Cervical cancer

Cervical cancer is cancer that starts in the cervix, the lower part of the uterus  that opens at the top of the vagina. 

It is the most common form of cancer in women in developing countries (because of lack screening programs), and the second most common form of cancer in the world as a whole.

incidence

Cervical cancer accounts for 6% of all malignancies in women.

It affect women of middle age or older mainly 45-55 years, but it may be diagnosed in any reproductive-aged woman.

Causes

Human papillomavirus (HPV) infection with high-risk types has been shown to be a necessary factor in the development of cervical cancer. HPV DNA may be detected in virtually all cases of cervical cancer.

Not all of the causes of cervical cancer are known. Several other contributing factors have been implicated.

Causes for cervical cancer: human papillomavirus (HPV) infection, HIV infection. chlamydia infection. stress and stress-related disorders. dietary factors. hormonal contraception. multiple pregnancies. exposure to the hormonal drug

diethylstilbestrol (DES) . Smoking. family history of cervical cancer. There is a possible genetic risk associated

with HLA-B7.

Risk groups for cervical cancer: Young age at first coitus(20years) Multiple sexual partners. Young age at first pregnancy. High parity . Low socioeconomic state. Smoking.

Pathology

Squamous cell carcinoma from squamo-columnar junction comprise approximately (80–85%) of cervical cancers.

Adenocarcinomas from the columnar cells inside the cervical canal

Cancer may appear as a fun gating, cauliflower – like growth which may completely fill the vagina or more commonly as an ulcer on the cervix. Cancer may expand cervix into barrel shaped.

Cervical cancers can spread by: *Direct Spread may be to cervical

stroma, corpus, vagina, bladder and parametrium.

*Lymphatic spread to pelvic and then para-aortic lymph nodes

*Hematogenous spread particularly to lungs, liver, and bone.

Clinical presentations

Signs and symptoms a symptomatic:the early stages of cervical cancer may be

completely asymptomatic. Vaginal bleeding, contact bleeding or (rarely) profuse vaginal discharge . cervical mass . moderate pain Symptoms of local spread :fistula formation (leak age of urine

or feces. Symptoms of distant metastases may be present as enlarged

inguinal and supraclavicular L.N. metastases in the abdomen, lungs or else where in case of advanced disease.

Systemic manifestation of advanced malignancy as: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or feces from the vagina, and bone fractures.

symptoms

1.Abnormal vaginal bleeding: *Post-coital bleeding. *Inter-menstrual bleeding. *Menorrhagia. (Some times) *Post menopausal bleeding. *Vaginal bleeding in pregnancy. 2. offensive vaginal discharge which may be blood

stained. 3. Pain. indicates extension of the growth beyond the

limits of the cervix. 4. Leg swelling. 5. Urinary frequency. 6. Incontinence of urine and some times of faeces may

occur. 7. bowel changes 8. malaise and weight loss.

Signs In early-stage cervical cancer, physical

examination findings can be relatively normal. *As the disease progresses, the cervix may

become abnormal in appearance, with nodule, ulcer, or mass. Enlarged cervix hard and barrel shaped.

*There is free bleeding on examination and offensive watery discharge.

*Mobility of cervix varies and eventually become fixed.

* Bimanual examination findings often reveal pelvic metastasis.

*Rectal examination which is essential to determine the extent of involvement.

*Pyometra occurs occasionally, causing uterine enlargement.

*There may be enlarged inguinal or supra-clavicular lymph nodes, oedema of legs, ascitis, pleural effusion, or hepatomegally.

Differential diagnosis

1.Cervicitis. 2.Cervical ectropion. 3.Endometrial carcinoma. 4.Pelvic inflammatory disease (PID). 5.Vaginal cancer

6.Metastatic cancer to cervix (rare). 7.Tuberculosis 8.Syphilitic chancre 9.Choriocarcinoma.

Investigations

Diagnosis should be based on histology and appropriate biopsies.

After the diagnosis is established, investigation which needed are:

Complete blood cell count Renal functions test Hepatic functions test Imaging Studies: for staging Chest radiograph should be obtained to help rule

out pulmonary metastasis. CT scan of the abdomen and pelvis is performed to

look for metastasis in the liver, lymph nodes, or other organs and to help rule out hydronephrosis/ hydroureter.

Barium enema (sometimes). Intravenous urogram.

