vogue (Fig. 24.9). High dose brachytherapy is safe and effective radiation received at two arbitrary points A and B. Point Ais
(NICE 2010). 2 cm cephalic and 2 cm lateral to the external os and is the point
In Paris and Manchester techniques, the source strength of crossing of the uterine artery and ureter. Point B is 2 cm
is smaller but exposure time is increased. The vaginal source cephalic and 5 cm lateral at the same plane and is approximately
is away from the cervix. They are used with either preloaded the site of obturator gland (see Fig. 31.3).

A B

Figs 24.9A to C: Different methods of brachytherapy-A. Stockholm technique: B. Paris technique: C. Manchester technique
 Genital Malignancy
Chapter 24 "
nodes
calculated that point A gets about 7000 Surgery Followed by Radlotherapy with posltive lymph
. bus been cases
B 2000 cGy. Taking into consideration that This is indicatecl in
8000 Gy
and point
7000-7500 ciy, the rest of the detected following surgery.
invaslve carcinomacervix of
cancerohtic dose is approximatcly of
supplenmented by external beam irradiation Accidentaldiscovery hysterectomy.
nal point B is For external removed by simple present.
00) civ spreading over
another three weeks.
electron
a uterus
tlssue resection mnargin is sterilize the
energy of 4 million When positive therapy is to
iation, lincar accelerator with of this form of nodes. The fact remains
commonly used. The objective lymph possible
volts or mor is ofthe source, the vagína and cervix cancer cells in the pelvic dissection it is not reduced
ln the immediate vicinity node
Bladder, ureter, and pelvic lymph Radiation dose is
toerate about 20,000-30,000 cGy. otlher hand thateven by the positive nodes.
7000 cGy. Small gut on the
tum cantolerate up to 4500 cGy. to removeall 5 weeks.
fractions overchemoradiation therapy
of only 4500 cGy in 24
tolerance limit
Postoperative adjuvant platinum-based chemo
to
has a radiation damage to the adjacent
For the prevention of with gauze radiation and rate when
packing the vagina should be done carefully development (extended field improved the survival
iscera. or needles. Recent significantly
anound the vaginal ovoids applicator (colpostats) has
therapy)
radical hysterectomy.
inserts with plastic wall. given following
of rungsten irradiation of the vaginal
minimized excess gamma ofirradiation in rectum and
bladder is
RadiotherapyFollowed by Surgery
barrel-shaped cervix.
Calculation of the amount can be done carcinoma with growth
modification
required dose Endocervical controls sepsis, the
done by dosimeter and field-see p. 421). Radiotherapy
necessary (for treatment dosimetry, exact Bulkytumor: tumor resectability is improved.
as and when of computer shrinks and the
With the advent each patient for each chemotherapy (NACT) Reduces
of the doses on modulated " Neoadjuvant advantages: (a) disease
calculation ntensity following micrometastatic
provided. has the
application is being (IMRT), based on computer NACT volume (b) Reduces Probably
external radiation
therapy accurately the target tumor resectability and (d)
generated algorithmsnormal can distinguish Linear accelerators, (c) Improves in tumor compared to
radiotherapy
tissue. survival rate when with bulky
tissue volume and technology can deliver highly improves specially useful in young women Neoadjuvant
mulileaf collimation through IMRT. IMRT
can alone. It is for FSS.
precise external
radiotherapy
radiation to normal tissues stage IB-IIB disease desiring radioptherapy.
of chemotherapy is followed by
preferentially limit the dose doses to tumor tissues. It
can
platinum-based combination chemo
deliver higher Treatment Three cycles of weeks by
and can
are less amenable ordinarily. PET to radiation therapy followed 3-6
reat tumor that
imaging using CT, MR,
and therapy with
and lymphadenectomy is done. This
planningis done on 3D radical hysterectomy (stage
volume. of the bulky > 4 cm
determine the tumor blood supply is poo, the has improved the resectability regimen had shown better
cases: As the irradiating IIA) disease. This
J Advanced anoxia may be overcome bycondition of IB2 and bulky reduced recurrence.
resultant chamber under overall disease free survival rate and
special difficult. Risk of ureteric
hese cases in a Due to fibrosis, surgery may be
hyperbaric oxygenation. carcinoma: Incidence of used are in combination
about fistula may be more. The drugs
JRecurrent cervical
disease after therapy
is
beam of Cisplatin, Ifosfamide or Paclitaxel.
Tecurrence or persistent irradiation with
external Concurrent chemoradiation includes radiation
pelvic
35%. Whole
radiotherapy has been
advocated. hysterec and weekly cisplatin-based combination (cisplatin and
detected after simple upon the paclitaxel) chemotherapy. Cisplatin-based concurrent
Carcinoma, cervix depends
management protocol microinvasive/ chemoradiation is used as a treatment of choice in:
omy: The Cancer histology:
lollowing factors: (i) negative/positive; (a) Early stage (IA2, IB, IIA) disease after radical
tissuemargin: hysterectomy. (b) As a primary treatment for patients with
invasive;(ii)Surgical mass: absent o present.remove
(iii) Residual tumor Radical surgeryto This is bulky (24 cm) tumor (stage IB and IIA) and (c) Locally
options: (1) advanced (stage IMB to TVA) disease as a primary therapy.
Management
the regional nodes.
therapy:
Test of tissues including patient. (2) Radiation residual Chemotherapy sensitizes the cancer cells to radiation and
young minimal improves the survival rate.
specially done in a y there is no or residual
la) Brachytherapy whenradiotherapy when gross u Laparoscopic Assisted Vaginal Radical
disease. (b) Full intensity with Pelvic and Aortic Trachelectomy
disease is present. radiotherapy:
Perforation of the
ofuterine tandem.
Lymphadeectomy
was designed (Daniel Dargent 1987) to (LARVT)
Complications of
duringintroductlon complications
treat early
invasive cervical cancer. This is done in a young
erusmayresult major woman
are the where childbearing function is to be
Radiation reactions of surgery, (fertility sparing surgery). Initially, pelvic and preserved
(see p. 420). the form
is done. Vaginal aortic
In be done, one lymph node dissection
Combination herapy: chemotherapy imay
radiotherapy and trachelectomy is done only when these nodes radical
following the other. are
 290 Textbook of Gynecology
PALLIATIVE TREATMENT
negative. laparnscopic appoAch is simlar to LARVH
to prde
(see p. 287). Vaginal part inchudes resection of cervical, Palliatlve treatment is primarly almed
along with
vaginal. paracervical, and paravaginal tissues. Vaginal comprehensive care for relief of symptoms
stage.
advanced
cuff is resected circumferentially about 2 cm below the treatment of cancer in the with
cenicovaginal junction. ldeally, the resected cervical discharge is treated
Apurulent or foul vaginal suppositories.
tissue margins should be free of disease as evaluated by antimicrobial vaginal creams or
frozen section. Cervical permanent cerclage operation
is done to prevent miscarriage and preterm labor. Bleeding or
Pallilative radlation therapy (180-200 eGy/day)
INDICATIONS OF TRACHELECTOMY of
chemotherapy may be used to relieve symptoms solutionpain or
Preservation of fertility bleeding. Tight vaginal pack soaked in Monsel's
(ferric subsulfate) against the cervix may control bleeding
Early stage disease (stage IA, A2, I81)
Small tumor volume (< 2 cm)
No pelvic node metastasis temporarily.
Cancer margin is at 1 cm below the internal os on MRI.
Pain
PLANNING OF TREATMENT MODALITIES
Palliation of pain is done either by reducing the pain
stimulus or by raising the pain threshold. Pain from bone
A. Early stage disease: See Table 24.10 metastasis is mainly due to prostaglandin production. It is
For early stage disease, the survival rate following best controlled by using nonsteroidal anti-inflarmmatory
treatment by either radical hysterectomy and pelvic drugs (NSAIDs). Palliative radiation with 2000 cGy over
Iynphadenectomy or with primary radiation with five treatment course mnay be an alternative. Anxiolytic
concurrent chemoradiation are almost equal. (benzodiazepines) or antidepressant drugs (amitriptyline)
B. Advanced stage disease may be helpful to raise the pain threshold. Opioid (oral

