Carcinoma cervix

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    • Cancer of the cervix
      • HPV 16 is the most prevalent HPV type in squamous cell carcinoma (MCQ)
      • HPV 18 the most prevalent in adenocarcinoma. (MCQ)
      • Other associated risk factors (MCQ)
        • Immunosuppression
        • infection with HIV
        • history of other sexually transmitted diseases,
        • tobacco use, high parity
        • oral contraceptive use.
      • HPV
        • epitheliotropic.
        • How does integration of HPV into the human genome is associated with cell immortalization allowing for malignant transformation.
          • Causes upregulation of the viral oncogenes E6 and E7. (MCQ)
          • These oncoproteins interfere with cell- cycle control in the human host cell.
          • E6 and E7 have the ability to complex with the tumor suppressor genes p53 and Rb, respectively.
      • At least 90% of squamous cell carcinomas of the cervix develop from the intraepithelial layers, almost always within 1 cm of the squamocolumnar junction of the cervix either on the portio vaginalis of the cervix or slightly higher in the endocervical canal. (MCQ)
    • Clinical presentation
      • The most common symptom of cervical cancer is abnormal vaginal bleeding or discharge(MCQ)
      • Abnormal bleeding may take the form of
        • postcoital spotting
        • intermenstrual bleeding
        • heavy menstrual bleeding (menorrhagia)
      • Serosanguineous or yellowish vaginal discharge, at times foul smelling, may occur with particularly advanced and necrotic carcinomas.
      • Extension to the pelvic side wall may cause sciatic pain or back pain associated with hydronephrosis(MCQ)
      • Metastatic involvement of the iliac and para-aortic lymph nodes can extend into the lumbosacral nerve roots and also present as lumbosacral back pain.
      • Bladder or rectal invasion by advanced-stage disease may produce urinary or rectal symptoms (e.g., hematuria, hematochezia).
    • Physical findings.
      • Cervical carcinoma most commonly appears as an exophytic cervical mass that characteristically bleeds on contact.
      • In these cases, bimanual examination may reveal a firm, indurated, often barrel-shaped cervix.
    • Spread of disease
      • Direct extension
        • Paracervical and parametrial extension. (MCQ)
          • The lateral spread of cervical cancer occurs through the cardinal ligament
          • significant involvement of the medial portion of cardinal ligament may result in ureteral obstruction.
          • Tumor cells commonly spread through parametrial lymphatic vessels to expand and replace parametrial lymph nodes.
        • Vaginal extension.
          • The upper vagina is frequently involved (50% of cases) when the primary tumor has extended beyond the confines of the cervix. (MCQ)
          • Anterior extension through the vesicovaginal septum is most common, and often the dissection plane between the bladder and underlying cervical tumor is obliterated, which makes surgical therapy difficult or impossible.
          • A deep posterior cul-de-sac can represent an anatomic barrier to direct tumor spread from the cervix and vagina to the rectum posteriorly.
        • Bladder and rectal involvement.
          • Anterior and posterior spread of cervical cancer to the bladder and rectum is uncommon in the absence of lateral parametrial disease.
      • Lymphatic spread
        • most commonly involved, in descending order of incidence, are the obturator, external iliac, and hypogastric lymph node groups
    • Staging (A very important High yield topic for MD Entrance exam)
      • FIGO revised the clinical staging of cervical carcinoma (MCQ)
      • IA1      
        • Confined to the cervix, diagnosed only by microscopy with invasion of < 3 mm in depth and lateral spread < 7 mm
      • IA2      
        • Confined to the cervix, diagnosed with microscopy with invasion of > 3 mm and < 5 mm with lateral spread < 7mm
      • IB1     
        • Clinically visible lesion or greater than A2, < 4 cm in greatest dimension
      • IB2     
        • Clinically visible lesion, > 4 cm in greatest dimension
      • IIA1     
        • Involvement of the upper two-thirds of the vagina, without parametrial invasion, < 4 cm in greatest dimension
      • IIA2    
        • 4 cm in greatest dimension
      • IIB       
        • With parametrial involvement
      • IIIA
        • Tumor involves lower third of the vagina, with no extension to the pelvic wall
      • III B  
        • Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
      • Stage IV
        • The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum.
        • A bullous edema, as such, does not permit a case to be allotted to Stage IV
      • IVA
        • Spread of the growth to adjacent organs
      • IV B  
        • Spread to distant organs
    • The most notable changes were for stage IA1 (microinvasive carcinoma), which is now defined as stromal invasion no greater than 3.0 mm in depth and no wider than 7.0 mm. This new definition reflects data indicating that patients with less than 3.0 mm of invasion are at very low risk of metastatic disease and may be treated more conservatively(MCQ)
    • FIGO’s clinical staging system for cervical carcinoma is based on (MCQ)
      • clinical evaluation (inspection, palpation, colposcopy)
      • radiographic examination of the chest, kidneys, and skeleton
      • endocervical curettage and biopsies as needed.
    • Findings that should not be used for clinical staging
      • Lymphangiograms
      • Arteriograms
      • CT scan findings
      • MRI
      • laparoscopy and laparotomy findings
    • Tumor characteristics.
      • Clinical stage of disease at the time of presentation is the most important determinant of subsequent survival regardless of treatment modality
      • For all stages of disease, when both pelvic and para-aortic lymph nodes are negative, 5-year survival is 75.2%. (MCQ)
      • Survival decreases to 45.6% with positive pelvic nodes, whereas involvement of para-aortic nodes lowers 5-year survival to 15.4%.
      • Patients with bilateral pelvic lymph node involvement have a worse prognosis than those with unilateral disease
      • Lesion size is an important predictor of survival, independent of other factors.
      • Survival is also strongly correlated with depth of tumor invasion into the stroma,
    • Pathology
      • Microinvasive carcinoma (MICA).
        • MICA is a lesion not apparent clinically
        • it is diagnosed by histologic examination of a cone biopsy or hysterectomy specimen that includes the entire lesion. (MCQ)
        • Findings that preclude a diagnosis of MICA
          • Involvement of the cone margins by invasive carcinoma
          • a high-grade intraepithelial lesion
        • Histologically, MICA is characterized by the presence of irregularly shaped tongues of epithelium projecting from the base of an intraepithelial lesion into the stroma.
        • Lesions fulfilling the FIGO criteria of MICA have virtually no potential for either metastases or recurrence  Therefore, this definition appears to be the most useful for guiding clinical management.
      • Invasive squamous cell carcinoma.
        • Squamous cell carcinoma is the most common histologic type of cervical cancer
      • Grade.
        • Grade 1 tumors
          • well differentiated with mature squamous cell
          • often form keratinized pearls of epithelial cells.
          • Mitotic activity is low.
        • Grade 2 tumors
          • Moderately well-differentiated carcinomas

