Cervical Cancer #1. Epidemiology, risk factor, evaluation, staging

다음주 부터는 주로 부인과를 돌게 되었습니다. 아마 추석 지나고 수술이 굉장히 많을 것이라 예상이 됩니다만, 어떻게든 지나가겠죠! ㅎㅅㅎ Novak을 찾아봅시다~ novak

• Human papillomavirus (HPV) infection is the causal agent of cervical cancer.
• Screening programs are effective at decreasing the incidence of cervical cancer.
• Although the most common histologic type of cervical cancer is squamous, the relative and absolute incidence of adenocarcinoma is increasing.
• Cervical cancer is clinically staged, although modern radiographic modalities such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or positon emission tomography (PET) may be beneficial for individual treatment planning. (치료계획으론 이용할 수 있으나 진단으로 영상학적 검사는 사용하지 않아요, sensitivity도 낮고 위양성율도 굉장히 높아요. 다만 a recent systematic review comparing CT scan(80%) with MRI has shown that MRI is significantly more sensitive with equivalent specificity)
• Treatment of cervical cancer is based on stage of disease. In general, early stage disease(Ia~IIa) can be treated with either radical surgery or radiation therapy. Advanced stage disease (IIb~IV) is best treated with chemoradiation.
• Vaginal cancer is a rare disease with many similarities to cervical cancer. Radiation therapy is the mainstay of treatment for most patients; however, select patients may be treated with radical surgery.
  
  

Cervical Cancer

Epidemiology and Risk Factors

1)Invasive cancer of the cervix is considered a preventable disease because it has a long preinvasive state, cervical cytology screening programs are currently available, and the treatment of preinvasive lesions is effective.

2)There are numerous risk factors for cervical cancer: young age at first intercourse (<16 years), multiple sexual partners, cigarette smoking, race, high parity, and lower socioeconomic status.

3)The initiating event in cervical dysplasia and carcinogenesis is infection with HPV.

Evaluation

1)Vaginal bleeding is the most common symptom occurring in patients with cancer of the cervix. Most often, this is postcoital bleeding, but it may occur as irregular or postmenopausal bleeding as well. Patients with advanced disease may present with a malodorous vaginal discharge, weight loss, or obstructive uropathy. In asymptomatic women, cervical cancer is most commonly identified through evaluation of abnormal cytologic screening tests. 

요약: 증상으로는 질출혈이 가장 흔하다. 성교 후 많지만 언제든 피날 수 있고, 진행한 경우 다른 증상들을 나타낼 수 있다. 무증상의 경우 pap smear 상 이상소견이 많다.

2)On pelvic examination, a speculum is inserted into the vagina, and the cervix is inspected for suspicious areas. The vaginal fornices should also be closely inspected. With invasive cancer, the cervix is usually firm and expanded, and these features should be confirmed by digital examination. Rectal examination is also important to help establish cervical consistency and size, particularly in patients with endocervical carcinomas.

요약 : 골반내진에서 먼저 질경을 통해 경부 모양을 관찰하고, 손가락으로 딱딱한 정도와 크기를 만져본다. 직장검사는 경부안쪽 암의 여부와 크기를 알기 위해 필요하다. 

When obvious tumor growth is present, a cervical biopsy is usually sufficient for diagnosis. If gross disease is not present, a colposcopic examination with cervical biopsies and endocervical curettage is warranted. If the diagnosis cannot be established conclusively with colposcopy and directed biopsies, cervical conization may be necessary.

요약 : 병변이 눈으로 보이면 생검해서 진단하고, 안보이면 colposcopy를 통해 생검하거나 자궁 안쪽을 긁어내는 것이 권장된다. 그래도 진단이 완전히 안될 경우 conization이 필요할 수 있다.(원추절제술)

3)Colposcopic Findings of Invasion

Colposcopic examination is mandatory for patients with (Ix.)suspected early invasive cancer based on cervical cytology and a grossly normal-appearing cervix. Colposcopic findings that suggest invasion are (i) abnormal blood vessels, (ii) irregular surface contour with loss of surface epithelium, and (iii) color tone change. Colposcopically directed biopsies may permit the diagnosis of frank invasion and thus avoid the need for diagnostic cone biopsy, allowing treatment to be administered without delay.

(i)Abnormal Blood Vessels

Abnormal vessels may be looped, branched, or reticular. Abnormal looped vessels are the most common colposcopic finding and arise from the punctated and mosaic vessels present in cervical intraepithelial neoplasia (CIN).

 

(A) Atypical vessels. The lesion on the anterior lip of the cervix exhibits large vessels running horizontal to the surface. The border is very distinct and the edge is raised. The lesion color is more yellow than white. Biopsy revealed invasive squamous carcinoma to a depth of 4 mm. Conization was consistent and radical hysterectomy found no evidence of disease spread. Patient is alive and well 17 years later.

