Cervical cancer

Cervical cancer

Cervical cancer is an invasive process that traditionally begins at the junction of stratified squamous epithelium into a single-layer cylindrical epithelium and is represented by either stratified squamous or glandular epithelium. Cervical cancer is one of the leading causes of death from cancer, despite a 50% decrease in the incidence of this disease over the past 30 years. The incidence of cervical cancer is 15.1 per 100,000. Predominant age

• • Invasive cervical cancer is most often detected at the age of 40-50 years.
  • Before the age of 30 and after 70 years, primary cervical cancer is detected in approximately 7 and 16% of women, respectively.

Risk factors

• • Infection with human papillomavirus (HPV), HSV type 2 (HSV-2), human immunodeficiency virus (HIV)
  • Smoking
  • Exposure to diethylstilbestrol in utero
  • Early onset of sexual activity
  • Large number of sexual partners
  • Early first birth
  • Venereal diseases
  • Taking oral contraceptives. Pathomorphology
  • The most common invasive squamous cell carcinoma (80-85%)
  • The second place in frequency is occupied by invasive adenocarcinoma (15–20%)
  • Small cell carcinoma, verrucous cancer, and lymphoma are less commonly diagnosed.

Clinical picture

• • Irregular spontaneous vaginal bleeding
  • With a widespread local lesion, fetid bloody discharge and dull pain in the lower abdomen appear.
  • Vaginal bleeding after intercourse
  • Dyspareunia
  • Hematuria
  • rectal bleeding
  • Enlargement of the cervix
  • There are several stages of the disease
  • Stage 0 – cancer in situ, intraepithelial cancer
  • Stage I 
  • A – microinvasive cancer
  • B – more pronounced infiltration within the cervix
  • Stage II 
  • A – extends to the body of the uterus 4 B – extends to the parameters, but does not reach the walls of the pelvis
  • B – extends to the vagina, not reaching its lower third
  • Stage III
  • A – reaches the walls of the pelvis
  • B – the lower 30% of the vagina is involved
  • B – isolated metastases near the pelvic wall
  • Stage IV
  • A – extends beyond the pelvis with damage to the bladder
  • B – goes to the rectum
  • B – metastases to distant organs.

Laboratory research

• • General blood test (possible anemia due to chronic blood loss)
  • Serum creatinine (possible urinary tract obstruction)
  • Liver function tests (likely metastasis)
  • Papanicolaou smears.

Special Studies

• • Colposcopy includes the study of the transformation zone and the border of the squamous and columnar epithelium at a 7.5-30-fold increase after application of 3-5% acetic acid solution
  • Curettage of the cervical canal is carried out in combination with colposcopy to exclude dysplasia that is not detected during colposcopy
  • Biopsy of the cervix. The piece should be of sufficient size so that the stroma of the cervix is ​​present, which will be necessary to determine the degree of invasion
  • Cervical cone biopsy is used at the initial degree of invasion or to clarify the depth of the lesion
  • Pre-treatment evaluation for histologically confirmed invasive cervical cancer focuses on known routes of spread (direct spread, lymphatic involvement, or hematogenous spread)
  • Required Research
  • Chest X-ray
  • Intravenous pyelography
  • Irrigography
  • Cystoscopy and sigmoidoscopy under anesthesia
  • Optional studies include CT, MRI, lymphangiography, fine needle biopsy of the tumor.

Differential Diagnosis

• • severe cervicitis
  • Polyp of the cervix
  • Endometrial cancer with spread to the cervix
  • Metastatic lesions, including choriocarcinoma.

Treatment:

Management tactics depend on the patient’s age, general condition and clinical stage of cancer.

