Stage II

• Stage II - Invasive cancer with tumor extending beyond the cervix and/or the upper two-thirds of the vagina , but not onto the pelvic wall. – Stage IIA - Tumor has spread beyond the

cervix to the upper part of the vagina. – Stage IIB - Tumor has spread to the tissue

next to the cervix - perimetrium.

1

Stage III

• Stage III - Invasive cancer with tumor spreading to the lower third of the vagina or onto the pelvic wall; tumor may be blocking the flow of urine from the kidneys to the bladder. – Stage IIIA - Tumor has spread to the lower

third of the vagina. – Stage IIIB - Tumor has spread to the pelvic

wall and/or blocks the flow of urine from the kidneys to the bladder.

2

Stage IV

• Stage IV - Invasive cancer with tumor spreading to other parts of the body. This is the most advanced stage of cervical cancer. – Stage IVA - Tumor has spread to organs

located near the cervix, such as the bladder or rectum .

– Stage IVB - Tumor has spread to parts of the body far from the cervix.

3

Metastases - via lymph vessels

• Most common way

• stage I – 13-20%

• stage II – 30-33%

• stage III – 40-60%

• In stages II and III

to surrounding tissues.4

Primary spread group

1. Parametrial nodes axe the small lymph nodes, traversing the parametria

2. Paracervical or ureteral nodes are located above the uterine artery where it crosses the ureter

3. Obturator: surrounding the obturator vessels and nerves

4. Internal iliac nodes course along the hypogastric (internal iliac) vein near its junction with externaliliac groups

5. Sacral nodes

5

Secondary spread group

• Common lilac nodes

• Inguinal nodes consist of the deep and superficial femoral lymph nodes

• Para-aortic nodes

6

Metastases – via veins

liverboneslungsbowelsbrainskin

cervical cancer

• Usually occur late. • prognosis is very bad here.

7

5 year survival rates:

Stage I : 80-90%

Stage II : 75%

Stage III : 35%

Stage IV :10-15%

Prognosis is stage dependent

8

Stage 1 - 32 months

Stage 2 - 24 months

Stage 3 - 11 months

Stage 4 - 5 months

Prognosis - if not treated

9

Clinical symptoms

10

1-st Clinical symptom ?

• Patients with early-stage cervical cancer are relatively asymptomatic.

• At the microscopic stage of disease, most cervical cancers produce no signs or

symptoms.

11

In early stage there are often no symptoms

other than an abnormal

Pap smear.

12

First clinical First clinical symptoms of symptoms of

cervical cancer are cervical cancer are the sign of advanced the sign of advanced

disease !!!disease !!!13

And these are not an early symptoms but first clinical

symptoms. Try to remember that!!

First clinical symptoms are not accompanied by any suffering. Late symptoms are followed by

pain and suffering.

14

First Clinical symptoms

• As the carcinoma grows, symptoms such as abnormal bleeding and vaginal discharge may occur

• Postcoital bleeding may be the first symptom in sexually active women.

15

Other clinical symptoms

• Larger tumors may cause size-related symptoms: urinary frequency or retention, rectal pressure, constipation, neurologic symptoms (eg, sciatic pain due to local extension), lower extremity pain, and swelling.

• Anemia – patients report feeling weak or dizzy .

• Urinary or fecal incontinence prompts patients to seek care.

16

17

Physical examination

• The most common sign of cervical cancer is a grossly visible lesion upon vaginal speculum examination

18

Attention !

An exophytic or ulcerative lesion may be

obvious during the clinical examination,

but an endocervical lesion may have

normal-appearing ectocervical mucosa in

the presence of a firm & enlarged cervix. 19

TREATMENT

20

TREATMENT

• Surgery

• Radiation therapy

• Chemotherapy

Strategies and proportion of methods depend on stage and

advancement of cancer. 21

Surgical treatment1. protective operation (conization,

amputation of cervics),

2. simple amputation of uterus’ trunk (hysterectomy) without adnexes,

3. radical hysterectomy with selective removal of lymph nodes +/– additional treatment

22

23

• brachytherapy (intravaginal and intrauterinal,)

• radiotherapy (teletherapy in coop. with brahytherapy),

• Radical surgery followed by radio-chemotherapy,

• radiotherapy combined with chemotherapy.

