- only 1-2% of malignant neoplasms of the female genital tract
CERVICAL CANCER
1 . Symptoms
1) vaginal bleeding
most common symptom
postcoital bleeding
irregular or postmenopausal bleeding
2) advanced disease
malodorous vaginal discharge, weight loss, or obstructive uropathy
2 . Physical examination
1) supracalvicular and groin lymph nodes
2) pelvic examination
speculum - cervix is inspected for suspicious areas
rectal exam - establish cervical consistency and size
parametrial extension of disease is best determined by
the finding of nodularity beyond the cervix
3) cervical biopsy
: colposcopy may be helpful
diagnostic conization
3 . Pathology
1) Microinvasive cervical squamous carcinoma
Cervical conization is required to assess correctly the depth and the linear extent of
involvement of microinvasion
Lesions the are < 3mm are classified as FIGO stage Ia1.
Lesions that are >3-5mm or more in depth and <7mm in linear extent are classified as
FIGOstage Ia2
The depth of invasion is significant for the development of pelvic lymph node metastasis and
tumor recurrence (more than 3-5mm : 5-8%)
2) Invasive cervical cancer
a. Squamous cell carcinoma
invasive squamous cell carcinoma is the most common variety of invasive cancer
large cell keratinizing /large cell nonkeratinizing / small cell types
The category of small cell carcinoma includes poorly differentiated squamous cell carcinoma and small cell anaplastic carcinoma , resembling oat cell carcinoma of the lung
Patients with the large cell type of carcinoma , with or without keratinization , have a better prognosis than with the small cell variant
b. Adenocarcinomas
increasing number of cervical adenocarcinomas affecting young women in their twenties and thirties
In addition, squamous neoplasia, intraepithelial or invasive , also occurs in 30-50% of cervical adenocarcinomas
Adenocarcinoma may be detected by cervical sampling but less reliably so than squamous carcinomas
A definitive diagnosis may require cervical conization
Pure - quite heterogeneous
wide range of cell types, growth patterns, and differentiation
80%, endocervical type with mucin production
endometrioid cells, clear cells, intestinal cells, or a mixture of more than
one cell type
extremly well- differentiated form of adenocarcinoma
more recent studies have found a favorable prognosis if the disease is detected early
villoglandular papillary adenocarcinoma
young women (pregnant or users of oral contraceptives)
none of theses tumors has recurred after cervical conization or hysteretomy
limited risk for spread beyond the uterus
mature adenosquamous carcinomas : identified on routine histologic sections
In poorly differentiated or immature adenosquamous carcinomas
mucicarmine and PAS - 30% of squamous carcinomas demonstrated mucin secretion
when stained with mucicarimine
mucin secretion have a higher incidence of pelvic lymph node metastases than
squamous cell carcinomas without mucin secretion
glassy cell carcinoma
poorly differentiated form of adenosquamous carcinoma
the poor diagnosis of this tumor is linked to understanding and resistance to
radiotherapy
adenoid basal carcinomas
simulates the basal cell carcinoma of the skin
peripheral palisading
mitoses are rare
tumor often extends deep into the cervical stroma
adenoid cystic carcinoma
invade into the adjacent tissues and metastasize late, often 8-10years after the
primary tumor has been removed
directly to the lung
c. Sarcoma
embryonal rhabdomyosarcoma
in chidren and young adults
grape- like polypoid nodules , the botryoid sarcoma
d. Malignant melanoma
on rare occasions, de novo in this area
the depth of invasion into the cervical stroma
e. Metastatic cancer
involved in cancer of the endometrium and vagina
consequently the clinical classification is that of cervical neoplasia extending to the vagina, rather than vice versa
three modes, direct extension from the endometrium, submucosal involvement by lymph vascular extension and multifocal disease
carcinomas of the urinary bladder and colon
lymphoma, leukemia, and carcinoma of the breast, stomach, and kidney is usually part of the systemic spread
f. Small cell carcinoma
at the time of diagnosis , it is usually disseminated with bone, brain, liver, and bone marrow being the most common sites of metastases
4. Colposcopy of the invasive lesion
: suggest invasion
abnormal blood vessels
irregular surface contour with loss of surface epithelium
color tone change
colposcopically directed biopsies may permit the diagnosis of frank invasion and thus avoid the
need for diagnostic cone biopsy, allowing treatment to be administered without delay
1) Abnormal blood vessels
: looped, branching, or reticular
looped vessels are the most common and arise from the punctation and mosaic vessels
present in cervical intraepithelial neoplasia (CIN)
the abnormal branching blood vessels
obtuse or right angles
enlarging after branching
abnormal reticular vessels
the terminal capillaries of the cervical epithelium
in a postmenopausal woman with atrophic epithelium
the surface is again eroded , and the capillary network is exposed ,these vessels are very
fine, short, and composed of small commas without an organized pattern
not specific for invasive cancer, atrophic cervicitis may also have this apperance
2) Irregular surface contour
papillary characteristic of the lesion
with a human papillovirus papillary growth on the cervix,
biopsies should be performed on all papillary cervical growths
3) Color tone change
as a result of the increasing vascularity, surface epithelial necrosis
, production of keratin
, yellow-orange
* Adenocarcinoma
: not have a specific colposcopic appearance
endocervical curettage is required as part of the colposcopic examination
5 . Staging
1) Clinical staging
: When there is doubt concerning the stage to which a cancer should be allocated , selection of the earlier stage is mandatory
After a clinical stage is assigned and treatment has been initiated, the stage must not be changes because of subsequent findings by either extended clinical staging or surgical staging
* extended clinical staging
lymphangiography, CT,USG,and MRI-be used in planning therapy
2) Patterns of spread
a. direct invasion
b. lymphatic metastasis
c. blood-born metastasis
d. intraperitoneal implantation
6. Treatment
: surgery, radiotherapy
(surgery alone is limited to patients with stage I and II a disease)
In general, radical hysterectomy is reserved for woman who are in good physical condition
1) Surgical therapy
staging
stage Ia - microinvasive Carcinoma
A microinvasive lesion is one in which neoplastic epithelium invades the stroma to
a depth of <3mm beneath the basement membrane and in which lymphatic or blood
vascular invlovement is not demonstrated." The purpose of defining microinvasionis
to identify a group of patients who are not at risk of lymph node metastasis or
recurrence and who therefore may be treated with less than radical therapy.
