PAPER

CERVICAL CANCER

Created by: 1. Rusdiana Khasanah 2. Fitri Eka W 3. Rima Andriyani 4. Sayida Royatun N 5. Siwi Dyah A (R0108010) (R0108021) (R0108036) (R0108039) (R0108040)

DIV MIDWIFERY STUDY PROGRAM OF MEDICAL FACULTY OF SEBELAS MARET UNIVERSITY 2012

CHAPTER 1 PREFACE 1. Background Health care providers have observed a high incidence of cervical cancer in many developing countries in Africa, Asia, and Central and South America, and in the absence of organized early-detection programmes the mortality rates from this disease remain high. The extremely limited health-care infrastructure available in many of these countries contributes to a compelling need to build a capacity to identify cervical cancer in early, preventable stages, preferably even before - and not in the wake of - the introduction of early detection programmes in such settings. A good knowledge of the etiology, pathophysiology and natural history of servical cancer in medical student is extremely important to identify it earlier. 2. The Aim
a. To make student more understand about servical cancer b. To make student know how to assess and give treatment on servical

cancers patients.

CAHPTER 2 CERVICAL CANCER A. Etiology Most cervical abnormalities caused by HPV infection are unlikely to progress to high-grade CIN or cervical cancer (Sellor,2003). High risk HPV(usually 16 or 18) is associated with high grade dysplasia and in situ cancer. Different HPV types appear to influence this differentiation: low risk with squamous, HPV16 usually with squamous, and HPV18 with adenosquamous or adenomatous (Pernoll, 2001). B. Symptoms and Signs The process whereby cervical cancer usually occurs begins with cervical intraepithelial neoplasia (CIN). There are no signs or symptoms of noninvasive cancer of the cervix.However, periodic testing (e.g., cytologic assessment by Pap smears, colposcopy, and biopsy) and a high index of suspicion must be applied. Postcoital spotting or blood-tinged leukorrhea is often an early sign of ulcerative cervical cancer. Hence, some form of intermenstrual bleeding is the most common symptom or sign of invasive cervical malignancy. Bladder or rectal discomfort or dysfunction and fistulas are late manifestations of cancer of the cervix. Pain, often unilateral and radiating to the hip, may develop with advanced cervical cancer when the ureter becomes partially occluded or when the sacral nerves are involved by the tumor. Anemia, anorexia, and weight loss are signs of advanced malignant disease. C. Staging Numerous staging schemes have been suggested, and the International Classification of Cancer of the Cervix (Table 21-1) is commonly used.

Table 1 International Classification Of Cancer Of The Cervix Preinvasive carcinoma Stage 0 Invasive carcinoma Carcinoma strictly confined to the cervix Stage I (extension to the corpus should be disregarded). Microinvasive carcinoma (early stromal IA invasion). All other cases of stage I. (Occult cancer IB should be labeled occ.) Carcinoma extends beyond the cervix but has not extended onto the pelvic wall. The StageII carcinoma involves the vagina but not the lower third. IIA No obvious parametrial involvement. IIB Obvious parametrial involvement. Carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer free space between the tumor and the pelvic wall. StageIII The tumor involves the lower third of the vagina. All cases with hydronephrosis or nonfunctioning kidney. IIIA No extension onto the pelvic wall. Extension onto the pelvic wall and/or IIIB hydronephrosis or nonfunctioning kidney. Carcinoma extended beyond the true pelvis or clinically involving the mucosa of the StageIV bladder or rectum. Do not allow a case of bullous edema as such to be allotted to stage IV. Spread of growth to adjacent organs (i.e., IVA rectum or bladder with positive biopsy from these organs). IVB Spread of growth to distant organs Source : American Joint Committee for Cancer Staging and End-Results Carcinoma in situ, intraepithelial carcinoma

