Gyn Cervix General

EPIDEMIOLOGY

  • 4th most common malignancy in women
  • The most common malignancy in women of child* bearing ages (15 – 34y)
  • 15,800 new cases a year with 4800 dead/year

RISK FACTORS

  • include low socioeconomic class
  • infectious disease (HPV 18/16/31, HSV II)
  • DES (for clear cell)
  • Smoking
  • Multiple sexual partners
  • Multiple parity
  • obesity
  • early intercourse.

ANATOMY

  • Uterus is located behind the bladder and anterior to rectum.
  • Covered with peritoneum only posteriorly and fundus.
  • Broad Ligaments – two layers of peritoneum extending from lateral aspect of uterus to sidewall; contains the ovaries and encloses the parametria.
  • Round ligaments – band of smooth muscle containing small vessels and nerves running from the anterolateral aspect of the fundus laterally to the sidewall then extends anteriorly through the inguinal ring through the inguinal canal and ending in the superficial fascia.
  • Cardinal ligaments – aka transverse cervical or Mackenrodt’s – Cervix to sidewall and contains uterine vessels
  • Uterine artery is the main blood supply and connects from the anterior division of the hypogastric (int. iliac)
  • Lymphatic drainage:

CLINICAL PRESENTATION

  • Typically present asymptomatically
  • Earliest symptom is abnormal bleeding: post* coital bleeding or vagianl douching.
  • Other symptoms are yellowish discharge, pelvic pain (necrosis, pressure, hydronephrosis), rectal or urinary symptoms. Back pain (+ PAN’s).

NATURAL HISTORY

  • Typically invasive cancer (malignant cells breaking through the basement membrane and into the stroma) occurs at the squamous* columnar junction of the endocervical canal and is preceded by dysplasia and CIS.
  • Barrel lesions are 6cm or greater at UF.
  • Local spread to the endocervix/uterus, vagina, paracervical, parametria, bladder, or bowel.
  • Lymphatic spread to the paracervical, obturator, external iliac, hypogastric, common iliac, sacral, paraaortic nodes, left scalene.
Stage % with + pelvic Nodes % with + aortic nodes OS-5
I 15%
IA1 1%
IA2 5% 95%
IB1 15% 5% 90%
IB1 30% 70%
II 30% 15%
II A 20% 10% 75%
II B 40% 20% 65%
III 45% 25%
IIIA 20% 50%
IIIB 30% 40%
IV >50% 30% 10%
  • Distant metastasis to the lungs, liver, bone.
  • If new lesion after treatment for cervix cancer, it must be 1) different histology, or 2) > 10 years since treatment or it is considered a recurrent cervix cancer, not a new primary.

PROGNOSTIC FACTORS

  • Presence of lymph nodes
  • Extension into the uterus
  • LVSI
  • Histological subtype: High grade adenocarcinoma, adenosquamous, glassy cell, are all bad.

Grade and LVSI are especially prognostic in adenocarcinoma

  • Depth of stromal invasion
  • Tumor size
  • Stage

PATHOLOGY

  • Benign differential: Endocervical polyps, condyloma, columnar eversion, microglandular endocervical hyperplasia,
  • Malignant differential: SSCA(~80%), adenocarcinoma(~20%), adenosquamous, clear cell adenocarcinoma,

Adenoid cystic

  • of cervix is found to be aggressive with high tendency to local recurrence and it also metastasizes early to lymph nodes and distant sites as compared to others
  • Five and 10 years survival of adenoid cystic carcinoma of the salivary gland is reported about 62 and 39% respectively while for cervix these figures are reported as about 37* 40% for four months to 12 year follow* up.

small cell (neuroendocrine)

  • survival rates of < 50% for early stage I disease
  • widespread hematogenous metastases are frequent, but brain metastases are rare unless preceded by pulmonary involvement.
  • glassy cell, sarcoma, mets from GU tumors
  • Micro* invasive disease goes beyond the BM into the stroma but not beyond 3mm deep or 7mm wide.

DIAGNOSIS

  • H/P with pelvic exam (rectal most important for evaluating extent of disease), L supraclav nodes.
  • EUA with cervical biopsy, Colposcopy, Endocervical curettage, D&C if suspect endometrial ca
  • Labs: CBC, Cr/BUN
  • Rays: CXR, IVP (or CT), Proctoscopy, Cystoscopy, Hysteroscopy,

CT scan of abdomen and pelvis needs to be done but not a part of the FIGO staging

  • Biopsy of bladder or rectum must be done before diagnosis of stage IVA disease.
  • Colposcopy is done with Lugol’s solution (acetic acid) to demonstrate areas of dysplasia.
  • Conization/LEEP is done if lesion extends into the endocervix, cannot see a lesion on colposcopy awith an abnormal PAP, and for treatment of high* grade dysplasia and possibly microinvasive disease.
  • Screening PAP: done for 3 consecutive years after become sexually active and then at the discretion of the physician.

STAGING

  • AJCC FIGO
TIS Stage 0 Carcinoma in situ
T1 Stage I Confined to the cervix
T1a1 IA1 ≤ 3mm depth stromal invasion and ≤ 7mm width
T1a2 IA2 3 - 5mm depth and > 7mm width
T1b1 IB1 > 5 mm deep or >7 mm wide or clinically evident
Confined to the cervix, < 4cm
T1b2 IB2 Confined to cervix & > 4 cm
T2 Stage II Beyond the cervix but not to the lower 1/3 of the vagina
T2a IIA proximal 2/3 vagina
T2b IIB Parametrial Involvement
T3 Stage III Within true pelvis
T3a IIIA Distal 1/3 of the vagina
T3b IIIB Pelvic sidewall, hydronephrosis or non* functioning kidney on IVP (LN+ for AJCC only)
T4 Stage IV Beyond the true pelvis or involves the bladder or rectum
IVA Spread to bladder, rectum, pelvic organs (bullous edema must be biopsied)
MI IVB Distant metastases
  • AJCC: Local* Regional Lymphatics: paracervical, obturator, external iliac, hypogastric, common iliac, sacral, paraaortic nodes.
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