Diagnosis must be based on a cone biopsy of the cervix
pathologic condition be described in terms
depth of invasion/width and beneath of the invasive area/presence or absence of
lymphatic vascular space invasion
Stage Ia1-<3mm invasion
< 1% incidence of pelvic node metastasis
extrafascial hysterectomy without node dissection
therapeutic conization appears to be adequate therapy for these patients if
childbearing capability is desired
surgical margins must be free of disease
if there is lymph vascular space invasion, an alternative is an pelvic node
dissection with a typeI (extrafascial) or II (modified radical) hysterectomy
Stage Ia2->3-5mm invasion
3. 8% incidence of pelvic node metastasis
pelvic node dissection is necessary for these lesions
modified radical hysterectomy (type II)
stageIb /II a invasive cancer
radical hysterectomy, pelvic lymphadenectomy, and para aortic lymph node evaluation
Types of hysterectomy
Modified radical hysterectomy (Type II)
medial one-half of the cardinal and uterosacral ligaments
Radical hysterectomy (Type III)
The operation includes a pelvic lymph node dissection, along with removal of most of the
uterosacral and cardinal ligaments and the upper one-third of the vagina
Extended radical hysterectomy (Type IV)
periureteral tissue, superior vesicle artery, and up to three-fourths of the vagina are
removed
Partial exenteration (TypeV)
portions of the distal ureter and bladder are resected
figure 32.8 the pelvic ligaments and spaces
* Modified radical hysterectomy
The uterine artery is transected at the level of the ureter, thus preserving the
ureteral brance to the ureter
The cardinal ligament is not divided near the sidewall but instead is divided
at approximately its midprotion near the ureteral dissection
The anterior vesicouterine ligment is divided, but the posterior vesicouterine
ligament is conserved
A smaller margin of vagina is removed
Complications of radical hysterectomy
Acute complications
blood loss (average 0.8 L)
ureterovaginal fistula (1-2%)
vesicovaginal fistula (<1%)
pulmonary embolus (1-2%)
small-bowel obstruction (1%)
febrile morbidity (25-50%)
most often pulmonary (10%)
pelvic cellulitis (7%)
urinary tract infection (6%)
Subacute complications
bladder dysfunction
important to maintain adequate bladder drainage during this time to prevent
overdistention (with a suprapubic catheter)
cystometrography may be performed 3 to 4 weeks postoperatively
For use of the cathter to be discontinued, the patient must be able to sense
the fullness of the bladder, initiate voiding , and void with a residual
urine level of <75ml.
Lymphocyst
fewer than 5% of patients
cause is uncertain
adequate drainage of the pelvis after radical hysterectomy may be an
important step in prevention
simple aspiration of the lymphocyst is generally not curative
,but percutaneous catheters with chronic drainage may allow healing
if this treatment is unsuccessful, operative intervention with excision of a
portion of the lymphocyst wall and placement of either large bowel
or omentum into the lymphocyst
Chronic complications
Bladder hypotonia (or atony)
3%
result of bladder denervation
voiding every 4-6 hours, increasing intra-abdominal pressure with the
Crede's maneuver, and intermittent self-catheterization may be used to
manage the hypotonic bladder
more than three positive pelvic lymph nodes- 68% recurrence rate
few - 30-50%
tumor emboli - 82.5% 5 yr survival rate
microinvasive - 62.1%
macroscopic disease - 54%
lesion size
independent predictor of survival
smaller than 2cm have a survival rate of approximately 90%
larger than 2cm have a 60% survival rate
larger than 4cm , the survival rate drops to 40%
depth of invasion
less than 1cm have a 5 yr survival rate around 90%
more than 1cm ,63-78%
parametrial spread
5-yr survival rate 69%
negative (95%)
lymph vascular space involvement
50-70%,
postoperative radiotherapy
with high-risk : metastasis to pelvic lymph nodes
invasion of paracervical tissue
deep cervival invasion
positive surgical margins
from retrospective studies, it appears that postoperative radiation therapy for positive
pelvic nodes can decrease pelvic recurrence but does not improve 5yr actuarial
survival
neoadjuvant chemotherapy
: use of chemotherapy to shrink the tumor before radical hysterectomy or radiotherapy
22-44% complete response rate, decrease the number of positive pelvic lymph nodes,
and improve the 2- and 3- year disease - free survival rates, particularly in
patients with stage I and II disease
Kim et al, cisplatin, vinblastine and bleomycin
(54patients with stage I and II a tumors larger than 4cm)
complete response rate of 44%
partial response rate of 50%
only three patients - recurred
94% disease - free survival with a minimum of 2 years follow-up
Panici et al,cisplatin, bleomycin, and methotrexate
(75patients with stage I ,II and III , larger than 4 cm)
100%,81% and 66% (3year disease - free survival rate)
initial large tumor size and parametrial infiltration significantly correlated with
a lower response to neoadjuvant therapy
recurrence was significantly correlated with FIGO stage, parametrial infiltration,
and residual cervical tumor