Cervical Cancer (CC)

Notes
  • It is normally a squamous cell carcinoma (and less frequently adenocarcinoma).
  • It is mainly caused by human papillomavirus (HPV) infection (in 99.7% of allcases) of which 70% are type 16 and 18.
  • CC is globally the 3rd most common gynaecogic cancer after endometrial and ovary cancers.
  • Most (86%) of the CC cases globally are found in the developing countries.
  • CC starts as cervical intraepithelial neoplasia (CIN) or cervical dysplasia of squamous cells on the surface of the cervix.
  • The risk factors that predispose women to cervical cancer are;

♦Multiple sex partners over one’s  life time.

♦Early age of engagement in sexual activities

♦Sex with men whose partners or previous partners has/had cervical cancer

♦Cigarette smoking

♦Immunodeficiency such as HIV

  • Statistics: proportion of womenwith cervical cancer who have not had a Pap smear for the last 10 years or more - 50%; time taken for cervical cancer to appear after HPV infection:10-20 yrs; burden of CC in Kenya - it constitutes 8-20% of all cancer cases and 70-80% of all genital tract cancers; incidence of CC in Kenya -2454; mortality rate of CC in Kenya -1676 / yr; peak age for CC - 35 to 45 yrs
  1. Staging of cervical cancer

STAGE

STAGE GROUPING

COMMENTS

Ia /FIGO 1A

T1a

N0

M0

♦T1a - CC is found only in the cervix and can be recognized by imaging tests or can be seen or felt.

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 95 -98%

Ia1/

FIGO 1A1

T1a1

N0

M0

♦T1a1-CC  ≤ 3mm in depth and ≤ 7 mm in length.

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

Ia2/

FIGO 1A2

T1a2

N0

M0

♦T1a2 - CC  3 to 5 mm in depth and ≤ 7 mm in length

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

Ib / FIGO 1B

T1b

N0

M0

♦T1b - CC  larger than T1a2 (3 to 5 mm in depth and ≤ 7 mm in length)

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 75 -85%

Ib1 / FIGO 1B1

T1b1

N0

M0

♦ T1b1 -≤ 4cm

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

Ib2 / FIGO 1B2

T1b2

N0

M0

♦ T1b2 - ≥4cm

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

IIa / FIGO 1IA

T2a

N0

M0

♦ T2a -CC has grown beyond the uterus but not to the pelvic wall or to the lower third of the vagina

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 65 -75%

IIa1 / FIGO 1IA1

T2a1

N0

M0

♦ T2a1 -CC has grown beyond the uterus but not to the pelvic wall or to the lower third of the vagina but CC is ≤ 4cm

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 65 -75%

IIa2 / FIGO 1IA2

T2a1

N0

M0

♦ T2a2 -CC has grown beyond the uterus but not to the pelvic wall or to the lower third of the vagina but CC is ≥4cm

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 65 -75%

IIb / FIGO 1IB

T2b

N0

M0

♦T2b -CC has spread to the tissue surrounding the uterus area (parametrial area)

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 65 -75%

III / FIGO 1II

T3

N0

M0

♦T3 – CC extends to the pelvic wall, and/or involves the lower third of the vagina, and/or causes swelling of the kidney  or a nonfunctioning kidney.

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 30%

IIIa / FIGO 1IIA

T3a

N0

M0

♦T3a -CC involves the lower third of the vagina, but it has not grown into the pelvic wall

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 30%

IIIb / FIGO 1IIb

T3b

N0

M0

♦T3b -CC has grown into the pelvic wall and/or causes hydronephrosis or nonfunctioning kidneys.

♦N0 -CC has not spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 30%

IIIb / FIGO 1IIB

T1 or

T2 or T3a

N1

M0

 

OR

 

T3b

any N (N0 or N1)

M0

♦CC has spread to the mucosa (lining) of the bladder or rectum and grown beyond the pelvis (regardless of whether there is cancer in the lymph nodes)

♦N0 -CC has not spread to the lymph node

♦N1 -CC has spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 30%

IVa / FIGO 1VA

T4

any N (N0 or N1)

M0

♦N0 -CC has spread to the mucosa (lining) of the bladder or rectum and grown beyond the pelvis

♦N0 -CC has not spread to the lymph node

♦N1 -CC has spread to the lymph node

♦M0 - CC has not metastasized

♦Survival rate: 5-10%

IVb / FIGO 1VB

any T, any N, M1

♦M1 - CC has metastasized

♦Survival rate: 5-10%

Symptoms
  • Mainly asymptomatic.
  • Irregular vaginal bleeding
  • Post-coital vaginal bleeding
  • Post-menopausal bleeding
  • Lower abdominal pain
  • Backache
  • Urinary frequency and urgency
  • At very late stage the following symptoms are common;

♦Weight loss

♦Urinary or fecal incontinence

♦Edema of lower libs

♦Dyspnoea

♦Oliguria

Diagnosis
  • Papanicolaou (PAP) smear – there is a decrease in the number and location of mature cells (dysplasia).
  • Colposcopically-directed biopsy and hist
  • Visual inspection with acetic acid (VIA) or Visual inspection with Lugol’s Iodine (VILI)
  • For suspected metastasis;

♦ MRI

♦ CT scan

♦ Chest X-Ray

♦ Bone X-Ray

Differential
  • Cervicitis
  • Endometrial Carcinoma
  • Pelvic Inflammatory Disease
  • Vaginitis
Prevention
  • Routine cervical Pap smear;

_After every 2 yrs for those 21 - 30 yrs  and every then 5 yrs up to age 65

_For HIV positive cases, screening should done at diagnosis, 6 monthly in the first year, then annually thereafter).

  • Human Papillomavirus Vaccine (HPV) _Dosage: 3 doses of 0.5-mL each, IM: 0, 1, and 6 months ( deltoid region of the upper arm) at age 9 -13 yrs (although women of the age of up to 26 yrs can benefit from this vaccination)

­_ It is also administered in males as it causes cancers of anus, mouth/throat (oropharynx), and penis.

  • Promotion of ABC - Sexual Abstinence (especially at adolescent), Being faithful to the spause and Condom use.
  • Screening during pregnancy until 20 wks gestation is advised. In case HPV or CC is detected, patients are treated at 6-12 wks post partum.
Management
  • Treatment of Precancerous Cervical Lesions;

_Freezing precancerous tissues with a probe (cooled by liquid nitrous oxide or carbon dioxide). This treatment  is not appropriate for large lesions (larger than the cryoprobe tip) or lesions that extend into the cervical canal.

  • Hysterectomy and pelvic lymphadenectomy if;

♦There are other gynecologic pathology or poor followup

♦Electrosurgical excision procedure / large loop excision of the transformation zone (LEEP/LLETZ) cone biopsy margins are clear and there is no vascular or lymphatic invasion

♦There is likelihood of adenocarcinoma

♦The lesions are  ≤4cm

  • External beam irradiation (when surgery is not suitable)
  • Intracavitary brachytherapy (when surgery is not suitable)
  • Radiation therapy with chemotherapy (for locally advanced disease).
  • Chemotherapy (mainly used alone in case the cancer has widely metastasized)

♦ The commonly used drugs include the following: 5FU, cisplatin, paclitaxel, navelbine, topotecan, carboplatin, docetaxel, gemcitabine, ifosfamide, hydroxyurea, mitomycin C.

♦ In developing countries the recommended regime is 5FU without or with cisplatin.

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