Cervix


 * **Epidemiolgy:** || Megan

Cervical cancer is cancer that forms in the tissue of the cervix, the organ connecting the uterus to the vagina, and is the third most common cancer in women. Although few symptoms exist, regular pap smears can provide early detection. Cervical cancer is a slow growing cancer, in cases taking between 10 and 20 years. Since only those with a cervix can develop cervical cancer, this is a disease solely associated with females. Although cervical cancer is almost always assoicated with the Human Pappilomavirus (HPV), not all HPV leads to cervical cancer. 1 At least half of sexually active people will have HPV at some point in their lives, but few women will get cervical cancer. 2 All women are at risk for cervical cancer, occuring most often in women over age 30. Each year, about 12,000 women in he United States are diagnosed with cervical cancer. 2 || The following are some of the signs and symptoms of cervical cancer: Some of the various tests and diagnostic procedures for cervical cancers can include: The following are the different types and subtypes of cervical cancer classified by the World Health Organization (WHO) The cervix is surrounded by a rich lymphatic system and the three most frequently effected involved nodes are: the obturator, internal iliac and external iliac lymph nodes.1 || The most common sites for cervical cancer to metastasize to are the lungs (21%), para-aortic nodes (11%), mediastinal and supraclavicular lymph nodes (7%), bones, and the liver. 5 || Megan Figure taken from Chao pg 498. 7 || 5 || Some of the common side effects of radiation therapy treatment associated with cervical cancer are: There are many different factors that determine a patient’s prognosis. 5 The following is a list of treatment options for cervical cancer according to its stage. __ Stage 0 (carcinoma in situ) __ Although the AJCC staging system classifies carcinoma in situ (CIS) as the earliest form of cancer, doctors often think of it as a pre-cancer. That is because the cancer cells in CIS are only in the surface layer of the cervix − they have not grown into deeper layers of cells. Treatment options for squamous cell carcinoma in situ are the same as for other pre-cancers (dysplasia or cervical intraepithelial neoplasia [CIN]). Options include cryosurgery, laser surgery, loop electrosurgical excision procedure (LEEP/LEETZ), and cold knife conization. For adenocarcinoma in situ, hysterectomy is usually recommended. For women who wish to have children, treatment with a cone biopsy may be an option. The cone specimen must have no cancer cells at the edges, and the patient must be closely watched. After the woman has finished having children, a hysterectomy is recommended. A simple hysterectomy is also an option for treatment of squamous cell carcinoma in situ, and might be done if it returns after other treatments. All cases of CIS can be cured with appropriate treatment. However, pre-cancerous changes can recur (come back) in the cervix or vagina, so it is very important for your doctor to watch you closely. This includes follow-up with regular Pap tests and in some instances with colposcopy. __ Stage IA is divided into stage IA1 and stage IA2 __ __ Stage IA1: For this stage you have 3 options __ __ Stage IA2: There are 3 treatment options __ If the cancer is found in any pelvic lymph nodes during surgery, some of the lymph nodes that lie along the aorta (the large artery in the abdomen) may be removed as well. Any tissue removed at surgery will be examined in the laboratory to see if the cancer has spread further than expected. If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, radiation therapy is usually recommended. Often chemotherapy will be given with the radiation therapy. If the pathology report says that the tumor had positive margins, this means that some cancer might have been left behind. This is also treated with pelvic radiation (given with cisplatin chemotherapy). The doctor may advise brachytherapy, as well. __ Stage IB is divided into stage IB1 and stage IB2 __ __Stage IB1: There are 3 options available:__ __ Stage IB2: There are 3 options available __ __ Stage II is divided into stage IIA and stage IIB __ __ Stage IIA: Treatment for this stage depends on the size of the tumor. __ __Stage IIB:__ Combined internal and external radiation