Dr. Maryam B. MAHMMUD

Incidence:  Cervical cancer is the most common form of cancer in women in developing countries.  Second most common form of carcinoma in the world as a whole.  Three-quarters of affected women live in developing countries  Its estimated that up to new cases of invasive cancer of the cervix occur per year in these countries

 However, the incidence of cervical cancer has fallen in the UK since 1988 that is after introduction of an effective call-recall system for cervical screening and lead to 5% reduction in mortality associated with this form of cancer.

 Although cervical cancer is characterize by rapid, uncontrolled growth of severely abnormal cell on cervix, fortunately, when detected at an early stage, cervical cancer is highly curable.

 Columnar epithelium is constantly changed into squamous cells in an area of the cervix called transformation zone.  As a result of this natural process of change, some cervical cells can become abnormal. Infection can also cause abnormal cellular change.  When abnormal cellular change persist over times and become irreversible, these cells may lead to development of cervical cancer.

 Epidemiological studies demonstrates that the major risk factor, indeed a necessary event for the development of pre-invasive and invasive carcinoma of the cervix, is Human papillomavirus (HPV) infection specially type 16 and 18.

 High parity.  Increasing number of sexual partner.  Young age at first intercourse.  Low socioeconomic status.  Positive smoking history.

 Squamous cell and adenosquamous carcinoma comprise approximately 85% and adenocarcinoma approximately 15% of cervical cancer.  Adenocarcinoma can be pure or mixed with squamous cell carcinoma; adenosquamous carcinoma or mixed carcinoma.

 The tumors are locally infiltrative in the pelvic area,  via lymphatic  in late stages via blood vessels.

 The clinical presentation is variable.  Many patients are a symptomatic and have been diagnosed as an incidental finding after a loop biopsy of the cervix or during routine testing.

 Post ciotal bleeding.  Intermenstrual bleeding.  Post-menopausal bleeding.  Offensive vaginal discharge.

 Late stage disease may presents with backache, leg pain/edema, hematuria, bowel changes, malaise and weight loss  On speculum examination: the cervix may looks normal or there may be an abnormal ulcer, mass or friable growth easily bleed on touch.

 A full history and clinical examination is undertaken. If diagnosis is suspected on bases of clinical finding and abnormal Pap smear then colposcopy should be performed.

Suspicious feature at colposcopy include  intense acetowhiteness,  atypical vessels,  raised/ulcerated surface,  contact bleeding,  and atypical consistency on bimanual examination.

 Diagnosis is based on histology and appropriate biopsies should be taken.  This biopsy should be either wedge or cone shaped to obtain sufficient material for histological assessment.

 once cancer has been diagnosed, it is important to stage the disease so that treatment can be planned appropriately, as staging will give an idea about type of treatment and prognosis.  Staging should include an assessment of disease extent and site of spread.

 Examination under anesthesia which should include a combined recto-vaginal assessment.  Biopsy of suspicious area, this should be suitably large to make definitive diagnosis.

 Cystoscopy.  Sigmoidoscopy.  Chest X-ray and IVU.  Other imaging as indicated and according to facilities available. These might include computerized tomography CT and MRI

 Stage I carcinoma confined to cervix Ia microscopic lesion confined to cervix Ib visible cancer by naked eye but confined to cervix

 Stage 2 carcinoma extends beyond the cervix but not extend to lower third of vagina or pelvic side wall 2a involving upper third of vagina 2b involving the parametrium.

 Stage 3 carcinoma involving the lower third of vagina and/or extending to the pelvic side wall 3a involving lower third of the vagina 3b extend to pelvic side wall or cause non-functioning kidney. (hydronephrosis)

 Stage 4 distance metastasis 4a carcinoma involve mucosa of bladder or rectum 4b more distance metastasis.

Treatment is given depending on the  stage of the disease  the age  fitness of the patient.  Ideally all cancer patients should be discussed within the context of a multidisciplinary team of doctors (surgeons, radiotherapists, radiologists, and pathologist) and nurses, so that the most appropriate treatment can be offered.

 The fitness of the patient is crucial before embarking on treatment as radical surgery may not be appropriate in an unfit patient.

 Pre-clinical lesions: stage Ia  Small lesions need to have clear margin of excision, but also the pre-invasive disease (CIN) must also be completely excised. This treatment enables fertility to be preserved and hysterectomy to be avoided.

 Clinical invasive cervical carcinoma: stage Ib-2a  Here the tumor volumes are much greater in patients with stage Ia disease and the fertility-preserving treatment for this group of patient is usually not an option.

 When the disease is stage Ib, then radical hysterectomy and pelvic node dissection (Wertheim’s hysterectomy) should be considered in pre-menopausal patients.

 This operation involves the removal of the whole uterus and cervix, upper third of vagina, and paramaterial tissue.  Pelvic lymph node removal includes the obturator, internal and external iliac nodes. The ovaries in premenopausal women can be spared

 Advantage of operation:  Cure rate is high.  Ovarian tissue can be preserved.  Avoid complication of radiotherapy.  Disadvantage:  Bladder atony.  Lymphoedama.

 Higher stage disease 2a and above:  Usually is treated with radiation and chemotherapy, but sometimes surgery is employed if cervical cancer comes back after it has already been treated.

 Radiation therapy is another option besides surgery for early stage cervical cancer; and in more advanced cervical cancer.  Surgery and radiotherapy have been shown to be equivalent treatments for early stages cervical cancers, and radiation can be used instead of surgery when patient are unfit for surgery.

 Advantage:  It can treat all the disease in the radiation field including the involved lymph nodes  Radiotherapy is divided into 2 types either its external source (external beam radiation) or an internal source (Brachytherapy).

 The external radiation is requiring several treatment fractions as an outpatient over 4 weeks. Although this treatment is given daily, the time of each fraction is no more than 10 minutes.

 Brachytherapy is a radiotherapy technique where the radiation is delivered internally to the patient.  The rode is inserted into the uterus under, and then attached to the radiotherapy source and the patient receive radiotherapy in isolation to protect the staff

 Complications:  Lethargy.  Bladder and bowel urgency.  Skin erythema-like sunburn  Bowel perforation, rare.  Vaginal fibrosis and stenosis.  Interstitial cystitis

 Chemotherapy is ideally given in conjunction with the radiotherapy as this combination increases cure rates more than when radiotherapy is used in isolation.  It probably works by enhancing the effects of radiotherapy and might also address micro metastases which are outside the radiation field.  The most widely used drug is Cisplatin, although 5-FU and Paclitaxil may also be employed

 When it is not possible to offer curative treatment then palliation of the symptoms becomes important. Patient may be experiencing a number of symptoms from local infiltration of the pelvis by the cancer.  Malignant pain, recto-and/or vasicovaginal fistula and bleeding may occur.  Radiotherapy may be used in bone metastasis.

 is very difficult to be treated but some time pelvic exenteration may be used, this is drastic operation that involves removal of uterus, ovaries, fallopian tubes, vagina, bladder, rectum and part of the colon. Now rarely used.

 The presentation is usually by abnormal vaginal bleeding  both Pap smear and colposcopy are safe during pregnancy.  Early stage disease Ia can allow the pregnancy to go to term and treated after that but this require close follow-up.

 In more advanced stages, time of treatment depends on gestational age, if its far from viability treatment is given immediately and after giving the first dose of radiation the baby will abort and if its near term we can do caesarean hysterectomy and continue treatment as in non pregnant.

GOOD LUCK AND SEE YOU NEXT IN SIX YEAR IN SHA ALLAH