Radio and chemo therapy

24

CIN III - preinvasive cancer

• Cervical conization – removal of the part of the cervix containing the preinvasive cancer ( HSIL / CIN III).

• Followed by abrasion of cervix’s canal = diagnosis and treatment

* cancer in canal => amputation25

Contradictions for protective operations - conization

– tumors and inflammation of adnexes ,

– myomas uteri,

– high grade disfigurement of vaginal part of cervix after delivery,

– little and tiny cervix,

– cancer in canal (abrasion).

26

• Microinvasive ca. stage IA1 – treatment is analogical to preinvasive cancer. But….

• Microinvasive ca. Stage IA2 – surgical treatment ± complementary radiotherapy.Surgery - radical hysterectomy with selective LN removal

27

• Invasive cancer IB1 (< 4 cm) –• Invasive cancer IB2 (> 4 cm) – • Invasive cancer IIA *

surgery ± radiotherapy.

* sampling – biopsy of paraaortic LN

28

RADICAL HYSTERECTOMY

Radical abdominal hysterectomy

(Wertheim – Meigs) is indicated for patients

with stage IA2-IIA of cervical cancer, who

are medically fit enough to tolerate an

aggressive surgical approach and wish to

avoid the long-term adverse effects of

radiation therapy.

29

RADICAL HYSTERECTOMY• Contraindications:

patients who are medically infirm and those who refuse surgical treatment.

1/3 -2/3 of surgical patients require transfusion, radiation therapy should be considered for patients whose religious or personal beliefs prohibit blood product transfusion.

As with any other surgery, careful preoperative risk assessment must be performed.

30

• Invasive cancer IIB • Invasive cancer IIIA • Invasive cancer IIIB• Invasive cancer IVA

radiotherapy.• Invasive cancer IVB – NO TREATMENT STANDARDS

31

Radio&chemotherapy

• 30-50% reduction of risk of death in comparison to radiotherapy only.

• Should be placed in standards of treatment for stages : Ib, II, III and IVa.

32

Nice To Know:The number of new cervical cancer diagnoses and the number of cervical

cancer deaths decline each year.

Experts believe these statistics would decline even more rapidly if regular Pap tests were given to all women who are or have been sexually active or have

reached the age of 18.33

Remember!

• It can be curable when detected

early with a Pap smear.

34

Pap smears guidelines

• recommended for all women: – beginning at age 25 (18 US) or, – when becomes sexually active (max

3y after).

• If normal + no risk factors – repeat every 3 years

• Highr risk groups – every year• HIV+,HPV+, immunosupression, HSIL – repat

within 12 months

35

Cervical Cancer in Pregnancy

• Aproximately 1/1000 – 10 000

• 1-3% of all CC

• Mean age 32-34 years

36

Cervical Cancer in Pregnancy

• Influence of pregnancy is controversial– Suppression of cellular resistance– High oestrogen levels

However the progress of dysplasia, preinvasive and microinvasive cancer is not enhanced

• No influence on prognosis and survival rate

37

Cervical Cancer in Pregnancy

• identical screening

• 50% - preinvasive and Figo I

• 81-87% squamous

• 7-15% adenocarcinoma

38

Cervical Cancer in Pregnancy

• Few cases = no guidlines

• Treatment depends on:

• Stage

• Hbd

• Having offsprings

• Individal’s decision

39

Cervical Cancer in Pregnancy

• Treatment may be delayed till foetus’ maturity– Early stages– DGN at the end of 2nd and 3rd trimester– Invasive IB <2cm without meta DGN in 1st trimester

• Tumor>4 cm => immediate treatment

40