CERVICAL CANCER
PRESENTER:
Dr ARCHANA K L
INTRODUCTION

CERVIX is the lower part of womb, it connects uterus and vagina.
cervix

The cervix is a tubular structure. It is composed of
stromal tissue which is lined by squamous epithelium in
the vagina (ectocervix) and columnar epithelium within
the cervical canal (endocervix).

The meeting of the two types of the epithelium is
called squamocolumnar junction (SCJ) and this is
usually at the ectocervix.
The squamocolumnar junction is a dynamic point.

In children it lies at the ectocervix that is just at the
external os.

At puberty and during pregnancy it extends outwards as
the cervix enlarges and in adult life it returns to the
ectocervix through the process of metaplasia
Transformation zone:

This region of the cervix where the columnar
epithelium has been replaced and/or is being replaced
by the new metaplastic squamous epithelium

It corresponds to the area of cervix bound by the
original squamocolumnar junction at the distal end and
proximally by the furthest extent that squamous
metaplasia known as new squamocolumnar junction

It is formed at puberty. Only in 4% of cases present at
birth.

The transformation zone TZ is the site where premalignancy and malignancy develop.
Phases of Cancer Development
Healthy cells
dysplasia
Carcinoma
in situ
Distant
metasatases
Regional
lymph node
involvement
Localized
invasive
cancer
EPIDEMIOLOGY

Cervical cancer significant cause of morbidity and mortality among women
globally, is the second most common cancer(after breast cancer)

80% of cervical cancer occur in developing countries… where cervical cancer
is the 2nd most cancer in women

In that 2/3rd of cervical cancer diagnosed at an advanced stage with a poor
prognosis for survival.
INCEDENCE

CURRENT DATA Indicates 50% decrease in both
incidence and mortality since 1947(3-4% per year)

PERIODIC CANCER SCREENING

EARLY DETECTION AND TREATMENT

DOWNSTAGING OF THE DISEASE
Risk factors for cervical cancer

Human papilloma virus infection

Being sexually active at a young age

Having many sexual partner

MULTIPARITY

Younge age at the first full term pregnancy

Weakened immune system(HIV positive, transplant patient)

Smoking cigarettes

Exposure of DES in mother’s womb
Symptoms of Cervical Cancer

Irregular vaginal bleeding(vaginal bleeding during and after intercourse)

Foul smelling vaginal discharge

Abnormal vaginal discharge

Post menopausal bleeding

Pain with sexual activity

Pelvic pain
LACUNAE

Lack of organised screening Programme in developing countries..
Accuracy of screening tests in developing
countries range in sensitivity and specificity
TEST
SENSITIVITY
SPECIFICITY
Cytology
31-78%
91-99%
HPV testing
61-90%
62-94%
VIA
50-96%
44-97%
VILI
44-93%
75-85%
IDEAL METHOD OF CERVICAL SCREENING IN
LOW RESOURCE SETTINGS

TEST SHOULD HAVE
o
SENSITIVITY
o
AFFORDABILITY
o
FEASIBILITY
o
MAXIMUM COVERAGE

VIA –BEST TEST..
Screening protocol for Cervical Cancer
Assess
likelihood
Abnormal vaginal bleeding (i.e post-coital, between
menstrual periods, post menopause)
Foul-smelling discharge
Pain during vaginal intercourse
Are the above symptoms associated with abdominal mass, low
back or abdominal pain
No
Ye
s
Clinical detected
cervical growth
or ulceration
No
Follow up
Ye
s
Refer
immediately
Requirements for VIA TESTING
Examination
Gloves
Speculum
Acetic acid
Ring lens
system
Cotton swabs
VIA Reporting
forms
Procedure for testing
Woman should lie down on
her back with legs folded
(lithotomy position not
required)
Insert speculum gently
and expose the cervix
Note any abnormal
discharge, bleeding or
growth in the cervix
Apply adequate amount of
acetic acid to the cervix
using cotton swabs
Wait for 1 minute to note
the changes
Identify the squamocolumnar junction as the
line joining the pink
smooth squamous
epithelium with red velvet
like columnar epithelium
Look for aceto-white
patches
All the aceto-white
patches are not
considered positive
If there are no acetowhite patches in the ectocervix, then the test is
negative
If there is a aceto-white
patch, its density, margin
and relationship to the
SCJ should be noted
Procedure should be
explained to woman
CERVIX-NORMAL & ACETO
WHITENING
INTERPRETATION 0F VIA RESULT
VIA Negative or
Normal
VIA Positive
Supicious of
invasive cancer
VIA NEGATIVE OR NORMAL
Diagnosis of cin:
I. Cytologic screening

Originally the “Pap” smear was introduced by Papanicolou, where cell
removed from the cervix using a wooden spatula and placed on glass
slide and fixed. This was then examined by a cytologist for the immature
squamous cells sheds from the area of the CIN.

Now Pap smear is superseded by liquid based cytology.
Cervical smear is taken using plastic spatula, then it is
rinsed in a liquid media. Cells are separated by
centrifugation, thin layer smear are made. It avoids
the risk of false postive, false negatie or
unsatisfactory smear.

Normal cervical cell has small nuclei that is flattened
and pyknotic but abnormal cell has large nuclei,
cytological atypia and high N/C
Colposcopy:

Colposcopy is the outpatient examination of the magnified cervix using a
light source. It is used for both diagnosis and treatment. After inserting a
speculum the cervix is examined using Binocular operative microscope
under magnification (5-20 time).
Colposcopy

5% acetic acid is applied, as it causes nucleoproteins within the cells to
coagulate. Therefore areas of increased cell turnover, for example CIN
will appear white.

An abnormal smear can show cells in different degree of maturity
(dyskaryosis) and is divided into:

Mild dyskaryosis and borderline changes (low grade)

Moderate and severe dyskaryosis (high grade)

Abnormal smears act as a mean of referring the patient to the
colposcopic clinic for further assessment.
colposcopy

Schiller’s test: by application of iodine, areas of CIN lack the presence of
intracellular glycogen and therefore are stain yellow as opposed to normal
which stain brown when iodine is applied.
colposcopy

Abnormal vascular pattern like punctuate or mosiasim.

Biopsy is taken from the most abnormal site.

Colposcopy is deemed unsatisfactory if TZ is not viewed adequately.
HPV DNA testing:

As HPV is the main causative factor of CIN and cervical cancer, recently
detection of HPV DNA in serum has been introduced to screening program.

HPV TRIAGE strategy includes
i.
Pap smear test(LBC)
ii.
HPV Testing
iii.
Colposcopy

The sensitivity of cervical smear in picking up women with CIN is around
70 percent, however, as there is slow progression for most women with CIN
to cancer, if a lesion is missed then this should be picked up on subsequent
smear. The specifity is 90%
.

If the test is negative the patient is re-placed on routine recall.
HPV VACCINES

Recently HPV vaccines have been developed to prevent primary
infection with certain oncogenic HPV types (16,18,31,33) from the
capsid coat of the virus.

Bivalent vaccines(cervarix)against HPV types 16,18

Quadrivalent vaccineL(gardasil) against types 6,11,16,18

Route of adminstration – intramuscular

Dose - 0.5ml

DOSAGE SCHEDULE – 0,1,6 OR 0,2,6