TABLE 24.10: MANAGEMENT OPTIONS OF CARCINOMA CERVIX

MICROINVASIVE (STAGE IA), EARLY INVASIVE (STAGE IB, IIA) AND ADVANCED (STAGE IIB-IV) CARCINOMA
Pelvic lymph node Pelvic lymph
Depth of invasion Stage involvement Surgery adenectomy
" Invasion s 3 mm IA1 0-0.6% " Therapeutic conization of cervix (knife cone see No
" No lymphovascular space p. 487)
invasion (LVSI) " Simple trachelectomy (see p. 500), provided
strongly motivated for long-term follow up.
Surgical margin (10 mm) must be free of disease
" Simplehysterectomy ifchild bearing is completed.
" Invasion 3-5 mm and IA2 0.6-10% " Simple trachelectomy +|
horizontal spread <7 mm " Simple hysterectomy

" Lymphovascular space IA1//A2 6.5% " Radical trachelectomy

involvement irrespective " Modified radical hysterectomy (type - 11)
of depth of penetration
" Stromal invasion exceeds IB, IIA 16-44% " Radical hysterectomy, pelvic lymphadenectomy
>5 mm (type ll) with paraaortic lymph node evaluation.
External radiation if the nodes are positive OR
primaryradiation with concomitant platinum
based chemotherapy (chemoradiation)
ADVANCED CANCER IIB-IVA 30-55% " Chemoradlatlon/palliative surgery
IVB
"
(nephrostomy/colostomy)
Chemoradlatlon ± palliative radiotherapy
Radical vaginal trachelectomy: Uterus is preserved. Medial half of parametrial and paravaginal tissues are removed. Descending
cervical branch of uteine is ligated. Upper 2cm of vagina removed. Type lExtrafascial hysterectomy; pubocervical ligament is incised
allowing lateral deflection of the urete. Type Il (Modified radlcal),. Medial half of the Mackenrodt and uterosacral ligaments along with
selective (clinically enlarged palpable) lymph nodes and upper (2 cm) of vagina are removed. The uterine arteries are ligated at the site
of crossingthe ureters. The medlal half of the parametria and proximal uterosacral ligaments are resected, TypellRadical hysterectomy
with removalof the uterus, upper third of vagina, paracervical and paravaginal tissues are done. The uterine arterv is liaated at its orlgin
(internal illac artery). Uterosacral and cardinal ligaments are resected at their attachments to the sacrum and pelvic side wall. Bilateral
pelvic lymphadenectomy is done. Type lV (Extended radical hysterectomy) see p. 490. Type V(Partlal exenteration) see p. 287.
 Chapter 24 " Genital Malignancy 291
morphie3- 10mg)combinediwith
paracetamolor
givenat aregularinterval(4-5 hours) or patient aspirin, TABLE 24.11: 5-YEAR SURVIVAL RATE
analgesia is widely usedIto reduce pain controlled 5-year survival rate (%)
Neuropathic pain is difficult to perception. Stage

