Cervical Cancer

CERVICAL CANCER

※원인
- 위험 요인 : 조기에 시작된 성적 활동, 다수의 셩교 상대자, 남성 요인, HPV 감염

※Symptoms
- vaginal bleeding(M/C) : postcoital bleeding , irregular or postmenopausal bleeding
혈액이 섞인 질 분비물
- 악취성 질 분비물
- 병변이 진행된 경우 골반통, 편측성 다리 부종, 요관 폐쇄

※Physical examination
- supracalvicular and groin lymph nodes : 전이 여부 파악
- speculum : 육안으로 보았을 때 질에도 번졌는지 확인
- rectal exam : 자궁 경부의 견고성, 크기를 평가
- 자궁 경부 뒤쪽의 nodularity는 parametrial extension 시사

※진단위한 검사
- screening : PAP
- punch Bx.
- Conization : 미세침윤의 범위 정확히 알기 위해서
- Colposcopy(PAP에서 초기 침윤성 암 의심되나 육안상 정상인 경우)
: 비정상적 혈관, 불규칙한 표면 윤곽 과 상피의 손실, 색깔 변화 있으면 침윤 의심
: Adenocarcinoma : 소견이 특이적이지 않아서 자궁경관 소파술 시행 필요

※병리
- Microinvasive cervical squamous carcinoma
: 원추생검이 침윤의 범위 확실히 알기 위해 필요함
3mm이하의 침윤이면 FIGO stage Ia1
3-5mm의 침윤이거나 옆으로 7mm 미만이면 FIGO stage Ia2
- Invasive cervical cancer
①Squamous cell carcinoma(M/C-85~90%)
종류 : large cell keratinizing /large cell nonkeratinizing / small cell types
②Adenocarcinomas(10%정도)
20~30대 젊은 여성에 많음
30~50%에서 squamous neoplasia가 관찰됨
PAP로 찾기 어려움 -> conization이 진단위해 필요
③Sarcoma
애나 젊은 성인에서 나타나는 태생성 횡문근 육종
④Malignant melanoma(rare)

※Staging
stage0
Carcinoma in situ. intraepitheliaal carcinoma
stageⅠ
Invasive cancer with tumor strictly confined to the cervix.

IA



IA1
Tumor has penetrated an area less than 3 mm deep and less than 7 mm wide. preclinical carcinoma(현미경으로만 보임)


IA2
Tumor has penetrated an area 3 to 5 mm deep and less than 7 mm wide.

IB
This stage includes tumors that can be seen without a microscope. It also includes tumors that cannot be seen without a microscope but that are more than 7 mm wide and have penetrated more than 5 mm of connective cervical tissue.


IB1
Tumor that is no bigger than 4 cm


IB2
Tumor that is bigger than 4 cm Tumor has spread to organs and tissues outside the cervix but is still limited to the pelvic area.
stageⅡ
Invasive cancer with tumor extending beyond the cervix and/or the upper two-thirds of the vagina, but not onto the pelvic wall.

ⅡA
Tumor has spread beyond the cervix to the upper part of the vagina.

ⅡB
Tumor has spread to the tissue next to the cervix.(parametruim)
stageⅢ
Invasive cancer with tumor spreading to the lower third of the vagina or onto the pelvic wall; tumor may be blocking the flow of urine from the kidneys to the bladder.

ⅢA
Tumor has spread to the lower third of the vagina.

ⅢB
Tumor has spread to the pelvic wall and/or blocks the flow of urine from the kidneys to the bladder.
stageⅣ
Invasive cancer with tumor spreading to other parts of the body. This is the most advanced stage of cervical cancer.

ⅣA
Tumor has spread to organs located near the cervix, such as the bladder or rectum.

ⅣB
Tumor has spread to parts of the body far from the cervix


※stagingng work up(밑줄을 필수 검사)
- CXR
- Cystoscopy
- Proctoscopy
- IVP
- Barium enema
- Computed tomography (CT scan)
- Magnetic resonance imaging (MRI)

※ 전파 양상
- 자궁경부 간질, 자궁 체부, 질과 자궁방결합 조직으로 직접 침윤
- 림프성 전이의 비율stageⅠ
stageⅡ
stageⅢ
stageⅣ
15~20%
25~40%
>50%
50~80%


- 혈행성 전이
- 복강내 파급
※ Treatment(surgery, radiotherapy)
- II a 미만에서만 수술 단독 요법이 가능
□Surgical therapy
수술의 종류
Type Ⅰ
Simple hysterectomy
Type II
Modified radical hysterectomy : medial one-half of the cardinal and uterosacral ligaments
Type III
Radical hysterectomy : 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
Type IV
Extended radical hysterectomy : periureteral tissue, superior vesicle artery, and up to three-fourths of the vagina are removed
TypeV
Partial exenteration : portions of the distal ureter and bladder are resected

□Complications of radical hysterectomy
Acute complications


blood loss
ureterovaginal fistula
vesicovaginal fistula
pulmonary embolus
small-bowel obstruction
febrile morbidity
most often pulmonary
pelvic cellulitis
urinary tract infection

Subacute complications
bladder dysfunction
Lymphocyst

Chronic complications
Bladder hypotonia (or atony)3%
Ureteral stricture(uncommon)

□수술후 생존율
stage1b이하인 경우 : 85~90%
stage2a : 75%
□수술 사망의 가장 흔한 원인은 폐동맥 색전증

□방사선 치료 : 자궁 경부암의 모든 병기에서 시행 가능
- 미세 침윤암의 치료에는 4000~5000cGy조사
- 임상증상 있으면 6000cGy
- 합병증 : perforation, fever, nausea, frequency, hematuria, hematochezia
만성 합병증 : proctosigmoiditis, fistular, stricture
- CCRT : cisplatin과 함께 RT하면 단독치료보다 성적 낫다

□neoadjuvant chemotherapy
- 2b이상의 환자에서 수술 가능하게 해서 수술하기도 함
- LN 전이율 낮춤
- 재발률 낮춤, 5년 생존율 올림