    have higher mitotic activity and less cellular maturation

          • accompanied by more nuclear pleomorphism
        • Grade 3 tumors
          • poorly differentiated
          • smaller cells with less cytoplasm and often bizarre nuclei.
          • Mitotic activity is high
      • Subclassification.
        • large cell keratinizing
        • large cell nonkeratinizing,
        • small cell types.
    • Treatment of invasive cervical cancer
    • Radical surgery(MCQ)
      • Radical hysterectomy with lymph node dissection.
      • Done only in patients with low-stage disease (IB–IIA).
    • Radiation therapy(MCQ)
      • High-dose delivery to the cervix and vagina, and minimal dosing to the bladder and rectum:
        • External-beam whole pelvic radiation.
        • Transvaginal intracavitary cesium: Transvaginal applicators allow significantly larger doses of radiation to surface of cervix.
    • Treatment of bulky central pelvic disease
      • Radical hysterectomy with adjuvant or neoadjuvant radiation therapy.
      • Tumor cytoreduction:
        • Use of cytotoxic chemotherapy before definitive treatment with radiation or radical surgery.
    • Follow-up of cervical carcinoma
      • Patients are examined every 3 months for the first 2 yr, then every 6 months in yr 3–5, and yearly thereafter. (MCQ)
      • An exam consists of a history, physical, and Pap.
      • A chest x-ray and CT scan of abdomen are performed annually.