figure 1: Aschematic diagram of clinical stages of invasive cancer of the cervix D. Diagnosis 1. Biopsy Biopsy and the microscopic assessment of tissue obtained are essential for the diagnosis of cancer or its elimination. Where to biopsy is especially important. Because necrosis and inflammatory elements are present in bleeding, presumably invasive cancer of the cervix, biopsies from an ulcerative area may be useless or difficult to interpret. 2. Colposcopy A colposcope is a low-power, stereoscopic, binocular field microscope with a powerful light source used for magnified visual examination of the uterine cervix to help in the diagnosis of cervical neoplasia. The most common indication of referral for colposcopy is positive screening tests (e.g., positive cytology, positive on visual inspection with acetic acid (VIA) etc.). 3. Visual Inspection with Acetic Acid (VIA) The characteristics of acetowhite changes, if any, on the cervix following the application of dilute acetic acid are useful in colposcopic interpretation and in directing biopsies.

E. Diagnosis Differential 1. Eversion and redness around the cervical os caused by infection, irritation,

or hormonal imbalance are smooth, soft, and minimally irregular. Unlike carcinoma, eversion is not exudative and does not bleed easily.
2. Abortion of a cervical pregnancy results in a soft, nontender, deep, freely

bleeding cavity, usually within the cervical canal.

3. Treponema pallidum may be identified by darkfield examination of the thin

exudate. Serologic tests for syphilis are positive.

F. Treatment

Treatment of servical cancer is according to stage of this cancer.

a. Stage IA (Microinvasive Carcinoma, Depth of Invasion <3 mm)

Total extrafascial abdominal hysterectomy with a wide vaginal cuff is current therapy. However, several limited studies have reported beneficial outcomes with cervical conization in highly selected cases. Nevertheless, many authorities suggest that those with >3.0mm, but <5.0 mm of invasion should be treated as stage IB because of some reasons. b. Stage IB External supervoltage radiation and intracavitary and forniceal cesium or radium therapy or radical hysterectomy and pelvic lymphadenectomy probably are equally effective in the treatment of stage IB carcinoma. The latter often is favored in young, otherwise healthy, slender patients. The ovaries need not be removed unless they are abnormal or the woman is perimenopausal. c. Stages IIA and IIB With rare exceptions, stage II cervical cancer should be treated by radiation. In some centers, pretreatment laparoscopy or laparotomy for biopsy of paraaortic lymph nodes may be done in stage IIB patients. d. Stages IIIA and IIIB Radiation therapy is used for all stage III cases.

e. Stage IV Supervoltage external radiation therapy to the whole pelvis is generally utilized for almost all stage IV patients. Chemotherapy may be an appropriate adjunct in some cases or if the patient fails to respond to conventional therapy. Neurosurgery for relief of pain may be considered in selected cases. G. Prognosis The earlier the stage at which cancer is diagnosed, the better the prognosis. Preinvasive cancer is commonly diagnosed in women <30 years, but most patients with invasive carcinoma are 4050 years old at the time of diagnosis. Thus, it appears to take 510 years for carcinoma to penetrate the basement membrane and become invasive. Untreated patients usually die 35 years after invasion occurs. H. Prevention The incidence of cervical cancer should be reduced by (1) improved personal hygiene, including prevention and prompt treatment of vaginitis and cervicitis, male circumcision in infancy, precoital washing of the penis, and habitual use of condoms; (2) avoidance of intercourse at an early age and limiting the number of consorts; (3) regular periodic cytologic screening of all women, especially parous women in low socioeconomic groups and those who have had numerous sexual partners; (4) prompt evaluation (colposcopy and possible biopsy) of any abnormalities detected by screening; and (5) treatment of suspicious cervical lesions.

CHAPTER 3 Conclusion

REFERENCES Sellor, John W and R. Sankaranarayanan. 2003. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia:ABeginners Manual. France: International Agency for Research on Cancer. Pernoll, Martin L. 2001. Benson and Pernolls Handbook of Obstetrics and Gynecology 10th ed. United States of America: McGraw-Hill Companies. Cunningham, F.Gary., JohnC.Hauth, Kenneth J.Leveno, LarryGilstrap III, StevenL.Bloom and KatharineD. Wenstrom. 2005. WilliamsObstetrics,Twenty-Second Edition. UnitedStatesof America: McGraw-HillCompanies.