blockade with local anesthetic

manage. Regional IIA 76.0
techniques has been con-
siderdin some cases. Pudendal block is helpful
73.3
forlower 50.5
pelic and perineal pain. Intrathecal (spinal, epidural) IIA
onioids are appropriate for pain from any region. 46.4

nilateral cordotomy (C1-2) is considered for widespread IVA

29.6
pain which is refractory. IVB
22.0
Persistent nausea and vomiting due to ileus may
be relieved by gastrostomy tube. Patient may need
percutaneous nephrostomy for obstruction of the ureters. Recurrent Cervical Cancer
are: Large tumor size,
Home hospice is an invaluable part of terminal care. Risk factors for recurrent disease lymph nodes,
lymphovascular space invasion, positive
CARCINOMA OF CERVIX AND PREGNANCY advanced stage disease.
recurrence is pelvic side
Most common site of
Incidence of invasive carcinoma of the cervix is about one recurrence are: Pain in the
in 2500 pregnancies. wall. Features of disease obstruction,
edema, ureteral
pelvis, back, unilateral leg
Diagnosis is often late. Cone biopsy may be necessary tumor in the pelvis,
vaginal bleeding, palpable
for confirmation. Complications of cone biopsy include: agent or multiagent
Hemorrhage, abortion, preterm labor, and infection (see and lymnphadenopathy. Single paclitaxel or ifosfamide is
chemotherapy with cisplatin,
p. 487). LEEP has no superiority over cone biopsy. used. Palliative radiation
used to those
therapy may be
Management who have been treated initially with surgery. occur in the
recurrences
The following points are taken into
consideration before Follow up: The majority of the
protocols should be at
actual management: (A) Period of gestation,
survival of
(B) first 2 years. As such, the follow upyears then at 6 months
the fetus and (C) wishes of the patient, and (D) histology. 3-4 months interval for the first 2
annually. Thorough
carcinoma may be
A. Patient with microinvasive revaluated following interval for next 2 years and thereafter examination of
followed up to term. Patient is physical examination is done including
or
delivery and treated as in the
nonpregnant state. supraclavicular and inguinal Iymph nodes. Cervical
first trimester, treatment annually.
B. Advanced stage: In the vaginal cytology is performed. Chest X-ray is done
nonpregnant state
modality is the same as in the following Stump Carcinoma
(chemoradiation). In late pregnancy,
by classical cesarean When the carcinoma develops in the cervical stump left
maturity, fetus is delivered radical
treatment with either behind after subtotal hysterectomy, it is called stump
Section. Subsequent chemoradiation is same
the carcinoma. In true stumnp carcinoma, malignancy
Surgery or radiotherapy or
develops 2 years after primary surgery. If it occurs earlier
as in the nonpregnant state.
to that, it is presumed that the carcinoma was present
at the time of primary surgery and, as such it is called
Prognosis is the single most
important
Clinical stage of the disease survival outcome appears coincidental, residual or false stump carcinoma.
Prognostic factor. Stage for stage
pregnancy and nonpregnant The incidence may be as high as 1%. It is difficult to
different between stage the disease.
O De no
see author's Textbook of Obstetrics, Ch 21).
sate (for details There is also difficulty in the treatment. Dense
adhesions of bladder, rectum and also ureters with the
RESULTS OF THERAPY FOR stump make the operation difficult and risky. The radiation
CARCINOMA CERVIX therapy is also technically difficult, because of absence of
of 5-year
in terms tabulated
expressed uterus and close proximity of bladder and rectum to the
The result of therapy is survival rate is
survival rate. The overall 5-year radiation source. Radical parametrectomy, removal of
in Table 24.11.
recurrence after 5
years. The cervix, upper vagina and pelvic lymphadenectomy is done
There is about 30% and
pelvis in early stage disease.
side wall of the remains
recurrence sites are in the
declared cured if she
External beam radiation therapy is given when the
central pelvis. A patient is therapy. The cervix is short. Vaginal radium application
well even after 10 vears following inital symptoms is also used. The (vaginal cone)
the patient after the prognosis is unfavorable. The 5-year
chance of survival rate of survival rate varies from 30-60%.
years.
PPear, if left untreated. is about 2