<Sawaya, G, Smith-McCune, K, Glob. libr. women's med., (ISSN: 1756-2228) 2010; DOI 10.3843/GLOWM.10019>

(ii)Irregular Surface Contour

Abnormal surface patterns are observed as tumor growth proceeds. The surface epithelium ulcerates as the cells lose intercellular cohesiveness secondary to loss of desmosomes. Irregular contour also may occur as a result of papillary characteristics of the lesion. This finding can be confused with a benign HPV papillary growth on the cervix. For that reason, biopsies should be performed on all papillary cervical growths to avoid missing invasive disease.

(iii)Color Tone

Color tone may change as a result of increasing vascularity, surface epithelial necrosis, and in some cases, production of keratin. The color tone is yellow-orange rather than the expected pink of intact squamous epithelium or the red of the endocervical epithelium.

Staging

Cervical cancer is a clinically staged disease. The FIGO staging system is the current standard and is applicable to all histologic types of cervical cancer. The current FIGO staging system is presented in Table 34.1 and Figure 34.3. The staging procedures allowed by FIGO are listed in Table 34.2. When there is doubt concerning the stage to which a cancer should be allocated, the earlier stage should be selected. After a clinical stage is assigned and treatment has been initiated, the stage must not be changed because of subsequent findings by either extended clinical staging or surgical staging.

FIGO Staging of Carcinoma of the Cervix Uteri

<reference - Revised FIGO Staging System 유 희 석 | 아주의대 산부인과 | Hee Sug Ryu, MD>

Preinvasive Carcinoma

Stage 0     Carcinoma in situ, intraepithelial carcinoma (cases of stage 0 should not be included in any                    therapeutic statistics). 상피내암

Invasive Carcinoma

Stage I      Carcinoma strictly confined to the cervix (extension to the corpus should be disregarded).

Stage Ia        Preclinical carcinomas of the cervix, that is, those diagnosed only by microscopy.

Stage Ia1   Lesions with less than 3 mm invasion

Stage Ia2   Lesions detected microscopically that can be measured. The upper limit of                 the measurement should show a depth of invasion of 3~5 mm taken from the base of the                 epithelium, either surface or glandular, from which it originates, and a second dimension,                 the horizontal spread, must not exceed 7 mm. Larger lesions should be staged as Ib.

Stage Ib            Lesions invasive > 5 mm.

Stage Ib1     Lesions < 4cm

Stage Ib2     Lesions > 4cm

Stage II    The carcinoma extends beyond the cervix but has not extended onto the wall

The carcinoma involves the vagina, but not the lower one third

Stage IIa    No obvious parametrial involvement

Stage IIb    Obvious parametrial involvement

Stage III    The carcinoma has extended onto the pelvic wall. On rectal examination, there is no 

cancer-free space between the tumor and the pelvic wall. The tumor involves the lower one third of the vagina. All cases with hydronephrosis or nonfunctioning kidney.

Stage IIIa     No extension to the pelvic wall.

Stage IIIb     Extension onto the pelvic wall and/or hydronephrosis or nonfunctioning kidney

Stage IV     The carcinoma has extended beyond the true pelvis or has clinically involved the                 mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be                     allotted to stage IV.

Stage IVa     Spread to the growth to adjacent organs.

Stage IVb     Spread to distant organs.

*Special tip

 자궁경부암의 병기설정에 있어서 몇 가지 논란거리가 있는데, 임상적 병기설정과 수술적 병기설정에 관한 것, 병기 IA1의 임상적 의의에 관한 것(4), 림프혈관 침윤에 대한 것, 림프절 전이상태에 관한 것(5),선암(adenocar-cinoma)의 병기설정에 대한 것 등이 대표적이다. 임상적 병기설정 방법은 최근 영상의학의 발달과 장비의 진보에도 불구하고 수술적 병기설정보다 부정확하다(6). 그러나 국소적으로 진행된 경우에서 수술

이 일차적 치료가 될 수 없고 또한 이러한 환자들은 의료자원이 충분하지않은 환경, 즉 개발도상국에서 많이 발생한다. 수술적 병기설정의 중요성을인정하지만 수술이 아닌 다른 치료방법과 같은 효과를 얻을 수 있는지 아직 확실하지 않다. 따라서 임상적 병기설정으로 지속하기로 결정되었다(Table 2).

<reference - Revised FIGO Staging System 유 희 석 | 아주의대 산부인과 | Hee Sug Ryu, MD>

<reference- Berek & Novak's gynecology. 14th edition>

그림이 짱이네요 ㅋㅋ