UNDERSTANDING CERVICAL CANCER

CERVICAL CANCER

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There are approximately 400,000 new cases of cervical cancer worldwide annually. In 2017 there were 12,820 anticipated new cases identified with approximately 4,210 deaths in the United States.

The most common symptom of cervical cancer is abnormal vaginal bleeding—specifically, postcoital and intermenstrual  bleeding, menorrhagia, and post- menopausal bleeding. Other symptoms include pelvic fullness/pain, unilateral leg swelling, bladder irritability, and tenesmus. Cervical cancer is also commonly asymptomatic, found only following an abnormal Pap smear, colposcopic exam, or cervical biopsy.

Common signs of advanced cervical cancer are a fungating cervical mass, uni- lateral leg edema, and obstructive renal failure. Cervical cancer often results from persistent infection with high-risk HPV types (most commonly 16 and 18). Risk factors associated with cervical cancer are: prior history of sexually transmitted diseases (STDs), early age of first coitus, multiple sexual partners, multiparity, non barrier methods of birth control, and smoking.

Cervical cancer primarily spreads by direct extension from the cervix to the parametria, vagina, uterine corpus, and the pelvis. Other routes of spread include lymphatic and hematogenous dissemination, as well as direct peritoneal seeding.

CERVICAL CANCER

PRE-TREATMENT WORKUP

The pre-treatment workup of cervical cancer begins with a history and physical exam. Laboratory studies to assess hematologic, renal, and liver functions should be performed. Imaging studies should also be performed to include pelvic imaging and a CXR.

Cervical cancer is a type of cancer that occurs in the cells of the cervix, the lower part of the uterus that connects to the vagina. It is primarily caused by certain strains of the human papillomavirus (HPV), a sexually transmitted infection. Here are the causes and symptoms of cervical cancer:

Causes:

  1. Human papillomavirus (HPV) infection: Persistent infection with high-risk strains of HPV, such as HPV types 16 and 18, is the most significant risk factor for cervical cancer. HPV is transmitted through sexual contact.
  1. Weakened immune system: A weakened immune system due to conditions such as HIV/AIDS or immunosuppressive medications can increase the risk of developing cervical cancer.
  1. Smoking: Cigarette smoking has been linked to an increased risk of cervical cancer, as it may affect the immune system’s ability to clear HPV infections.
  2. Long-term use of oral contraceptives: Women who have used oral contraceptives for a prolonged period may have a slightly higher risk of developing cervical cancer.
  1. Sexual activity at an early age: Engaging in sexual activity at a young age increases the risk of exposure to HPV.

Symptoms:

  1. Abnormal vaginal bleeding: Unusual bleeding between menstrual periods, after sexual intercourse, or     after menopause may be a symptom of cervical cancer.
  1. Unusual vaginal discharge: Increased vaginal discharge that may be watery, bloody, or have a foul odor can be a symptom of cervical cancer.
  1. Pelvic pain: Persistent pain in the pelvic area or pain during sexual intercourse may indicate advanced cervical cancer.
  1. Painful urination: In advanced stages, It can cause pain or discomfort during urination.
  1. Back or leg pain: If the cancer has spread beyond the cervix, it may cause persistent pain in the back, legs, or pelvis.

It’s important to note that in the early stages, It may not cause noticeable symptoms, which is why regular cervical screenings such as Pap tests and HPV tests are crucial for early detection.

If you experience any of these symptoms or have concerns about cervical cancer, it is recommended to consult a healthcare professional for evaluation and appropriate testing.

      

HISTOLOGY

There are several different histologic types of cervical cancer, the most common being squamous (85%). Other types include adenocarcinoma (15%–20%), verrucous carcinoma, adeno squamous carcinoma, clear cell carcinoma, neuroendocrine carcinomas, and undifferentiated types.
Adenocarcinoma: about 15% have no visible lesion because the lesion arises from the endocervical canal, forming a “barrel-shaped” lesion. Cells frequently stain CEA+. Variants are the more common mucinous endocervical, mucinous intestinal type, signet ring type, and colloid variants. 

Verrucous carcinoma: this is a well-differentiated squamous cell carcinoma. It is known to recur locally, but does not metastasize. Historically, these tumors should not be treated with radiation therapy (XRT) because radiation can cause anaplastic transformation; however, recent evidence does not support this. It is associated with HPV6.

Adeno squamous carcinoma: this is a mixed glandular and squamous carcinoma. It behaves similar to adenocarcinoma.

Glassy cell carcinoma: this is a poorly differentiated type of adeno squamous carcinoma.

Clear cell carcinoma: this is a poorly differentiated carcinoma. It is nodular and reddish in gross appearance. It has a hobnail cell shape microscopically. It can be associated with intrauterine DES exposure.

TREATMENT

The treatment of  may involve the use of surgery, chemotherapy, radiation therapy (XRT) or a combination of therapies. About 70% of newly diagnosed patients with invasive carcinoma of the cervix have disease limited to the uterine cervix and are, therefore, potential operative candidates. 54 to 84% of these patients will need adjuvant therapies for intermediate or high-risk factors; so thorough investigation of the full extent of disease should be performed. NCI statements support treatment with the fewest number of interventions; thus, if high-risk factors are found on conization, which predict a high probability for the need of adjuvant therapies, it may be prudent to not perform surgery.

FOLLOW-UP

Every 3 months for the first 2 years l Every 6 months for years 3 to 5

Annually thereafter

The follow-up visit should include:

° A directed physical and pelvic examination

° An annual Pap smear without HPV testing is considered adequate surveillance

° A Pap smear is not performed within the first 3 months following XRT due

to XRT-associated changes

° Consideration can be given to CT scan of the abdomen and pelvis every 6 to

12 months

° PET scanning can be considered

REFERENCES

  1. Massad LS. Assessing disease extent in women with bulky or clinically evident metastatic: yield of pretreatment studies. Gynecol Oncol. 2000;76(3):383-387.
  2. Havrilesky LJ. FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol. 2005;97(1):183-191.
  3. Amit A. The role of hybrid PET/CT in the evaluation of patients with cervical cancer. Gynecol Oncol. 2006;100(1):65-69.
  1. Roma AA, Mistretta T, Diaz De Vivar A, et al. New pattern-based personalized risk stratification system for endocervical adenocarcinoma with important clinical implications and surgical outcome. Gynecol Oncol. 2016;141:36-42.
  2. Landoni F. Class II vs. class III radical hysterectomy in stage IB–IIA a prospective randomized study. Gynecol Oncol. 2001;80(1):3-12.
author

Aman k. Kashyap

I am a hard-working and driven medical student who isn't afraid to face any challenge. I'm passionate about my work . I would describe myself as an open and honest person who doesn't believe in misleading other people and tries to be fair in everything I do.

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