Invasive Cervical Cancer 2
◈ Invasive Cervical Cancer
1. Epidemiology (From 2001년도 한국중앙암등록 사업) ; 등록분율
2. Risk factors
: young age at first intercourse(<16 year)
: multiple sexual partners
: cigarette smoking
: race
: high parity
: low socioeconomic status
: oral contraceptive - controversial
* Many these risk factors are linked to sexual activity and exposure to sexually transmitted diseases
* Viral association - Human papillomavirus(HPV)
: 99% of women with squamous cervical carcinoma
: > 80 types of HPV
=> 13 high-risk HPV subtype
=> HPV type 16 and 18 : most high risk factor (62% of cervical carcinoma)
3. Clinical manifestation
=> no specific symptoms for cervical cancer
1) Early Sx : Abnormal vaginal bleeding
- prolonged menstrual period or profuse flow at the time of a normal period
2) Disease progression : initially scant serosanguineous discharge -> grossly hemorrhagic
: daily appearance of a little blood, usually noted after voiding
3) Advanced stages : characteristic bloody, malodorous discharge, together with pain from fistula formation or nerve irritation
(Pain - sciatic distribution ; radiate to the back of the buttock, thigh, and knee)
* Endophytic tumor : may cause little or no bleeding or discharge
: may spread rapidly to the sacral plexus and produce severe pain
* Two types of gross lesions
(1) Exophytic (proliferative) lesion - involve the entire cervix and have a cauliflowerlike appearance
(2) Endophytic (ulcerating) lesion - predilection to invade upward into the endocervical canal
=> Endophytic lesion이 더 일찍 침윤하는 경향이 있지만 침범하는 부위는 비슷하다.
4. Diagnosis
Suspected Sx
↓
Physical examination
↓
Cervical biopsy
5. Differential Diagnosis
1) Benign lesions : polyps, papillary endocervicitis, papillomas, tuberculosis, syphilitic chancres, and granuloma inguinale
2) Direct extension of cancer : cancers from the corpus or the vagina
3) Metastatic cancer : ovarian, bladder, and breast carcinomas
6. `Pathology
1) Squamous cell carcinoma : 80%
- 3 types : keratinizing, nonkeratinizing, and small-cell carcinoma
: 이중 small cell carcinoma는 clinical outcome이 다른 것들과 다르다
- extremely aggressive, propensity for distant metastasis
2) Adenocarcinoma : 10~15% ( 25% in women younger than 35 years)
3) The others : sarcomas, melanoma, choriocarcinoma, lymphomas, secondary tumors
* 'invasive' cancer : the breakdown of the basement membrane and the involvement of the stroma
7. Mode of spread
=> direct local invasion, lymphatic metastasis, hematologic metastasis, peritoneal implantation
: Contiguous spread to the 1)vagina and 2)uterine cavity and 3)laterally through the cardinal and uterosacral ligaments
* Lateral spread -> encompass and obstruct the ureters -> hydroureter -> hydronephrosis -> loss of kidney function -> uremia -> death
* Extension into the bladder or bowel -> vesicovaginal or rectovaginal fistulas
: Lymph node metastases
: Distant organ metastases
- lung, liver, and bone
8. Clinical Staging of Cervical Cancer
=> FIGO staging
; Current clinical and radiographic modalities used to stage
- physical examination under anesthesia (pelvic & rectal), cystoscopy, proctoscopy,
intravenous urogram, and chest radiograph
; vary with the experience of the examiner
; discrepancies between the clinical staging and the surgical findings : 25-40%
: 25% of metastasis to the pelvic or paraaortal lymph nodes - not detected by clinical examination
=> imaging study의 역할 증대 (but 아직 FIGO staging에 반영되지는 않고 있음)
(From Imaging of cancer of the cervix, Scheidler J - Radiol Clin North Am 2002; 40(3): 577-90)
US -> Physical examination과 동급으로 여기고 staging에는 부적합
CT -> tumor size, stromal invasion - accuracy 60%
lymph node metastasis - accuracy 86%
parametrial involvement - accuracy 55~70%
MRI -> the most reliable pretherapeutic modality(accuracy 90%)
lymph node metastasis는 CT와 비슷
; final staging cannot be changed once therapy has begun
9. Treatment
1) Therapeutic modalities
* 1차 치료 방법: surgery, radiation
* Complication of surgery
1) Acute complications : blood loss, ureterovaginal fistula, vesicovaginal fistula, pulmonary embolism, small bowel obstruction, febrile morbidity(infection)
2) Subacute complications : bladder dysfunction, lymphcyst
3) Chronic complications : bladder hypotonia or atony, ureteral stricture
* Complication of radiation
1) Acute complication : 방사선 숙취, diarrhea, cystitis Sx(hematuria)
2) Chronic complication : bladder, rectum, sigmoid colon, small intestine, vagina 등의 장애
; ulcer, obstruction, stricture, abnormal function, fistula, etc.
