Cervical cancer all u need for pmdc part 3

Cervical cancer is usually a squamous cell carcinoma caused by human papillomavirus infection; less often, it is an adenocarcinoma. Cervical neoplasia is asymptomatic; the first symptom of early cervical cancer is usually irregular, often postcoital vaginal bleeding. Diagnosis is by a screening cervical Papanicolaou test and biopsy. Staging is clinical. Treatment usually involves surgical resection for early-stage disease or radiation therapy plus chemotherapy for locally advanced disease. If the cancer has widely metastasized, chemotherapy is often used alone.

Cervical cancer is the 3rd most common gynecologic cancer and the 8th most common cancer among women in the US. Mean age at diagnosis is about 50, but the cancer can occur as early as age 20. It caused an estimated 12,300 new cases and 4000 deaths in 2013.

Cervical cancer results from cervical intraepithelial neoplasia (CIN), which appears to be caused by infection with human papillomavirus (HPV) type 16, 18, 31, 33, 35, or 39. Risk factors for cervical cancer include

Younger age at first intercourse
A high lifetime number of sex partners
Intercourse with men whose previous partners had cervical cancer
Other factors such as cigarette smoking and immunodeficiency also appear to contribute.

Pathology
CIN is graded as 1 (mild cervical dysplasia), 2 (moderate dysplasia), or 3 (severe dysplasia and carcinoma in situ). CIN 3 is unlikely to regress spontaneously; if untreated, it may, over months or years, penetrate the basement membrane, becoming invasive carcinoma.

About 80 to 85% of all cervical cancers are squamous cell carcinoma; most of the rest are adenocarcinomas. Sarcomas and small cell neuroendocrine tumors are rare.

Invasive cervical cancer usually spreads by direct extension into surrounding tissues or via the lymphatics to the pelvic and para-aortic lymph nodes. Hematogenous spread is possible but rare.
Symptoms and Signs
CIN is usually asymptomatic. Early cervical cancer can be asymptomatic. The first symptom is usually irregular vaginal bleeding, which is most often postcoital but may occur spontaneously between menses. Larger cancers are more likely to bleed spontaneously and may cause a foul-smelling vaginal discharge or pelvic pain. More widespread cancer may cause obstructive uropathy, back pain, and leg swelling due to venous or lymphatic obstruction; pelvic examination may detect an exophytic necrotic tumor in the cervix.

Diagnosis
Papanicolaou (Pap) test
Biopsy
Clinical staging, usually by biopsy, pelvic examination, and chest x-ray
Cervical cancer may be diagnosed during a routine gynecologic examination. It is considered in women with

Visible cervical lesions
Abnormal routine Pap test results
Abnormal vaginal bleeding
CIN is usually evident on Pap tests, but about 50% of patients with cervical cancer have not had a Pap test for ≥ 10 yr. Patients at highest risk are the least likely to obtain regular preventive health care and to be tested regularly.

Reporting of cervical cytology results is standardized (Table 1: Bethesda Classification of Cervical Cytology*). Further evaluation is indicated if atypical or cancerous cells are found, particularly in women at risk. If cytology does not show any obvious cancer, colposcopy (examination of the vagina and cervix with a magnifying lens) can be used to identify areas that require biopsy. Colposcopy-directed biopsy with endocervical curettage is usually diagnostic. If not, cone biopsy (conization) is required; a cone of tissue is removed using a loop electrical excision procedure (LEEP), laser, or cold knife.
Prognosis
In squamous cell carcinoma, distant metastases usually occur only when the cancer is advanced or recurrent. The 5-yr survival rates are as follows:

Stage I: 80 to 90%
Stage II: 60 to 75%
Stage III: 30 to 40%
Stage IV: 0 to 15%
Nearly 80% of recurrences manifest within 2 yr. Adverse prognostic factors include lymph node involvement, large tumor size and volume, deep cervical stromal invasion, parametrial invasion, vascular space invasion, and nonsquamous histology.

