Cervical Carcinoma

Following abnormal cytology, DUB, dyspareunia/postcoital bleeding


Cervical Cancer is the 2nd most common malignancy in women worldwide, after breast cancer.
The change in epidemiological trend in the first world countries has been attributed to mass screening with Papanicolaou tests. Cervical cancer is only found in women, and its incidence highest among women aged 50-79 years and Hispanics.

Risk Factors

Current research steers from sexual activity to human papillomaviruses (HPVs) as prime suspects.
HPV is a heterogenous group of viruses with closed circular double-stranded DNA. 6 early open reading frame proteins (bind with Rb protein and p53) with 2 late open reading frame proteins that make up the viral capsid.

77 different genotypes of HPV haven been identified adn cloned to date. Note types that affect anogenital tissues 6, 11, 16, 18, 26, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 53, 54, 55, 56, 58, 59, 66 and 68.
  • low risks HPV 6b and 11
  • High risks HPV 16 and 18, found in up to 90% invasive cancers

Influential factors for progression of low-grade SIL (squamous intraepithelial lesions) to high-grades SILs:
  • type and duration of viral infection
  • host conditions that comprise immunity e.g. multiparity, poor nutritional status, smoking, oral contraceptive use, vitamin deficiencies
  • gynacological factors i.e. age of of menarche, age of first intercourse, number of sexual partners



The tumour grows by extending upward to the endometrial cavity, downward to the vagina, and laterally to the pelvic wall. It can invade the bladder and rectum directly. The common sites for distant metastasis include extrapelvic lymph nodes, liver, lung and bone.

Signs and Symptoms

Present as abnormal vaginal bleeding, usually postcoital. Organ involvement of cervical tumour are indicated by symptoms such as constipation, hematuria, fistula, ureteral obstruction. Pelvic wall involvement signified by triad of leg edema, pain and hydronephrosis.

V/E As the disease progresses, the cervix become abnormal in appearance, with gross erosion, ulcer, or mass. These abnormalities can extend to the vagina.
Bimanual Ex may find pelvic metastasis
R/E may reveal external mass or groww blood from tumour erosion
O/E px with early-stage cervical cancer can be relatively normal. Leg oedema may suggest lymphatic/vascular obstruction from tumour. Hepatomegaly may be detected. Pulmonary metastasis difficult to detect, with pleural effusion or bronchial obstruction.

Differential Diagnosis

Endometrial carcinoma
Pelvic inflammatory disease
Uterine Cancer


  • Diagnostic tests
Papanicolaou test
Colposcopy, direct biopsies, endocervical curretage
Tip in colp: Squmous-epithelial Junction; acetic acid stain highlights abnormal junction

  • Metastasis detection and staging
FBE, U&E for renal and hepatic functions to detect metastasis
Chest X-ray to rule out pulmonary metastasis, CT abdomen and pelvis for metastasis in the liver, lymph nodes; rule out hydronephrosis/hydroureter.
Conization of cervix, cystoscopy, proctosigmoidoscopy
external image cervical-dysplasia-procedure-part-2-picture.jpg

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Staging of dysplasia
  • CIN I mild dysplasia
  • CIN II moderate dysplasia
  • CIN III severe dysplasia / carcinoma in situ

Staging of cervical cancer
  • Stage 0
  • Stage 1A < 5.0mm
  • Stage 1 B clinically visible
  • Stage 2A beyond uterus
  • Stage 2 parametrial involvement
  • Stage 3 wall of pelvis 3A lower 1/3 vagina
  • Stage 3B pelvic wall/kidney
  • Stage 4A organs adjacent
  • Stage 4B organs distant


Stage 0 LLETZ (Long loop excision of transformation zone)
LEEP (loop electrosurgical excision procedure)
laser therapy, conization, cryotherapy
(post-menopausal; Eostrogen tablets twice/week medroxyprogesterone acetate 200-400mg oral)
Stage 1A Surgery (total hysterectomy, radical hysterectomy, conization)
Stage 1B, 2A External beam radiation + brachytherapy (internal radiotherapy) OR
Radical hysterectomy + bilateral pelvic lymphadenectomy
In the case of preserving fertility, trachelectomy (cervicectomy) + pelvici lymph node dissection (for lesions less than 2 cm)
(Brachytherapy is delivered using afterloading applicators that are placed in the uterine cavity and vagina)
Stage 2B- 4A Radiation therapy + cisplatin-based chemotherapy
Stage 4B and recurrent radiation therapy with chemotherapy (cisplatin adn topotecam


5 year survival rate
Stage 1: 90%
Stage 2: 60-80%
Stage 3: 50%
Stage 4: less than 30%