* Types of hysterectomy
(1) Type I Hysterectomy (= Extrafascial or simple hysterectomy)
(2) Type II Hysterectomy (= Modified radical hysterectomy)
: removal of medical ½ of cardinal lig. & uterosacral lig.
: selective removal of enlarged lymph node
(3) Type III Hysterectomy (= Radical hysterectomy)
: pelvic lymph node dissection
: removal of most cardinal lig. & uterosacral lig.
: removal of upper ⅓ of vagina
(4) Type Ⅳ Hysterectomy (= Extended radical hysterectomy)
: removal of periureteral tissue, sup. vesical artery, up to ¾ of vagina
(5) Type Ⅴ Hysterectomy (= Partial exenteration)
: anterior exenteration - removal of the bladder, vagina, cervix, and uterus
: posterior exenteration - removal of the rectum, vagina, cervix, and uterus
2) Treatment by stage
3) Recurrent cervical cancer
(1) Curative Tx
: prior surgery -> radiation
: prior radiation -> surgery (exenteration OP)
(2) Palliative Tx
: chemotherapy( cisplatin only - 18% response, 기타 여러 combination trial이 시도되는 중)
: localized metastatic lesion -> radiotherapy
10. Prognosis
=> Stage 이외에 lymph node invasion 여부에 따라 예후가 달라진다.
- Negative lymph node -> 85-90% of 5-year survival
- Positive lymph node -> 20-74% of 5-year survival
11. Screening
: PAP smear - 성생활을 하는 모든 여성을 대상으로 최소 1년에 1회, 고위험 여성의 경우 6개월에 1회
1. Epidemiology (From 2001년도 한국중앙암등록 사업) ; 등록분율
2. Risk factors
: young age at first intercourse(<16 year)
: multiple sexual partners
: cigarette smoking
: race
: high parity
: low socioeconomic status
: oral contraceptive - controversial
* Many these risk factors are linked to sexual activity and exposure to sexually transmitted diseases
* Viral association - Human papillomavirus(HPV)
: 99% of women with squamous cervical carcinoma
: > 80 types of HPV
=> 13 high-risk HPV subtype
=> HPV type 16 and 18 : most high risk factor (62% of cervical carcinoma)
3. Clinical manifestation
=> no specific symptoms for cervical cancer
1) Early Sx : Abnormal vaginal bleeding
- prolonged menstrual period or profuse flow at the time of a normal period
2) Disease progression : initially scant serosanguineous discharge -> grossly hemorrhagic
: daily appearance of a little blood, usually noted after voiding
3) Advanced stages : characteristic bloody, malodorous discharge, together with pain from fistula formation or nerve irritation
(Pain - sciatic distribution ; radiate to the back of the buttock, thigh, and knee)
* Endophytic tumor : may cause little or no bleeding or discharge
: may spread rapidly to the sacral plexus and produce severe pain
* Two types of gross lesions
(1) Exophytic (proliferative) lesion - involve the entire cervix and have a cauliflowerlike appearance
(2) Endophytic (ulcerating) lesion - predilection to invade upward into the endocervical canal
=> Endophytic lesion이 더 일찍 침윤하는 경향이 있지만 침범하는 부위는 비슷하다.
