Cervical cancer lecture

2021-03-22 12:00 AM

The outcome of cervical cancer treatment depends on the time of diagnosis. If diagnosed late, it is difficult to treat and treatment results are low.

Outline and risk factors

Cervical cancer is the second leading malignancy after breast cancer, usually occurring at the boundary between the stratum and cylindrical epithelium of the cervix.

According to the World Cancer Prevention Association, cervical cancer accounts for 12% of female genital cancers. At the Hanoi Cancer Institute, cervical cancer accounts for about 6%. If calculated on the total population, cervical cancer accounts for 6.6 - 8.6 / 100,000 population.

The outcome of cervical cancer treatment depends on the time of diagnosis. If diagnosed late, it is difficult to treat and treatment results are low.

Stages of Cervical cancer

Stages of Cervical cancer

The danger elements

Inflammation of Human Papillomavirus (HPV), Herpes virus.

Age: 40-70 years old.

Smoking

Birth: from 5 children or more.

Having sex early.

Have multiple sex partners.

Poor personal hygiene.

A decreased immune system such as HIV / AIDS infection, prolonged use of corticosteroids, chemotherapy ...

Oral contraceptive pills, family factors.

History of genital tract infections, many times.

Pathology

Carcinoma

Cancer cells occupy the entire thickness of the epithelium but have not invaded through the basal membrane.

Cell abnormalities: Many pathological cells have a large, uneven nucleus, a darkly stained chromosome, and many of the nuclei of a nucleus.

Structural abnormalities: Loss of normal stratification of the cell layers.

Invasive cancer

Cancer cells destroy the basal membrane and invade the stroma, in this case, we call invasive cancer. Approximately 95% of cases are sliced ​​carcinoma and about 5% of cylindrical carcinoma.

The spread of cervical cancer

In place:

From the transition area on the surface of the cervix - the vagina spreads down the vagina, to the waist of the uterus.

Invasion deeply forward, to the bladder-vaginal wall and bladder.

Invasive to the posterior rectal - vagina and rectum.

Invasive to the base of the ligament, ureter, and pelvic wall.

According to the lymphatic route:

The cancer spreads in this way to the external pelvic ganglia, the inner pelvis, sometimes cancer spreads abnormally, such as ignoring the pelvic lymph nodes immediately to the abdominal aortic ganglion group "metastasize in a knight-like manner".

It is very rare to see cancer metastasize in the bloodstream.

Symptom 

Preclinical lesions

In the early stages, muscle symptoms are usually poor. On a vaginal examination - the cervix with speculum may reveal that the cervix looks normal or has a slippery sore, an atypical white area, or increased blood vessel proliferation.

Clinical manifestations of the lesions

Patients often present with symptoms of irregular vaginal bleeding between menstruation, bleeding after intercourse, or bad gas, bloody, which may be combined with a depleted body condition.

Platypus examination reveals a blistering, easily bleeding mass to the touch. When applying Lugol, the affected area does not discolor (negative Schiller test). In some cases, the cervix will be deformed later, deep ulcers or the cervix will lose its shape completely. A biopsy is performed in both healthy and pathological areas. In addition, it is necessary to evaluate the extent of cancer spread and invasiveness into sacs of the vagina, broad ligament base, bladder, rectum, and adjacent areas.

Subclinical

Vaginal cells:  Helps detect changes at the cellular level in the direction of precancer or cancer. The template is dyed according to the Papanicolaou method and classified according to the Bethesda 2001 nomenclature including:

Sliced ​​epithelial cell changes:

ASCUS (slice cell atypical of unspecified significance).

LSIL (low-level traumatic injury).

HSIL (high-grade slice of the epithelium).

Cancer.

Cylindrical epithelial cell changes:

AGUS (significant adenocarcinoma).

AIS (adenocarcinoma).

Cancer.

Colposcopy:

Unprepared: warty or ulcerative lesions, bleeding surface, multiple proliferation of blood vessels.

Hinselmann test (acetic acid test): When 3% acetic acid is applied, the affected area becomes opaque, may have a bottom or stone pattern.

Schiller test: Apply Lugol 3% solution, the affected area does not turn brown.

In addition to the above lesions, it is necessary to define the transition zone.

Biopsy:  Taken from the transition and suspect region, allowing an accurate and complete histological examination.

Image analyzation:

To help fully evaluate the extent of cancer spread and invasiveness, some of the following investigations can be indicated: ultrasound, UIV scan, computed tomography (CT Scan), nuclear magnetic resonance (MRI) ).

Clinical stages

Classify by FIGO (International Federation of Gynecology and Obstetrics).

Stage Ia: Invasive cancer can only be identified microscopically. All macroscopic lesions, even with superficial invasive stage Ib cancer, are limited to stromal tissue up to 5 mm deep and not wider than 7 mm.

Stage Ia1: Infiltration of the stromal tissue not more than 3mm deep and not more than 7mm wide.

Stage Ia2: Infiltration of stromal tissue deeper than 3mm, but not more than 5mm and spread no more than 7mm.

Stage Ib: Localized clinical lesion of the cervix or preclinical lesion is greater than stage Ia.

