Carcinoma Of The Cervix 2

CARCINOMA OF THE CERVIX INTRODUCTION • Is an invasive proliferation of the epithelium of the cervix with cytological features of malignancy • Could be microscopic or macroscopic • Forms the commonest female genital tract cancer and the second commonest female cancer worldwide • Originates from the squamocolumnar junction, which is also the origin of most preinvasive lesions of the cervix. INCIDENCE • Unknown Risk Factors • Women of lower socio economic group • Women who had first intercourse at an early age • Women who have a history of sexual promiscuity • Multiparous women • Smokers Lower incidence is seen in nulliparous, sexually inactive women e g Nuns, virgins, Predisposing / Associated Factors • Infection with Human Papilloma virus types 16, 18, and 33 • Prenatal exposure to DES No definite evidence exists linking the use of oral contraceptives with carcinoma of the cervix

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NATURAL HISTORY/ SPREAD • Most proceed from preinvasive lesions of the cervix • A few others occur de novo • Spread is predominantly by either direct invasion or lymphatic permeation. • Haematogenous dissemination occurs less frequently but may be seen with more advanced stages. • Common sites of haematogenous spread are the lungs, mediastinal and supraclavicular lymph nodes, bones and liver PATHOLOGY • Up to 95% are squamous cell carcinoma • About 5% are adenocarcinoma PRESENTATION • Asymptomatic – detection is from abnormal cell cytology • Symptomatic – abnormal vaginal bleeding (postcoital bleeding, intermenstrual bleeding) Postmenopausal bleeding Offensive blood stained vaginal discharge Others-backache, leg pain/edema, haematuria, bowel changes, malaise and weight loss. DIAGNOSIS Good history Appropriate / detailed examination . Cytological smears . Colposcopy . Punch biopsies . Conization 2

.D&C . EUA including cystoscopy, rectosigmoidoscopy

INVESTIGATIONS . FBC . Group and Cross match 2 units of blood . Serum E/U/Cr + Uric acid . LFT . Urinalysis . IVU . CXR – PA . Barium Enema . USS . Lymphangiography . CAT Scan . MRI

STAGING . Enables appropriate planning of treatment . Gives an idea of prognosis i.e survival is stage dependent . Facilitates exchange of information between treatment centres

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FIGO STAGING OF CERVICAL CANCER (1995) STAGE

DESCRIPTION

0

Preinvasive carcinoma (carcinoma-in-situ, CIN)

I

Carcinoma confined to the cervix (extension to the corpus should be disregarded)

Ia

Preclinical carcinoma of the cervix i e invasive cancer identified only microscopically measured stromal depth should not be >5 mm and not wider than 7mm

Ia1

Measured invasion not greater 3mm in depth and not wider than 7mm

Ia2

Measured depth of invasion greater 3mm in depth, but not more than 5mm, not wider than 7mm

Ib

Clinical lesions confined to the cervix or preclinical lesions greater than Ia

Ib1

Clinical lesion < 4 cm in diameter

Ib2

Clinical lesions ≥ 4cm in diameter

II

Carcinoma extend beyond the cervix & involving the vagina (but not the lower 3rd) & or infiltrating the parametrium (but not reaching the pelvic side well)

IIa

Carcinoma has involved the vagina

IIb

Carcinoma parametrium

III

carcinoma involving the lower 3rd of the vagina & / or extending to the pelvic side wall (there is no free space b/w the tumour and the pelvic side wall). All cases with a hydronephrosis or nonfunctional kidney should be included

has

infiltrated

the

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unless they are known to be due to another cause. IIIa

Carcinoma involving the lower 3rd of the vagina

IIIb

Carcinoma extending to the pelvic wall and/or hydronephosis or non functioning kidney due to ureterostenosis caused by tumour

IV

Carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum

IVa

Spread of the growth to adjacent organs

IVb

Spread to distant organs

MANAGEMENT Options are

. Surgery . Radiotherapy . Chemotherapy . Combinations of these modalities

Close collaboration between the gynaecologic oncologist and the radiation oncologist is necessary Stage 0

Management Modalities total hysterectomy

Remarks if family size is completed

Conization Cryotherapy patients desire to retain fertility Laser ablation 1A

Conization LEEP procedure Total hysterectomy Modified radical hysterectomy Intracavitary brachytherapy (5,500 to 7, 500cGy to Point A)

Legions upto 3mm in depth

Stage 1A2

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IB & IIA

Radical hysterectomy + bilateral pelvic lymphadenectomy + oophorectomy

. for young women . Ovaries preserved . Reduced risk of sexual dysfunction

Radical radiotherapy

.Surgical expertise not available . Women with large tumours (> 4cm in diameter) . Medically unfit for surgery Combined radical radiotherapy & Adjuvant Hysterectomy . Not advocated . Morbidity . No attendant gain in cure or survival rate Combined primary surgery & adjuvant radiation therapy

Chemotherapy

IIB – IVA

Radical radiotherapy

. Patient with pelvic lymph node . Large tumour volume (>4cm) . Tumour at excision margins . Risk factors that make recurrence likely

. Only in clinical trials . Intent of cure

Palliative radiotherapy

. Does not prolong survival but can control symptoms especially pain Chemotherapy (either as a neo adjuvant or radiosensitizers) Surgery (pelvic exenteration)

. Only in stage 6

IVa with Fistular already present. IVB

No standard modality. Depends on the location & extend of the Disease.

RECURRENT CANCER • Expertise of gynaecological, radiation and medical oncologists required • Appropriately equipped intensive care centre with above expertise. • Refer appropriately •

If the initial treatment was surgery, now radiotherapy with some protocols including chemotherapy can be used.

•

If the initial treatment was radiotherapy and the disease is confined to the pelvis, pelvic exenteration is done where the patient is surgically fit. However, where the patient is not surgically fit and or recurrence is beyond the pelvis, no treatment protocol.

CARCINOMA OF THE CERVIX IN PREGNANCY •

Prior to 24 weeks (viability), treat as in non pregnant women

• After the age of fetal viability, radical caesarean hysterectomy or caesarean delivery & therapy instituted thereafter. • B/4 the age of fetal viability or patient’s refusal of therapeutic abortion based on moral or religious grounds presents the greatest challenge. • Survival figures stage for stage are the same as those for nonpregnant women. FOLLOW UP 7

• For life • Every 3 months for the 1st 2 yrs • Thereafter every 6 months for the next 3yrs • Then yearly At each visit ask of general health, coping with work. Look for anaemia. Do careful abdominal, vaginal, rectal examination for evidence of metastasis / recurrence.

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