Cervical cancer

The most common cause of death from cancer in women.

Regular screening with Pap smear has markedly decreased the incidence.
The mean age is 51.4 years, with 2 peaks (early thirties & early sixties).
Types: SCC (80%), adenocarcinoma, adenosquamous
Dysplasia: lesion in which part of the epithelium is replaced by cells showing
varying degrees of atypia.
Cervical Intraepithelial Neoplasia (CIN): Intraepithelial dysplastic atypia
occurring within the met plastic epithelium of the transformation zone.

SYMPTOMS:
Not sexually active Asymptomatic until quite advanced because intercourse
causes the bleeding.
Sexual active:
o Abnormal vaginal bleeding (PCB, IMB & PMB), most common
Advanced disease:
o Persistent vaginal discharge
o Pelvic pain, leg swelling, and urinary frequency

PHYSICAL EXAM:
General exam (early normal, weight loss occurs late).
Advanced disease
o Enlarged inguinal or supraclavicular LNs, edema of the legs
o Ascites, hepatomegaly or pleural effusion.
Pelvic exam:
o In early disease may be normal (esp. endocervical lesion)
o Ulcerative, exophytic, granular, or necrotic cells.
o The cervix may be friable and bleed on palpation.
o Serous, purulent, or bloody discharge.
Rectovaginal exam: (determine the degree of cervical expansion & spread)
The Pap smear may be normal in up to 50% (false-negative rate), because the
necrotic cancer cells slough easily and we lost them

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PATTERN OF SPREAD:
1. Direct invasion into the cervical stroma, corpus, vagina, and parametrium.
2. Lymphatic permeation and metastasis into the pelvic, para-aortic.
3. Hematogenous dissemination into the lung, liver, bone.

INVESTIGATIONS:
CBC, LFT, KFT (risk of hydronephrosis).
CXR, Plevi-abdominal CT Scan.
Biopsy of the lesion.
Clinical staging Cystoscopy & proctoscopy.
PET Scan (delineate the extent of disease at the 10 site & in LNs.

STAGING
1. Stage 1 limited to cervix.
2. Stage 2 outside cervix, parametrium & upper vagina.
3. Stage 3 pelvic side wall or lower vagina.
4. Stage 4 bladder or rectal mucosa and distant mets.

TREATMENT:
The corner stone is radiotherapy.
Surgery applicable only to early stages.
External radio damages the ovaries & internal radio damage the vagina.

RECURRENT or METASTATIC Disease:

Chemotherapy (the most active drug is the cisplatin).
Pelvic exenteration (for central recurrence following irradiation).
Total exenteration (removal of uterus, tubes, ovaries, bladder & rectum).
Radiotherapy (if initially treated with surgery alone).

PROGNOSIS
Its directly related to clinical stage.
Adenocarcinoma & adensquamous carcinoma have a somewhat lower 5-year
survival rate than do SCC.

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 RADIOTHERAPY COMPLICATIONS:

ACUTE:
1. Bladder Acute cystitis (hematuria, urgency & frequency).
2. Bowel
a. Proctosigmoiditis (tenesmus , diarrhea, passage of blood & mucus.
b. Enteritis (nausea, vomiting, diarrhea & colicky abdominal pain).
3. BM depression.

CHRONIC:
1. Bowel
Proctosigmoiditis (pelvic pain, tenesmus, diarrhea & rectal bleeding).
Ulceration (rectal bleeding and tenesmus).
Rectovaginal fistula (passage of stool through the vagina).
Rectum or sigmoid stenosis (progressive large bowel obstruction).
Small bowel injury (abdominal pain, vomiting & alternating bowel habit.
2. Vagina Vaginal vault necrosis (severe pain, tenderness & profuse discharge.
3. Urologic Injuries
Hemorrhagic cystitis (may need blood transfusion & urinary diversion).
Vesicovaginal fistula (urine leakage demonstrable by cystoscopy).
Ureterovaginal fistula (urine leakage demonstrable by IVU).
Ureteric stenosis (progressive hydronephrosis).

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