    Recurrent cervical carcinoma

        • Thirty percent of patients treated for cervical cancer will have a recur- rence.
        • Recurrence of cancer can occur anywhere, but occur mainly in the pelvis (vagina, cervix, or lateral pelvic wall).
      • Screening for recurrence
        • Look for:
          • Vaginal bleeding.
          • Hematuria/dysuria.
          • Constipation/melena.
          • Pelvic and leg pain.
          • Fistulas (in bladder or bowel).
          • Sacral backache or pain in sciatic distribution.
          • Costovertebral angle and flank pain.
        • Cause of death
          • Uremia is the major cause of death in cervical cancer (found in 50% of pa- tients). (MCQ)
          • Excretory urogram can identify periureteral compression by tumor.
      • Treatment of cervical cancer by stage: (MCQ) A very impotant topic
        • 0–1: (MCQ)
          • Laser or cryotherapy (endocervix);
          • loop electrosurgical excision
          • procedure (LEEP)
          • cold knife cone biopsy (ectocervix)
          • total abdominal hysterectomy (TAH; if completed childbearing)
          • conization or cryo (if patient wants to retain uterus).
        • 1a–2a: (MCQ)
          • Radical hysterectomy or radiation
          • pelvic lymphadenectomy
          • para-aortic lymphadenectomy.
        • 2b–4b: (MCQ)
          • Chemotherapy (cisplatin) and radiation.
      • General principles of treatment:
        • Patients may undergo definitive treatment only if disease is confined to pelvis. (MCQ)
        • Patients with local recurrence after radical hysterectomy are treated with radiation. (MCQ)
        • Patients previously treated with radiotherapy are treated only by radical pelvic surgery. (MCQ)
      • Chemotherapy:
        • Response rates are higher with combination therapy.
        • Most combinations include platinum. (MCQ)
        • Response rates: 50–70% for 4–6 months of life.
      • Cervical cancer in pregnancy
        • Three percent of all invasive cervical cancers occur during pregnancy.
        • Symptoms
          • One-third of pregnant patients with cervical cancer are asymptomatic.
          • Symptoms in pregnancy include vaginal bleeding and discharge.
        • Screening
          • Cervical cytology should be performed at the initial obstetric visit (if > 21 years old). (MCQ)
            • ASCUS and LGSIL in patients > 21 years old managed as in nonpreg-nant patient, although colposcopy may be deferred until 6 weeks post- partum. (MCQ)
            • Atypical squamous cells with possible high-grade squamous intraepithelial lesion (ASC-H), high-grade squamous intraepithelial lesion (HG- SIL), and atypical glandular cells (AGCs) require colposcopy with biopsy (endocervical curettage [ECC] contraindicated). (MCQ)
            • If antepartum colposcopy is negative, repeat colposcopy at 6-week post- partum visit.
          • Therapeutic conization is contraindicated during pregnancy
          • Diagnostic conization is reserved for patients in whom an invasive lesion is sus- pected but cannot be confirmed by biopsy and the results will alter the timing or mode of delivery.
            • Otherwise, conization is performed postpartum.
          • Cone biopsy, if necessary, should be performed in the second trimester. (MCQ)
            • Complications are common including hemorrhage and pre- term labor.
          • Clinical staging unchanged, except magnetic resonance imaging (MRI) should replace CT scans.
        • Treatment
          • Definitive treatment is incompatible with pregnancy continuation.
          • Therapy should be influenced by gestational age, tumor stage, and met- astatic evaluation. If the patient chooses to continue the pregnancy, therapy can be postponed until after delivery or the pregnancy can be terminated.
          • A pregnancy can be terminated to begin treatment.
          • Radiation cannot be given during pregnancy, only chemotherapy. (MCQ)
            • In early-stage disease a diagnostic CKC (cold-knife conization) can be done if the patient has a Stage IA1 cancer.
            • If the stage is > Stage IA2, then after delivery, treatment can be instituted.
          • Second-trimester treatments can include platinum-based chemotherapies, which would allow prolongation of pregnancy for fetal maturity. (MCQ)
          • A cold knife conization during pregnancy can lead to severe complications such as hemorrhage and loss of pregnancy. (MCQ)
          • Third-trimester treatments include radical hysterectomy and pelvic lymphadenectomy after high classic cesarean delivery. (MCQ)
          • Delays in treatment have not been reported to recurrence rates in stage I disease. (MCQ)
        • Delivery
          • Consideration of possible tumor hemorrhage and size/shape influence delivery method.
          • Patients with small-volume stage IA tumors may be candidates for vaginal delivery. (MCQ)
          • Episiotomies should be avoided due to case reports of cancer implantation at such sites.
          • Patients with > Stage IA1 cancer, require a cesarean section for delivery, and then treatment. (MCQ)
      • Adenocarcinoma of cervix
        • Makes up 10–15% of cervical cancers.
        • Affects women aged 16–27; median age—19 yr.
        • Carcinomas mainly arise from the endocervix; lesions are “endophytic.”
        • Overall survival rate: 80%.(MCQ)
        • Five-year survival rate for stage I disease: > 90%.
        • Screening of DES-exposed women(MCQ)
          • Annual Pap smear.
          • Careful palpation of vaginal walls to rule out adenosis or masses.
        • Treatment
          • Similar to treatment of squamous cell carcinoma of cervix.
          • Preferred treatment is radical hysterectomy and pelvic lymph node dissection for stage IB or IIA. (MCQ)
          • Vaginectomy if vagina is involved.
        • Disease recurrence
          • Most DES-related clear cell carcinomas recur after  3 yr of initial treatment.
          • Pulmonary and supraclavicular nodal metastasis common
          • yearly screening chest x-ray recommended.