Treatment
Excision or curative radiation therapy if there is no spread to parametria or beyond
Radiation therapy and chemotherapy if there is spread to parametria or beyond
Chemotherapy for metastatic and recurrent cancer
Treatment may include surgery, radiation therapy, and chemotherapy. If hysterectomy is indicated but patients cannot tolerate it, radiation therapy plus chemotherapy is used.

CIN and squamous cell carcinoma stage IA1: Cone biopsy with LEEP, laser, or cold knife is usually sufficient treatment. Hysterectomy is done for stage IA1 cancer if there are adverse prognostic factors (nonsquamous histology or lymphatic or vascular invasion). Radical hysterectomy is recommended by some experts, particularly if the lymphatic or vascular space is invaded; it includes bilateral pelvic lymphadenectomy and removal of all adjacent ligaments (eg, cardinal, uterosacral) and parametria and the upper 2 cm of the vagina. Hysterectomy can also be done if women no longer desire fertility. If there are no adverse prognostic factors, simple (extrafascial) hysterectomy is usually sufficient because risk of recurrence and lymph node metastasis is < 1%. Pelvic lymph node dissection is not indicated.

Stages IA2 to IIA: Treatment options include a radical hysterectomy and pelvic lymphadenectomy alone (stages IA2 to IB1) or a radical hysterectomy and pelvic lymphadenectomy with possible combined chemotherapy and pelvic radiation (stages IB2 to IIA). Chemotherapy is usually given concurrently with radiation therapy. With either treatment, the 5-yr cure rate in stage IB or IIA is 85 to 90%. Surgery provides additional staging data and preserves the ovaries. If extracervical spread is noted during surgery, postoperative radiation therapy may prevent local recurrence.

In some patients who have early-stage cervical cancer and who wish to preserve fertility, a radical trachelectomy may be done. An abdominal or a vaginal, laparoscopic, or robotic-assisted approach can be used. In this procedure, the cervix, parametria immediately adjacent to the cervix, upper 2 cm of the vagina, and pelvic lymph nodes are removed. The remaining uterus is reattached to the upper vagina, preserving the potential for fertility. Ideal candidates for this procedure are patients with the following:

Histologic subtypes such as squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma
Stage IA1/grade 2 or 3 with vascular space invasion
Stage IA2
Stage IB1 with lesions < 2 cm in size
Invasion of the upper cervix and lower uterine segment should be excluded by MRI. Rates of recurrence and death are similar to those after radical hysterectomy. If patients who have this procedure plan to have children, delivery must be cesarean. Fertility rates after a radical trachelectomy range from 50 to 70%.

Prevention
Pap tests: Routine cervical Pap tests are recommended every 2 yr for women aged 21 to 30. The Pap test and HPV test should be done simultaneously beginning at age 30. If results of both are negative, the screening interval should be extended to every 3 to 5 yr. Testing continues until age 65. If women have had a hysterectomy for a disorder other than cancer and have not had abnormal Pap test results, screening is not indicated. (See also cervical cancer screening guidelines.)

HPV testing is the preferred method of follow-up evaluation for all women with ASCUS (atypical squamous cells of undetermined significance), an inconclusive finding detected by Pap tests. If HPV testing shows that the woman does not have HPV, screening should continue at the routinely scheduled intervals. If HPV is present, colposcopy should be done.

HPV vaccine: Preventive vaccines (see Human Papillomavirus) that target HPV subtypes 16, 18, and sometimes 6 and 11 are available. These subtypes are the ones most commonly associated with cervical intraepithelial lesions, genital warts, and cervical cancer. The vaccines aim to prevent cervical cancer but do not treat it. Three doses are given over 6 mo. The vaccine is recommended for boys and girls, ideally before they become sexually active. The standard recommendation is to vaccinate boys and girls beginning at age 9.