therapy is the usual treatment. The radiation is given with the chemotherapy drug cisplatin. Sometimes other chemo drugs may be given along with cisplatin. __Stage III and IVA__ Combined internal and external radiation therapy given with cisplatin is the recommended treatment. If cancer has spread to the lymph nodes (especially those in the upper part of the abdomen) it can be a sign that the cancer has spread to other areas in the body. Some experts recommend checking the lymph nodes for cancer before giving radiation. One way to do this is by surgery. Another way is to do a CT or MRI scan to see how big the lymph nodes are. Lymph nodes that are bigger than usual are more likely to have cancer. Those lymph nodes can be biopsied to see if they contain cancer. If lymph nodes in the upper part of the abdomen (the para-aortic lymph nodes) are cancerous, doctors may want to do other tests to see if the cancer has spread to other parts of the body. __ Stage IVB __ At this stage, the cancer has spread out of the pelvis to other areas of the body. Stage IVB cervical cancer is not usually considered curable. Treatment options include radiation therapy to relieve the symptoms of cancer that has spread to the areas near the cervix or to distant sites (such as the lungs or bone). Chemo is often recommended. Most standard regimens use a platinum compound (such as cisplatin or carboplatin) along with another drug such as paclitaxel (Taxol), gemcitabine (Gemzar), or topotecan. Clinical trials are testing other combinations of chemo drugs, as well as some other experimental treatments. 9 || v Bladder—6500—Contracture v Femoral Heads—6000—Necrosis v Small intestine—4000—Obstruction/perforation v Rectum—6000-Ulcer, stricture 10 || Back to Week 5
 * **Etiology:** || Kevin Tsai
 * Human Papilloma Virus (HPV) infection (most important risk factor for cervical cancer) 3
 * Smoking
 * Weakened immune system
 * Chlamydia infection
 * Diet
 * Being overweight
 * Birth control pills
 * Having many pregnancies
 * Young age at the time of first full-term pregnancy
 * Low income
 * DES (diethylstilbestrol)
 * Family history ||
 * **Signs & Symptoms:** || Erin
 * Postcoital bleeding 4
 * Increased menstrual bleeding
 * Discomfort with intercourse
 * Foul smelling discharge
 * Pelvic pain
 * Urinary symptoms
 * Rectal symptoms ||
 * **Diagnostic Procedures:** || Spencer
 * Pap Smear – Should be done at the age of 21 or 3 years after the onset of sexual activity. 5
 * HPV Testing – This test determines the form of HPV 16 and 18, which are sexually transmitted diseases, very well recognized as an etiologic agent in cervical cancers.1 This test may also be used in conjunction with Pap Smear.1
 * Colposcopy
 * Chest X-Ray
 * Computed Tomography (CT) Scan
 * Magnetic Resonance Imaging (MRI)
 * Positron Emission Tomography (PET)
 * Barium Enema – This is usually done on patients with progressive disease to check into the colon and rectum.
 * Cystoscopy/Rectosigmoidoscopy – This procedure is recommended for patients with mid to late disease progression. 5 ||
 * **Histology:** || Pablo
 * Squamous cell carcinoma (epidermoid carcinoma)
 * Keratinising (well differentiated and moderately differentiated)
 * non keratinising (large and small cell types)
 * Spindle cell carcinoma
 * Adenocarcinoma endocervical type
 * Variant : adenoma malignum (minimal deviation carcinoma)
 * Variant :villoglandular papillary adenocarcinoma
 * Endometrioid adenocarcinoma
 * Clear cell adenocarcinoma
 * Serous adenocarcinoma
 * Mesonephric adenocarcinoma
 * Intestinal type (signet ring) adenocarcinoma
 * Other epithelial tumours
 * Adenosquamous carcinoma
 * Adenoid cystic carcinoma
 * Small cell carcinoma
 * Undifferentiated carcinoma
 * Metastatic tumours (breast, ovary, colon, and direct spread of endometrial carcinoma) 5 ||
 * **Lymph node drainage:** || Becky
 * **Metastatic spread:** || Adam
 * **Grading:** || [[image:uwlmedicaldosimetry2013/Cervical Grading.JPG width="747" height="387"]]
 * **Staging:** || Kevin Tsai
 * **Radiation side effects:** || Erin
 * Fatigue 8
 * Upset stomach
 * Diarrhea or loose stools
 * Nausea and vomitting
 * Bladder irritation
 * Premature menopause
 * Skin changes ||
 * **Prognosis:** || Spencer
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">The prognosis is the same in younger women as in older women.
