Cervical Cancer Treatment Flashcards
Longitudinal studies have shown that in patients with untreated in situ cervical cancer
The precursor lesion is dysplasia: cervical intraepithelial neoplasia (CIN) or adenocarcinoma in situ, which can subsequently become invasive cancer. This process can be quite slow. Longitudinal studies have shown that in patients with untreated in situ cervical cancer, 30% to 70% will develop invasive carcinoma over a period of 10 to 12 years. However, in about 10% of patients, lesions can progress from in situ to invasive in a period of less than 1 year. As it becomes invasive, the tumor breaks through the basement membrane and invades the cervical stroma. Extension of the tumor in the cervix may ultimately manifest as ulceration, exophytic tumor, or extensive infiltration of underlying tissue, including the bladder or rectum.
Risk Factors for cervical cancer
- 16 and 18
- High parity.
- Increased number of sexual partners.
- Young age at time of first sexual intercourse. ¥ Low socioeconomic status.
- History of smoking.
- Long-term use of oral contraceptives.
What are symptoms of cervical cancer
Early cervical cancer may not cause noticeable signs or symptoms.
- Possible signs and symptoms of cervical cancer include the following:
- Vaginal bleeding.
- Unusual vaginal discharge.
- Pelvic pain.
- Dyspareunia.
- Postcoital bleeding.
Comment on HPV testing
HPV DNA testing has proven useful in triaging patients with atypical squamous cells of undetermined significance to colposcopy and has been integrated into current screening guidelines.[15-17]
HPV DNA tests are unlikely to separate patients with low-grade squamous intraepithelial lesions into those who do and those who do not need further evaluation. A study of 642 women found that 83% had one or more tumorigenic HPV types when cervical cytologic specimens were assayed by a sensitive (hybrid capture) technique.[15] The authors of the study and of an accompanying editorial concluded that using HPV DNA testing in this setting does not add sufficient information to justify its cost.[15]
Other studies show that patients with low-risk cytology and high-risk HPV infection with types
Other studies show that patients with low-risk cytology and high-risk HPV infection with types 16, 18, and 31 are more likely to have CIN or microinvasive histopathology on biopsy
And what age group is HPV more effective than cytology alone and predicting the risk of developing CIN3 or worse
For women older than 30 years who are more likely to have persistent HPV infection, HPV typing can successfully triage women into high- and low-risk groups for CIN 3 or worse disease. In this age group, HPV DNA testing is more effective than cytology alone in predicting the risk of developing CIN 3 or worse.[22] Other studies have shown the effectiveness of a primary HPV DNA-screening strategy with cytology triage over the previously used cytology-based screening algorithms.[23,24]
Pap and HPV testing are not performed on approximately __% of eligible women,
Pap and HPV testing are not performed on approximately 33% of eligible women,
What variables are significant for progression free survival
- Periaortic and pelvic lymph node status. . Tumor size.
- . Patient age.
- . Performance status.
- . Bilateral disease.
- . Clinical stage.
In a large, surgicopathologic staging study of patients with clinical stage IB disease reported by the Gynecologic Oncology Group (GOG) (GOG-49), the factors that most prominently predicted for lymph node metastases and a decrease in disease-free survival were
In a large, surgicopathologic staging study of patients with clinical stage IB disease reported by the Gynecologic Oncology Group (COG) (COG-49), the factors that most prominently predicted for lymph node metastases and a decrease in disease-free survival were capillary-lymphatic space involvement by tumor, increasing tumor size, and increasing depth of stromal invasion, with the latter being the most important and reproducible.
What is the status of pelvic know it’s important.
The study confirmed the overriding importance of positive periaortic nodes and suggested further evaluation of these nodes in locally advanced cervical cancer. The status of the pelvic nodes was important only if the periaortic nodes were negative. This was also true for tumor size.
What are the patterns of spread for cervical cancer
In a large series of cervical cancer patients treated by radiation therapy, the incidence of distant metastases (most frequently to the lung, abdominal cavity, liver, and gastrointestinal tract) was shown to increase as the stage of disease increased, from 3% in stage IA to 75% in stage IVA.[38] A multivariate analysis of factors influencing the incidence of distant metastases showed stage, endometrial extension of tumor, and pelvic tumor control to be significant indicators of distant dissemination.[38]
Delay in radiation delivery completion is associated with
Delay in radiation delivery completion is associated with poorer progression-free survival when clinical staging is used.
Other prognostic factors that may affect outcome include the following:
- Other prognostic factors that may affect outcome include the following:
- . Human immunodeficiency virus (HIV) status: Women with HIV have more aggressive and advanced disease and a poorer prognosis.[40]
- . C-myc overexpression: A study of patients with known invasive squamous carcinoma of the cervix found that overexpression of the C-myc oncogene was associated with a poorer prognosis.[41]
- . Number of cells in S phase: The number of cells in S phase may also have prognostic significance in early cervical carcinoma.[42]
- . HPV-18 DNA: HPV-18 DNA has been found to be an independent adverse molecular prognostic factor. Two studies have shown a worse outcome when HPV-18 was identified in cervical cancers of patients undergoing radical hysterectomy and pelvic lym phadenectomy.[43,44]
- . A polymorphism in the Gamma-glutamyl hydrolase enzyme, which is related to folate metabolism, has been shown to decrease response to cisplatin, and as a result is associated with poorer
Follow-up After Treatment
High-quality studies are lacking, and the optimal treatment follow-up for patients after treatment for cervical cancer is unknown. Retrospective studies have shown that patients who recur are most likely to do so within the first 2 years.[46] As a result, most guidelines suggest routine follow-up every 3 to 4 months for the first 2 years, followed by evaluations every 6 months. Most recurrences are diagnosed secondary to new patient symptoms and signs,[47,48] and the usefulness of routine testing including a Pap smear and chest x-ray is
Follow-up should be centered around a thorough history and physical examination with a careful review of symptoms; imaging should be reserved for evaluation of a positive finding. Patients should be asked about possible warning signs, including the following:
. Abdominal pain.
. Back pain.
. Painful or swollen leg. .
Problems with urination. .
Cough.
. Fatigue.
Cellular Classification of Cervical Cancer
- Squamous cell (epidermoid) carcinoma comprises approximately 90% of cervical cancers
- adenocarcinoma comprises approximately 10% of cervical cancers. Adenosquamous and small cell carcinomas are relatively rare.
- Primary sarcomas of the cervix and primary and
- Secondary malignant lymphomas of the cervix have also been reported.
Tests and procedures to evaluate the extent of the disease include the following:
. CT scan.
. Positron emission tomography scan.
. Cystoscopy.
. Laparoscopy.
. Chest x-ray.
. Ultrasound.[2] . Magnetic resonance imaging.[2]