4. Diagnosis
Suspected Sx
↓
Physical examination
↓
Cervical biopsy
5. Differential Diagnosis
1) Benign lesions : polyps, papillary endocervicitis, papillomas, tuberculosis, syphilitic chancres, and granuloma inguinale
2) Direct extension of cancer : cancers from the corpus or the vagina
3) Metastatic cancer : ovarian, bladder, and breast carcinomas
6. `Pathology
1) Squamous cell carcinoma : 80%
- 3 types : keratinizing, nonkeratinizing, and small-cell carcinoma
: 이중 small cell carcinoma는 clinical outcome이 다른 것들과 다르다
- extremely aggressive, propensity for distant metastasis
2) Adenocarcinoma : 10~15% ( 25% in women younger than 35 years)
3) The others : sarcomas, melanoma, choriocarcinoma, lymphomas, secondary tumors
* 'invasive' cancer : the breakdown of the basement membrane and the involvement of the stroma
7. Mode of spread
=> direct local invasion, lymphatic metastasis, hematologic metastasis, peritoneal implantation
: Contiguous spread to the 1)vagina and 2)uterine cavity and 3)laterally through the cardinal and uterosacral ligaments
* Lateral spread -> encompass and obstruct the ureters -> hydroureter -> hydronephrosis -> loss of kidney function -> uremia -> death
* Extension into the bladder or bowel -> vesicovaginal or rectovaginal fistulas
: Lymph node metastases
: Distant organ metastases
- lung, liver, and bone
8. Clinical Staging of Cervical Cancer
=> FIGO staging
; Current clinical and radiographic modalities used to stage
- physical examination under anesthesia (pelvic & rectal), cystoscopy, proctoscopy,
intravenous urogram, and chest radiograph
; vary with the experience of the examiner
; discrepancies between the clinical staging and the surgical findings : 25-40%
: 25% of metastasis to the pelvic or paraaortal lymph nodes - not detected by clinical examination
=> imaging study의 역할 증대 (but 아직 FIGO staging에 반영되지는 않고 있음)
(From Imaging of cancer of the cervix, Scheidler J - Radiol Clin North Am 2002; 40(3): 577-90)
US -> Physical examination과 동급으로 여기고 staging에는 부적합
CT -> tumor size, stromal invasion - accuracy 60%
lymph node metastasis - accuracy 86%
parametrial involvement - accuracy 55~70%
MRI -> the most reliable pretherapeutic modality(accuracy 90%)
lymph node metastasis는 CT와 비슷
; final staging cannot be changed once therapy has begun
9. Treatment
1) Therapeutic modalities
* 1차 치료 방법: surgery, radiation
* Complication of surgery
1) Acute complications : blood loss, ureterovaginal fistula, vesicovaginal fistula, pulmonary embolism, small bowel obstruction, febrile morbidity(infection)
2) Subacute complications : bladder dysfunction, lymphcyst
3) Chronic complications : bladder hypotonia or atony, ureteral stricture
* Complication of radiation
1) Acute complication : 방사선 숙취, diarrhea, cystitis Sx(hematuria)
2) Chronic complication : bladder, rectum, sigmoid colon, small intestine, vagina 등의 장애
; ulcer, obstruction, stricture, abnormal function, fistula, etc.
* Types of hysterectomy
(1) Type I Hysterectomy (= Extrafascial or simple hysterectomy)
(2) Type II Hysterectomy (= Modified radical hysterectomy)
: removal of medical ½ of cardinal lig. & uterosacral lig.
: selective removal of enlarged lymph node
(3) Type III Hysterectomy (= Radical hysterectomy)
: pelvic lymph node dissection
: removal of most cardinal lig. & uterosacral lig.
: removal of upper ⅓ of vagina
(4) Type Ⅳ Hysterectomy (= Extended radical hysterectomy)
: removal of periureteral tissue, sup. vesical artery, up to ¾ of vagina
(5) Type Ⅴ Hysterectomy (= Partial exenteration)
: anterior exenteration - removal of the bladder, vagina, cervix, and uterus
: posterior exenteration - removal of the rectum, vagina, cervix, and uterus
2) Treatment by stage
3) Recurrent cervical cancer
(1) Curative Tx
: prior surgery -> radiation
: prior radiation -> surgery (exenteration OP)
(2) Palliative Tx
: chemotherapy( cisplatin only - 18% response, 기타 여러 combination trial이 시도되는 중)
: localized metastatic lesion -> radiotherapy
10. Prognosis
=> Stage 이외에 lymph node invasion 여부에 따라 예후가 달라진다.
- Negative lymph node -> 85-90% of 5-year survival
- Positive lymph node -> 20-74% of 5-year survival
11. Screening
: PAP smear - 성생활을 하는 모든 여성을 대상으로 최소 1년에 1회, 고위험 여성의 경우 6개월에 1회