CERVICAL CANCER

DR DASHIT, F. M.

MBBS  (UNIJOS)

pic culled from news-medical.net

OUTLINE

Cervical cancer is a potentially preventable disease, and it is the second most common cancer in women worldwide.
In northern Nigeria it is the most common cancer in women while in Southern Nigeria it is second to Breast Cancer.
Cervical screening allows the detection of the curable premalignant disease.

Cervical cancer usually occurs in the fifth and sixth decade of life at a mean age of 54 years.
The premalignant disease frequently occurs in younger women often under the age of 40 years.
It is common in women of low socioeconomic status.
Cervical cancer is rare or almost unknown in virgins.

The cevix is the narrow part of the uterus. It pierces the anterior wall of the vagina and is divided into supravaginal and vaginal parts.
The cervical canal communicates with the uterine cavity via the internal os and the vaginal canal via the external os.
The ectocervix is lined by stratified squamous non-keratinized epithelium.
The endocervix is lined by mucus-secreting columnar epithelium.
The squamocolumnar junction(the area where the endocervix and ectocervix meet)
The SCJ is dynamic and this forms the TZ(transformation zone)

Human papilloma virus(HPV) is the most oncogenic cause of cervical cancers.HPV type 16,18,31 and 33.Other implicated carcinogens are HSV-2 and the histone and protamine of the sperm.
Below are the high-risk factors:
Early coitarche(before the age of 18 years)
Early first child birth(before the age of 20years)
Multiple sexual partners
High-risk males
Multiparity with poor birth spacing
Smoking and drug abuse including alcohol
Immunosuppressed states e.gHIV/AIDS,Hodgkin’s disease
Long-term use oral of contraceptive pills over 8-year period doubles the risk of adenocarcinoma
Women who do not come for regular check up pap smear.

The premalignant disease,also known as CIN,precedes the invasive disease by about 10-15years
The persistence of HPV infections in the cervix induces cervical dysplasia in which the cells resemble cancer cells.
CIN is a histopathological description in which a part or the full thickness of the stratified squamous is replaced by dysplastic cells, however the basement membrane remains intact.
There exists CIN1,CIN2 and CIN3 depending on the depth of neoplasia.
CIN I and CIN 2 can regress back to normal, remain static or progress to CIN3 which is more susceptible to progression to malignant disease.

The essence of cervical screening is to detect these premalignant lesions early enough to institute curative therapeutic measures thereby abating their progression to cervical cancer which is very challenging to manage.
The following treatment options are available depending on some factors:
Observation with repeat smear and colposcopy every 4-6 months.
Local ablative methods:cryotherapy,electrodiathermy,cold coagulation and laser vaporization.
Excisional methods:LLETZ,cone excision
Hysterectomy.

Cervical cancer is squamous cell carcinoma in 90-95% of cases and an adenocarcinoma in the remaining 5-10%.
It arises from either the ectocervix or from the endocervix.
The site of growth bears no relation to the histological type as some squamous carcinomas are found in the endocervical canal.
The tumour is grossly of 3 types:ulcerative,proliferative,and excavating.
Cancers of the cervix are spread via the direct,haematogenous and lymphatic routes.

In the early stage the patient may be asymptomatic; or presents with:
Vaginal bleeding in the form of postcoital bleeding,irregular bleeding, intermenstrual bleeding, and postmenopausal bleeding.
Vaginal discharge which is usually watery, blood-stained and of offensive odour.
In the advanced stage patients may present with:pain, diarrhoea or constipation, haematuria;urinary and faecal incontinence; oedema of the leg.
In terminal cases there is weight loss, oliguria/anuria.
On examination, the patient may or may not look ill, has offensive odour, is pale and cachetic.

Carcinoma of the cervix must be differentiated from other causes of contact bleeding like:
Cervicitis with ectopy
Mucous cervical polyps
Primary chancre
Schistosomiasis of the cervix
Tuberculosis of the cervix
Fibroid polyps
Septic abortion with products of conception extruding from the os may be mistaken for carcinoma

Primary prevention: It involves identifying the causal factors and eliminating or preventing those from exerting their effects. These are easily said but difficult to implement in practice.
Prophylactic HPV vaccine: These vaccines are cervarix(HPV types 16 & 18) and gardasil(HPV types 16, 18, 6, and 11).
Use of condom during early intercourse, raising the age of marriage and of first birth, limitation of family, maintenance of local hygiene, and effective treatment of STIs are positive steps in prevention.
Total hysterectomy as a routine for benign lesion is a definite step in prevention of stump carcinoma.
Secondary prevention involves identifying and treating the disease earlier in the more treatable stage.

The treatment of cervical cancer is highly specialised and involves the combined effort of the gynaecologist and radiotherapist.
There are 3 modes of treatment: surgery alone,radiotherapy alone and combined surgery and radiotherapy.

Cervical cancer is often a preventable disease.
Creation of awareness for cervical cancer and its prevention, prevention of sexually transmitted disease
Adolescent reproductive health education
Provision of resources necessary to perform and interpret pap smear.

Textbook of Obstetrics and Gynaecology for Medical Students Second edition Edited by Akin agboola
Shaw’s Textbook of Gynaecology 16th Edition
DC Dutta’s Textbook of Gynaecology 7th edition.