B6M1 case 6 tg

• Cervical carcinoma is the second most common cancer among Filipino women. Breast cancer is the most common cancer among Filipino women.
• Median age


  40 years old
• Cervical carcinoma is prevalent among women in the low socioeconomic class because of inadequate access to good health care and cancer screening tests (pap smear).
• Majority (>75%) of women are diagnosed in late stages of the disease (stage II-IV) and therefore have poor response to primary cancer treatment. Survival rate at these stages is 30-35%
• Human Papilloma virus (HPV)


  • Sexually transmitted virus, is the etiologic agent of cervical carcinoma
  • Sexual practices that increase the virus consequently increase the risk of the patient
• Risk factors for cervical carcinoma

  • Multiple sexual partners (patient and/or partner)
  • Early age of the first sexual intercourse
  • None-barrier method of contraception in patients with multiple partners
  • Male partner has uncircumcised penis
  • Multiparity
  • Smoking
• Cervical carcinoma is not a familial type of cancer. There is no evidence that it is part of any familial cancer syndrome or that one's risk increases when an immediate relative was diagnosed with the disease.
• Pathogenesis of cervical cancer


  1. Viral infection and integration occurs in the transformation zone of the cervix

  2. Transformation zone is the area on the ectocervix bordered by the old and new squamocolumnar junction

  3. Columnar epithelium undergoes metaplastic transformation as it is exposed to vaginal acidity and transforms into an immature squamous metaplastic epithelium

  4. Immature squamous metaplastic cells are susceptible to HPV infection. Viral integration occurs and human protein regulatory mechanisms are affected

  5. P53-Viral E6 complex: p53 (tumor suppressor gene) regulates cellular apoptosis (cell death) or cellular repair. Complex formation with viral E6 inhibits the function of p53

  6. PRB-E7 complex: Human PRB gene regulates the cell cycle. Complex formation with viral E7 gene inhibits the function of PRB gene and instead synchronizes the cells in the S phase of the cycle

  7. Initially, Cervical Intraepithelial Neoplasia, a preinvasive disease of the cervix, develops. Progression from CIN I to CIN III then to invasive cervical cancer occur when the disease is not diagnosed and appropriate treatment is not administered
• Clinical manifestations of cervical carcinoma

  • Post-coital bleeding
  • Foul smelling discharge
  • Pelvic pain
  • Leg edema
  • Difficulty in urination
  • Weight loss
  • Loss of appetite
• Physical and pelvic examination findings

  • Pale conjunctivae
  • Fungating mass on speculum exam
  • Bilateral parametrial masses extending to the pelvic wall
• Pap smear procedure


  1. Cervix exposed using vaginal speculum, without using lubricants

  2. Sample is taken from the endocervix using a cytobrush and rotating it 90 to 180

  3. Specimen is spread thinly on a glass slide and the cellular specimen immediately fixed, either in 90% alcohol or sprayed with fixative

  4. Another sample is taken using a wood or plastic spatula in scraping the exocervix so as to include the entire transformation zone
• Bethesda Classification


  Most commonly used classification to describe the Pap smear result
• Bethesda Classification components


  • Adequacy of smear
  • Infection type
  • Squamous abnormalities
  • Glandular cells
• In the presence of a fungating mass on the cervix, a pap smear is not necessary. The pap smear is a screening test performed on the general population and high-risk groups to detect pre-incasive disease
• In the presence of a fungating mass on the cervix, a magnified evaluation of the cervix using a colposcope is not necessary. Colposcopy will be needed in patients with abnormal smears where lesions may be too small to be identified on speculum exam.
• Colposcopy procedure


  1. Examination of cervix

  2. Application of 3% acetic acid
• Abnormal areas identified during colposcopy


  • Acetowhite epithelium
  • Punctation
  • Mosaic
• Differential diagnosis


  • Vaginal discharge: Pelvic inflammatory disease (PID), Chronic cervicitis, Vaginitis
  • Post coital vaginal bleeding: Cervical polyp, Prolapsed submucous myoma
  • Pelvic pain: Endometriosis
  • Fungating mass and parametrial masses
• Cervical Intra-epithelial Neoplasia (CIN)


  Pre-invasive phase of cervical carcinoma, subdivided into CIN I, CIN II, CIN III
• Cervical carcinoma


  Evidence of invasion of neoplastic cells beyond the basement membrane and into the cervical stroma
• Histopathologic subtypes of cervical carcinoma

  • Squamous cell carcinoma
  • Adenocarcinoma
  • Neuroendocrine
  • Sarcoma
  • Malignant melanoma
• FIGO staging of cervical cancer

  • Stage IA1
  • Stage IA2
  • Stage IB1
  • Stage IB2
  • Stage IIA
  • Stage IIB
  • Stage IIIA
  • Stage IIIB
  • Stage IVA
  • Stage IVB
• Treatment options for cervical cancer

  • Extrafascial hysterectomy for Stage IA1
  • Radical hysterectomy with lymphadenectomy for Stage IA2, IB1, IIA
  • Chemoradiation for Stage IA2, IB1, IB2 to IV
• Complications of treatment


  • Chemotherapy: Nausea and vomiting, Fatigue, loss of appetite, Hematologic disorders, Abnormal liver and kidney function tests, Hypersensitivity reaction
  • Radiation: Radiation proctitis, Radiation cystitis, Diarrhea, Burns
  • Surgery: Hemorrhage, Injury of adjacent organs, Spastic bladder, Infection, Deep vein thrombosis
• The patient is followed up every 3 months for the first two years and every 6 months until five years after achieving complete response (cure) from the initial treatment.
• Survival rates by stage

  • Stage IA1: 95.1%
  • Stage IA2: 94.9%
  • Stage IB: 80.1%
  • Stage IIA: 66.3%
  • Stage IIB: 63.5%
  • Stage IIIA: 33.3%
  • Stage IIIB: 38.7%
  • Stage IVA: 17.1%
  • Stage IVB: 9.4%
• Preventive measures


  • Pap smear
  • Avoid high risk sexual practices
  • Condom use