• • Primary measures are surgical treatment and radiation therapy
  • Chemotherapy can be used in addition to radiation
  • Radiation therapy is possible at all stages of cervical cancer with both radical and palliative purposes. It is used in combination with surgery for large (4 cm or more) tumors in stages IB and IIA and chemotherapy (hydroxyurea, cisplatin and fluorouracil) for advanced localized tumors in stages IIB-IVA. Surgery
  • The initial stages of the disease
  • In lesions with invasion less than 3 mm and intact lymph nodes and blood vessels
  • Cone biopsy, then hysterectomy
  • Vaginal hysterectomy
  • For cancer limited to the cervix (stage I) with invasion greater than 3 mm
  • Radical hysterectomy with para-aortic and pelvic lymphadenectomy. The procedure includes the removal of the uterus, cervix, upper third of the vagina, parametrium, recto-uterine and utero-vesical ligaments in a single block. At the same time, the lymph nodes of the para-aortic zone are removed as a single block
  • Radiation therapy may be given before surgery
  • At stage II and more, radiation therapy is carried out, more often in combination with chemotherapy.
  • Relapses
  • If the process is localized, a partial or total pelvic exenteration is performed (removal of the uterus, cervix, vagina, parametrium, bladder and rectum as a single block)
  • In the presence of distant metastases, patients traditionally receive chemotherapy. Radiation therapy can be used to palliatively treat painful metastases.

Drug therapy

• • To enhance the effect of radiation therapy
  • Fluorouracil
  • Hydroxyurea
  • Cisplatin
  • With recurrence and metastasis
  • Bleomycin
  • etoposide
  • Cisplatin or carboplatin
  • Ifosfamide
  • For the prevention and relief of nausea and vomiting – ondansetron, metoclopramide.

Observation

• • During treatment, physical examination and Pap smears
  • After treatment – periodic visits to the doctor for examination of the pelvic organs and taking a Rai smear; also studies include chest x-ray and intravenous pyelography
  • During the first year – after 3 months
  • Then within 5 years – after 6 months
  • After 5 years, the control is carried out annually
  • Suspicious signs and symptoms
  • Chronic inflammation of the cervix
  • Unexplained weight loss
  • Edema of the lower limb on one side
  • Pain in the lower abdomen or in the projection of the sciatic nerve
  • Mucosanguineous

vaginal discharge

• • Progressive ureteral obstruction
  • Enlarged supraclavicular lymph nodes
  • Persistent cough or hemoptysis.

Prevention

• • Papanicolaou smear examination
  • Regular examinations should begin with the onset of sexual activity.
  • In the presence of high-risk factors, the examination is carried out annually
  • If the risk of tumor development is low and if there are 2 consecutive negative smear results, the examination can be carried out after 2 years
  • To give up smoking
  • Prevention of sexually transmitted diseases.

Complications

• • Fistula in the urethra (less than 2% of cases with treatment)
  • hydronephrosis
  • Uremia.

Course and forecast

• • 5-year survival after surgical treatment
  • Stage 1B – 84%
  • Stage HA – 52%
  • 5-year survival after radiotherapy
  • Stage 1B – 85%
  • PA stage – 80%
  • PB stage – 67%
  • Stage II1A – 45%
  • Stage SB – 33%
  • Stage IVA – 14%
  • Locally limited relapses. 25% of patients who initially undergo surgical treatment can be spared from recurrence of the disease with the help of radiation therapy of the pelvic organs
  • metastatic recurrences. Cases of cure are extremely rare, and the therapeutic effect is individual and short-lived. Concomitant pathology
  • Cancer in situ and invasive vaginal cancer
  • Cancer in situ and invasive vulvar cancer
  • Warts. Pregnancy. Cervical cancer in pregnant women is found in 1% of all cases of cancer of this localization.
  • cancer in situ. Treatment is delayed until delivery (can be done through the natural birth canal)
  • Invasive cancer
  • I trimester – radical hysterectomy or radiation therapy after abortion
  • II trimester – the fetus is removed by hysterotomy, then radiotherapy or surgical treatment is performed
  • III trimester – treatment is postponed until the viability of the fetus is reached. Childbirth through natural ways is contraindicated.

See also Tumor, radiotherapy; Tumor, markers, Tumor, treatments, Tumor, stages, Warts, Cervical polyps, Vulvar cancer, Endometrial cancer, Cervicitis Abbreviations

• • HPV – human papillomavirus
  • HSV-2 – herpes simplex virus type 2

ICD. C53 Malignant neoplasms of the cervix Choriocarcinoma is one of the most malignant tumors, originating from the cytotrophoblast; forms irregular strands and proliferates surrounded by lakes of blood; chorionic villi are not found.