CA Cervix

CARCINOMA OF CERVIX

Carcinoma of the cervix was one of the most common causes of cancer death in women, but over the past 30 years, mortality rate has decreased by 50% due to the widespread screening with the PAP smear. It remains the major gynecologic cancer in undeveloped countries. It is more common in lower socioeconomic groups, in women with early initial sexual activity and/or multiple sexual partners, and in smokers. Venereal transmission of human papilloma viruses has an important etiologic role. Over 66 types of HPV have been isolated, and many are associated with cervical carcinoma are 16,18,31,45, and 51 to 53. These along with many other types are also associated with cervical intra epithelial Neoplasia (CIN). Vaccination against pathologic HPV appears quite promising as a cervix cancer prevention strategy.

Uncomplicated HPV lower genital tract infection and Condylomatous atypia of the cervix can progress to CIN. This lesion precedes invasive cervical carcinoma and is classified as low grade squamous intraepithelial lesion (SIL), high-grade SIL, and carcinoma in situ. Carcinoma in situ demonstrates cytologic evidence of Neoplasia without invasion through the basement membrane can persist unchanged for 10 to 20 years, but eventually progresses to invasive carcinoma.

The PAP smear is 90-95% accurate in detecting early lesions such as CIN but is less sensitive in detecting cancer when frankly invasive cancer or fangating masses are present. Inflammation, necrosis, and haemorrhage may produce false-positive smears, and colposcopic directed biopsy is required when any lesion is visible on the cervix, regardless of PAP smear findings. The PAP smear can be reported as normal, atypical squamous cells of undetermined significance (ASCUS) or cannot exclude high grade SIL (ASEH); low-or high grade CIN; or frankly malignant. Women with ASCUS, ASC-H, or low-grade CIN should have repeat smears in 3-6 months and be tested for HPV. Women with high grade CIN or frankly malignant PAP smears should have colposcopic directed cervical biopsy.

Approximately 80% of invasive cervix cancers are squamous cell tumour, 10-15% are adenocarcinomas, 2-5% are adenosquamous with epithelial and glandular structures, and 1-2% are clear cell mesonephric tumours.

Patients with cervix cancer generally present with abnormal bleeding or post coital spotting that may increase to inter-menstrual of prominent menstrual bleeding. Yellowish vaginal discharge, lumbo-sacral back pain, and urinary symptoms can also be seen.

The staging of cervical carcinoma is clinical and generally completed with a pelvic examination under anesthesia with Cystoscopy and proctoscopy. Chest x-rays, intravenous pyelograms, and computed tomography are generally required and magnetic resonance imaging (MRI) may be used to asses extra-cervical extension.

Stage 0 is carcinoma in situ

• Stage I is disease confined to the cervix

• Stage II is disease invades beyond the cervix but not to the pelvic wall or lower third of the vagina

• Stage III-disease extends to the pelvic wall or lower third of vagina or causes hydronephrosis

• Stage IV is present when the tumour invades the mucosa of bladder or rectum or extends beyond the true pelvis.

Five year survivals are follows

Stage I- 85%

Stage II- 60%

Stage III- 33%

Stage IV- 7%

Carcinoma in situ (Stage 0) can be arranged successfully by biopsy or by abdominal hysterectomy. For Stage I disease, results appear equivalent for either radical hysterectomy or radiation therapy. Patients with Stage II to IV diseases are primarily managed with radical radiation therapy or combined modality therapy