      Cervical cancer screening and management of abnormal PAP smears
      Cervical Cancer Staging
      This 3D medical animation begins with a detailed explanation of the criteria doctors use to stage cervical cancer. Staging refers to the extent of the spread of the disease. Stage 0, Stage IA, Stage IIA, Stage IIIA, Stage IVA, Stage IB, Stage IIB, Stage IIIV, Stage IVAB are each shown in detail.
      Cervical carcinoma hysterectomy
      Nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy
      MAKNA Getting to know Cervical Cancer
      Cervical Cancer was the second most common cancer among women in Peninsular Malaysia between 2003 to 2005. It constituted 10.6% of all female cancers.

      The cervix is a very strong muscle that connects a woman’s womb and her vagina. It forms a small opening which lets through menstrual blood and sperm.

      Cervical cancer usually starts in cells on the surface of the cervix. It happens when cells begin to grow and divide uncontrollably. These cells gradually spread into the tissue of the cervix. From there they may move to other parts of the body such as the vagina, womb or bowel. Cervical cancer can take years to develop. But before it develops, early changes take place in the cells on the surface of the cervix. At this point, the abnormal cells can easily be detected using Pap Smear Test.

      Early cervical cancer often has no symptoms. But, visit your doctor if you notice the following signs:
      – Bleeding between periods
      – Bleeding during or after sex
      – Bleeding after you have been through menopause
      – Any unpleasant vaginal discharge
      – Discomfort or pain during sex

      These symptoms do not necessarily mean you have cervical cancer. However, it is advisable to check with a doctor.

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      MAKNA (Majlis Kanser Nasional) or National Cancer Council is a not-for-profit mainly tasked to pool and utilise every effort, expertise and welfare from every faction of society to fight cancer and to reduce the pain, suffering and morbidity that cancer patients often experience.

      It aims to provide curative care and preventive care, cancer research and support services to cancer patients and their families, high-risk groups and the general public in Malaysia and the region.

      Together with ordinary Malaysians from all walks of life, MAKNA hopes to inspire extraordinary change and give people affected by cancer renewed hope in life.
      Cervical Cancer Progression and Staging
      aparoscopic radical hysterectomy for carcinoma cervix
      laparoscopic radical hysterectomy for carcinoma cervix
      Cancer Cure – Cervical Cancer Symptoms
      he symptoms of cervical cancer aren’t always obvious and it may not cause any symptoms at all until it has reached an advanced stage.
      This is why it’s very important for you to attend your cervical screening appointments.
      Unusual bleeding

      cervical cancer symptoms

      In most cases, vaginal bleeding is the first noticeable symptom of cervical cancer. It usually occurs after having sex.
      Bleeding at any other time, other than your expected monthly period, is also considered unusual.
      This includes bleeding after the menopause (when a woman’s monthly periods stop).
      If you have any type of unusual vaginal bleeding, visit your GP for advice.
      Other symptoms

      cervical cancer symptoms

      Other symptoms of cervical cancer may include:
      pain and discomfort during sex
      an unpleasant smelling vaginal discharge
      Advanced cervical cancer

      cervical cancer symptoms

      If the cancer spreads out of your cervix and into surrounding tissue and organs, it can trigger a range of other symptoms, including:
      constipation
      blood in your urine (haematuria)
      loss of bladder control (urinary incontinence)
      bone pain
      swelling of one of your legs
      severe pain in your side or back caused by swelling in your kidneys related to a condition called hydronephrosis
      changes to your bowel and bladder habits
      loss of appetite
      weight loss
      tiredness and lack of energy

      Cáncer de cervical o de cancer de cervix. ¿Como se produce el cancer Cuello Uterino? – Adn UBPH
      El cérvix es parte del sistema reproductivo de la mujer. Está en la pelvis. El cuello uterino es la parte estrecha del útero (matriz) inferior.
      Treatments for Cervical Cancer
      This 3D medical animation reviews the treatment options for cervical cancer such as surgery, radiation therapy, and chemotherapy.