During this period of instruction, we're going to talk about carcinoma of the cervix and four particular features of it, namely diagnosis, staging treatment and several unusual presentations for primary and metastatic cervical carcinoma. Cervical carcinoma refers to invasive carcinoma drive from the squamous epithelium of the exhaust cervix or from Columbia, epithelium of the endo cervix, which has undergone meta play asia in these two areas of the cervix benign processes also occur, namely the dysplasia, mild, moderate and severe or carcinoma. Insitu, the importance of cervical dysplasia and carcinoma insitu is to recognize them as non invasive processes and to differentiate them from invasive cancer. The remainder of this presentation will concern itself only with invasive carcinoma of the cervix. Cervical carcinoma is the second most frequent cancer in women. Surpassed in incidents only by breast carcinoma. The age of first chorus and the number of different sexual partners are two factors which correlates most closely with the incidence of the disease. An exact ideological role has not been established. However, the herpes virus remains a suspect. The most common symptom of cervical carcinoma is vaginal bleeding which occurs in 80-90% of patients and may present as inter menstrual spotting, post coital spotting, post spotting or Maharaja. A foul vaginal discharge is also a common symptom, pelvic pain, weight loss and anorexia are signs and symptoms of very advanced disease. There are several clinical types. First, I would mention micro invasive carcinoma. Micro invasive carcinoma refers to invasive cancer cells that penetrate beneath the basement membrane of the epithelial surface. If penetration is greater than 5 mm we then term this type of disease, invasive cancer of the invasive cancers. There is an exotic type, probable cauliflower like masses which may fill the upper part of the vagina. May arise from only a small portion of the cervix and prophetic type lesion will bleed very readily. It will be easy to obtain a Papanikolaou smear showing abnormal cells cells from this type of invasive cancer. In addition, this type of cancer will undergo very rapid regression with radiotherapy. When the cancer cells infiltrate this troma of the cervix, the regression with radiotherapy is less the opportunity to obtain cells from cytology or exfoliated cells that have come off and see them on a pap smear is decreased and the lesion may not bleed but maybe only palpitation or e as a non regularity noted within the cervix a later stage. When or later. Another type actually, when cancer cells infiltrate cause necrosis, actual, all sorts of craters exist. If the tumor arises from the exhaust cervix. These three types frequently are noted if it arises from the endo cervix, the barrel shaped lesion, the expansion of the endo cervical canal is a very common clinical presentation Concerning squamous and adenocarcinoma. As approximately 85-90% of invasive carcinoma of the Cervix is squamous carcinoma. The remainder being adenocarcinoma, we find at M D Anderson that there is no difference in the survival. The treatment is the same for the two types of two cell types of cancer. This is a photo michael, a picture taken through uh the vagina of an ex offender lesion arising from the anterior lip of the cervix. If one saw this patient, one could easily obtain cells by scraping the lesion with a spatula and applying them to a glass slide read by the psychologist. The paper, Nicholas smear would likely be abnormal. A biopsy could easily be taken. This lesion would lend itself to Corpus Ka pik examination. However, the culpa scope is usually used when no visible gross lesion is noted. If a gross visible lesion such as this is noted, it most certainly should be biopsied. In addition to the Papanikolaou smear the endo cervical canal just inferior to this exotic mass lends itself to evaluation of the endometrial cavity and of the endo cervix office biopsy. I mentioned legal solution is applied to the cervix, the apex of the vaginal vault. If the patient has had uh the cervix is obliterated or if it's removed, it can be applied to the entire vagina and areas that fail to take up the iodine stain, our suspect and should be biopsied. The endo cervix, as I mentioned should be corrected in office. Diagnosis of carcinoma of the cervix. Special cure ETS are made for obtaining tissue directly from the endo cervical canal. The endometrium should also be evaluated. A patient has abnormal bleeding. The diagnosis of cervical carcinoma is present if there's no disease in the endometrium, patient can have endometrial adenocarcinoma was spread to the cervix and present with a cervical gross lesion. The endometrium needs to be evaluated. There are some common ares we see in failing to do all the appropriate diagnostic tests. First common area that we can bring attention to is the reliance on the pap smear and failing to biopsy. A visible lesion. Second air we'd like to refer to is performing a colonization on a patient. When a simple biopsy as an office procedure would make the diagnosis. This involves unnecessary hospitalizations and the colonization distorts anatomy which may make radiotherapy and the administration of inter cavatelli radiotherapy a little bit more difficult. The third air we point to is failing to do a fractional curettage including cervical biopsies prior to hysterectomy. In a symptomatic patient, a patient who has uh bleeding foul discharge needs to have a thorough office evaluation. Prior to contemplated surgery, we can talk about several perspectives of cervical carcinoma. One, there's an orderly spread pattern to pelvic nodes first and