Stage Ib1: Clinical lesions not more than 4cm in size.

Stage Ib2: Clinical lesions larger than 4cm.

Stage II: Cancer has spread from the cervix but has not yet spread to the pelvic wall.

Cancer has invaded the vagina but has not spread to the bottom 1/3.

Stage IIa: There is no infection to the base of the broad ligament.

Stage IIb: There is a clear infection of the broad ligament base.

Stage III: Cancer spreads to the pelvic wall. On rectal examination, no cancer-free space was found between the tumor and the pelvic wall. The tumor spread to 1/3 below the vagina. All cases of hydrocephalus or dumb kidneys are stage III unless it's caused by something else.

Stage IIIa: Does not spread to the pelvic wall but invades the lower third of the vagina.

Stage IIIb: Spread to the pelvic wall or renal fluid retention or dumb kidney.

Stage IV: Cancer has spread from the pelvic region or there is clinical evidence of invasive bladder or rectal mucosa.

Stage IVa: Spread to neighboring agencies.

Stage IVb: Spread to distant organs.

Differential diagnosis

The route, cervical apical ulcer: is a common lesion in the cervix.

Cervical polyps: The form of glandular polyps with necrosis or infection.

Endometriosis: Most easily mistaken for the bleeding phase coincides with menstruation on the background of endometriosis.

Cervical syphilis: primary syphilis can be found in the cervix.

Cervical tuberculosis: very rare, a history of genital TB.

Treatment

Treatment measures

Radiotherapy:

External radiotherapy: use Cobalt 60, total dose 50-60 grays. Common complications are cystitis, enteritis, skin reactions such as scleroderma. Radiotherapy is used as an add-on measure in case of lymph node metastasis, or preoperative treatment in case the tumor is too large.

Local radiation therapy: using radium or césium, by placing radiation sources into the vagina - cervix. 

Common complications are Infections, transient cystitis, rectal ulcer, bladder-vaginal probe, bladder-rectal probe.

This method is only capable of destroying cancer in place and some nearby chains of lymph nodes.

Surgical treatment:

Methods to remove lesions in place: Cut tip.

Wertheim-Meigs surgery.

Extensive total hysterectomy up to 1/3 above the vagina.

Take the lymph nodes and remove adipose tissue along the pelvic ganglia chains.

Take the aortic ganglion group.

Chemical treatment:

Preoperative chemotherapy has been shown to be helpful in tumors over 2cm.

Treatments with Cisplatin 50 mg / m2, Vincristine 1 mg / m2, and Bleomycine 25 mg / m2 for 1 to 3 weeks can reduce tumor size, facilitate easy surgery and prolong the time. recurrence time.

Optimal chemotherapy after surgery has not been determined to date, but results from existing studies indicate low-dose Cisplatin alone (40 mg / m2 weekly) or Cisplatin (50 - 75 mg / m2 of day 1) combined with 5-FU (1000 mg / m2 for the next 4 days) may improve patient survival.

Indications for treatment

Intracellular cancer:

In young women, who still wish to give birth, can prune or amputate the cervix, and then need to be carefully monitored every 6 months with 3-4 times vaginal cytology. In a woman with enough children, the elderly can extensively have a complete hysterectomy.

Invasive cancer:

Usually managed according to a combination regimen of radiation therapy and surgery.

Stage I - IIa: Mainly surgery according to Wertheim-Meigs method, complete hysterectomy, cut two appendages, cut 1/3 on the vagina, remove all connective organizations under two broad ligament leaves, curettage in the pelvic fossa and along the abdominal aorta. For stage Ib, many authors state the benefits of radiotherapy before surgery to reduce the level of malignancy of cancer cells, destroy the pervasive foci around the primary lesion, and prevent metastasis. In preoperative radiotherapy, the source of radiation used is césium or radium, stop radiation therapy about 6 weeks before surgery, radiotherapy after surgery using Cobalt rays shining into the pelvic area where lymph nodes have been removed.

Stage IIb and stage III: radiotherapy and reassessment to consider indications for surgery. 

Stage IV: radiation therapy and supportive treatment, can apply temporary surgery such as bladder drainage, artificial anus.

Prognosis

Prognostic factors: depends on the stage of the disease, lymph node metastasis, the size of cancer, the patient's condition, and the severity of the surgery.

The survival rate after 5 years:

Intracellular cancer stage: 100%.

Stage I: 80%.

Stage II: 50%.

Stage III: 20-30%.

Stage IV: less than 10%.

Prevention

Cervical cancer is dangerous because it causes high mortality in the invasive stage, but progresses slowly, if detected early, it can be cured. Therefore, the prevention of cervical cancer plays a huge role in reducing morbidity and mortality. To prevent disease, it is recommended that women:

Little birth.

Practice good women's hygiene.

Periodic gynecological examination, at least 1 time/year to perform screening tests (making vaginal - cervical smear ...) or go to a specialist facility when there are abnormal signs such as bleeding after intercourse, abnormal gas damage.

Early and thorough treatment of benign cervical lesions.

Avoid having sex too soon, avoid having multiple sex partners.