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">There is some correlation between race or socioeconomic characteristics and even the outcome of therapy.
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">There has been some signs of decreased survival in patients with oral temperatures higher than 100 degrees Fahrenheit.
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Women who have acquired either the human immunodeficiency virus (HIV) and/or acquired immunodeficiency syndrome (AIDS) are at a much higher risk for tumor recurrence after treatment.
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">The stage of tumor, volume, histology, and even the vascular and lymphatic invasion are all highly important prognostic factors that are taken into account. ||
 * **Treatments:** || Pablo
 * If you still want to be able to have children, first the cancer is removed with a cone biopsy, and then you are watched closely to see if the cancer comes back.
 * If the cone biopsy doesn't remove all of the cancer (or if you are done having children), the uterus will be removed (hysterectomy).
 * If the cancer has invaded the blood vessels or lymph vessels, you might need a radical hysterectomy along with removal of the pelvic lymph nodes. For women who still want to be able to have children, a radical trachelectomy can be done instead of the radical hysterectomy.
 * Radical hysterectomy along with removal of lymph nodes in the pelvis
 * Brachytherapy with or without external beam radiation therapy to the pelvis
 * Radical trachelectomy with removal of pelvic lymph nodes can be done if you still want to be able to have children
 * The standard treatment is a radical hysterectomy with removal of lymph nodes in the pelvis. Some lymph nodes from higher up in the abdomen (called para-aortic lymph nodes) are also removed to see if the cancer has spread there. If cancer cells are found in the edges of the tissues removed (positive margins) or if cancer cells are found in lymph nodes during this operation, radiation therapy may be given, possibly with chemotherapy, after surgery.
 * The second treatment option is radiation with both brachytherapy and external beam radiation therapy.
 * Radical trachelectomy with removal of pelvic (and some para-aortic) lymph nodes is an option if the patient still wants to be able to have children
 * The standard treatment is the combination of chemotherapy with cisplatin and radiation therapy to the pelvis plus brachytherapy.
 * Another choice is radical hysterectomy with removal of pelvic (and some para-aortic) lymph nodes. If cancer cells are found in the lymph nodes removed, or in the margins, radiation therapy may be given, possibly with chemotherapy, after surgery.
 * Some doctors advise radiation given with chemotherapy (first option) followed by a hysterectomy.
 * One choice for treatment is brachytherapy and external radiation therapy. This is most often recommended if the tumor is larger than 4 cm (about 1½ inches). Chemotherapy with cisplatin will be given along with the radiation.
 * Some experts recommend removing the uterus after the radiation therapy is done.
 * If the cancer is not larger than 4 cm, it may be treated with a radical hysterectomy and removal of lymph nodes in the pelvis (and some in the para-aortic area). If the tissue removed at surgery shows cancer cells in the margins or cancer in the lymph nodes, radiation treatments to the pelvis will be given with chemotherapy. Brachytherapy may be given as well.
 * **TD 5/5:** || Becky
 * **References:** || Adam
 * 1) National Cancer Institute website. Cervical Cancer. []. Accessed June19, 2013.
 * 2) U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2009 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2013. Available at: [].
 * 3) American Cancer Society. Cervical Cancer Overview. Available at: http://www.cancer.org/Cancer/CervicalCancer/OverviewGuide/cervical-cancer-overview-what-causes. Accessed at: June 25, 2013.
 * 4) Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 2nd ed. St. Louis, MO: Mosby Inc; 2004:784.
 * 5) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
 * 6) Eurocytology. Web site. []. Accessed Jun 24, 2013.
 * 7) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:498.
 * 8) American Cancer Society. Cervical Cancer. []. Revised April 11, 2013. Accessed June 27, 2013.
 * 9) American Cancer Society. Web site. []. Accessed Jun 24, 2013.
 * 10) Dasher BG, Wiggers NH, Vann AM. Gynecological cancers. In: Dasher BG, Wiggers NH, Vann AM. Portal Design in Radiation Therapy. 4th edition. United States: DWV Enterprises; 1994:125-135. ||