then as the disease advances to aortic nodes, important in treatment is knowing to spread. Important in treatment is evaluating tumor volume. Certainly the greater the volume of tumor, the more intensive the therapy will need to be for extensive spread beyond that, which can be encountered in uh conventional therapy. Radical surgery needs to be involved, sometimes radical radiation and sometimes adjunctive chemotherapy. I'd like to talk this slide merely shows the lymph nodes that we were talking about. The pelvic and periodic cervical lesion from this area will spread first to principal nodes. External iliac nodes, common iliac nodes, pre cable or para aortic nodes. This brings us to the discussion of staging for practical purposes. Lesions confined to the cervix considered stage one if lesions involved the upper one third of the vagina or involved the param a tree um will be considered stage to disease Reasons involving are spreading from the Cervix to the lower part of the Vagina or spreading from the Cervix to the Pelvic Wall are stage three lesions that involve the mucosa of the bladder or the mucosa of the rectum or spread beyond the harmony will ring or involved lymph nodes in the groin or Super curricular areas or other areas distant are staged. four certain treatment principles. Carcinoma confined to the cervix. Clinical stage. one may be treated by radical hysterectomy and pelvic lymphatic ectomy. This in essence removes all cancer and the spread the nodal spread pattern areas. If cancer from the cervix spread to the pelvic nodes, we remove the pelvic nodes and the uterus and the tissues, all the tissues in in between early stage. One regions may also be treated with radiation therapy. The results between radical hysterectomy, pelvic lymph ectomy and radiation therapy are very similar. More extensive cancers can best be treated by radiation, bulky, central cancers at M D Anderson are treated with radiation and adjunctive surgery. Earlier we mentioned tumor volume and the important role that it plays if the volume of tumor is greater than that, which could be easily treated with or effectively treated with radiation therapy. After the spread pattern, areas are treated, the bulk of the tumor is removed. Here we are talking about those endo cervical lesions. The ones that expand the endo cervix not really uh sometimes being visible but uh creating uh advanced disease situations. The standard radiation therapy field Or a pelvic portal is a 15 x 15 cm square. This slide shows two things. The lesion here in the cervix appears to be x if it may involve a little bit of the parametric um shows it's spread pattern to the principal nodes common and pre cable lymph nodes shows that the spread has been two has advanced. Beyond this standard pelvic radiation therapy treatment field, how would we know this? We would know that this has spread to this extent by first performing a lymph angiogram which allows us to visualize these notes if they are abnormal. We know that the standard treatment would be inadequate in some patients. We also explore the abdomen and explore the periodic nodal areas, finding positive nodes. We know that the treatment has advanced beyond the standard radiation field for those patients in whom the cancer has not spread this far or is or have an earlier lesion. The standard field provides very adequate therapy and Anderson, we combine external radiation through a standard portal as just was described with inter Cavatelli radium where a tandem is inserted into the uterus to the height of the uterine cavity. Oh voids are positioned adjacent to the cervix. They give a radiation field with maximum intensity forming a pear shaped ice a dose curve. This configuration of ovoid and tandems effectively treats the area of central disease. They round circle here happens to be die in a fully catheter in the bladder. The combination of external or radiation therapy and inter Cavatelli radiation therapy. We feel it's very important. This slide is meant only to show that we take into consideration radiation delivered by whole pelvis by radium and in some instances by radiation fields that shield the midline and combined the different modalities of delivering radiotherapy for the stage of disease at Anderson. Cervical cancer is treated with a tailored approach. Patients aren't treated by a quote cookbook, but each patient, the volume and the extended disease is individualized and treatment tailored to the patient's needs. I'd like to show several unusual presentations of carcinoma of the cervix. Here, it has metastasized to a fingertip. This is not very common, but it Is a very difficult and painful situation for the patient. We have recently had a patient who had metastasis to all 10 fingers and all 10 toes and a certain amount of necrosis occurred and bleeding, radiation therapy was delivered to the involved fingers and the patient has symptomatic relief. Another unusual presentation was metastatic squamous carcinoma to the skin. This erythematosus irregular rash on multiple biopsies revealed squamous carcinoma in the skin. This is a very unusual finding. A patient had a radiation injury and required an illegal conduit or a urinary diversion. And at the side of the storm, a for the audio conduit had a friable mass developed which on biopsy showed invasive carcinoma metastatic from the cervix. In summary, then we've discussed carcinoma of the cervix. The diagnostic measures used to describe the lesion to identify it. We've discussed the staging and basically the treatment, surgery for the early lesions or radiation and radiation therapy, external and inter category for the more extended lesions. Thank you very much.