Staging

Clinical Staged Disease Physical Exam Blood Work Cystoscopy Proctoscopy IVP

Stage 0 - full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ)

Stage I - limited to the cervix IA - diagnosed only by microscopy; no visible lesions

IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread

IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less

IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm IB1 - visible lesion 4 cm or less in greatest dimension IB2 - visible lesion more than 4 cm

Stage II - invades beyond cervix IIA - without parametrial invasion, but involve upper 2/3 of

vagina IIB - with parametrial invasion

Stage III - extends to pelvic wall or lower third of the vagina IIIA - involves lower third of vagina IIIB - extends to pelvic wall and/or causes hydronephrosis or

non-functioning kidney IVA - invades mucosa of bladder or rectum and/or extends

beyond true pelvis IVB - distant metastasis

Stage 0 carcinoma-in-situ Stage I the tumor is confined to the cervix IA microinvasive disease, with the lesion not

grossly visible: no deeper than 5 mm and no wider than 7 mm

  IA1 invasion <3 mm and no wider than 7 mm IA2 invasion >3 mm but <5 mm and no wider

than 7 mm IB larger tumor than in IA or grossly visible,

confined to cervix IB1 clinical lesion no greater than 4 cm IB2 clinical lesion greater than 4 cm

Stage II extends beyond the cervix, but does not involve the pelvic side wall or lowest third of the vagina

IIA involvement of the upper 2/3 of vagina, without lateral extension into the parametrium

IIB lateral extension into parametrial tissue

Stage III involves the lowest third of the vagina or pelvic side wall, or causes hydronephrosis

IIIA involvement of the lowest third of the vagina

IIIB involvement of pelvic side wall or hydronephrosis

Stage IV extensive local infiltration or has spread to a distant site

IVAinvolvement of bladder or rectal mucosa

IVBdistant metastases

Treatment of Early Disease Conization or simple hysterectomy

(removal of the uterus) - microinvasive cancer

Radical hysterectomy - removal of the uterus with its associated connective tissues, the upper vagina, and pelvic lymph nodes. Ovarian preservation is possible.

Chemoradiation therapy

Factors that influence the mode of treatment include:

1. Stage and type of lesion. 2. Age of patient. 3. Health status. The treatment of cervical cancer

frequently requires a multidisciplinary approach.

1. Surgery should only be considered an option for early

disease (stage 1 and stage 11a). 2. Radiation The standard treatment of cervical cancer may

involve: 1. surgery or 2. radiotherapy or 3. a combination of both. Early cervical cancers (stage I and IIA) may be

treated by either procedure. Radiotherapy is the treatment of choice once the disease has spread beyond the confines of the cervix and vaginal fornices, when surgery is not effective.

Stage Ib2-IVa

1. Surgery *The standered surgical procedure of

cervical carcinoma is a Wertheim's radical abdominal hysterectomy which involves removal of the uterus, paracervical tissue, and upper vagina and pelvic lymph nodes.

Early microinvasive disease can be

treated by cone biopsy or excisional treatment alone .

Complications of radical hysterectomy:

The most frequent complication of radical hysterectomy is:

1. Urinary dysfunction 2. Hemorrhage 3. Infection. 4. Bowel obstruction. 5. Bladder and rectovaginal fistulas.

2. Radiation Can be used for all stages. Once the disease has

spread outside cervix, radiotherapy is the mainstay of treatment.

Radiotherapy of cervical cancer may often involve a combination of:

A. external radiotherapy (for whole pelvis radiation)

B. transvaginal intracavitary irradiation (to the central part of the disease)

Palliative radiation often is used individually to control bleeding, pelvic pain, or urinary or partial large bowel obstructions from pelvic disease.

Complications from radiation 1. Acute adverse effect: A. gastrointestinal effects include

diarrhea, abdominal cramping, rectal discomfort, or bleeding.

B. Cystourethritis can occur, which leads to dysuria, frequency, and nocturia.

2. Late sequelae of radiation usually appear 1-4 years after treatment. The major sequelae include rectal or vaginal stenosis, small bowel obstruction, malabsorption, and chronic cystitis.

Symptoms of Recurrence

Weight loss, fatigue and anorexia Abnormal vaginal bleeding Pelvic pain Unilateral leg swelling or pain Foul discharge Signs of distant metastases NOTE: must distinguish radiation

side effects from recurrent cancer

Management of Recurrence Chemoradiation may be curative or

palliative, especially in women who have not received prior radiation therapy.

Isolated soft tissue recurrence may occasionally be treated by resection with long-term survival.

CERVICAL CANCER DURING PREGNANCY

Prior to 24 weeks: the treatment recommended is the

same as for women who are not pregnant.

after 24 weeks: When cancer is detected at the time of

fetal viability, radical Caesarean hysterectomy can be offered or the fetus

can be delivered and therapy instituted thereafter.

The route of delivery has traditionally been Caesarean section, though this is more

related to the possibility of increased bleeding, rather than the older concept of spread of disease if the vaginal route is chosen.

Prognosis

FIVE YEAR SURVIVAL RATES FOR CERVICAL CANCER

  Stage I 80% Stage II 65% Stage III 30% Stage IV 15%

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