Cervical cancer

Cervical Cancer
Classification and external resources

Histopathologic image (H&E stain) of carcinoma in situ, stage 0.

Cervical cancer is malignant neoplasm of the cervix uteri or cervical area. One of the most common symptoms is abnormal vaginal bleeding, but in some cases there may be no obvious symptoms until the cancer is in its advanced stages.[1] Treatment consists of surgery (including local excision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease. Pap smear screening can identify potentially precancerous changes. Treatment of high grade changes can prevent the development of cancer. In developed countries, the widespread use of cervical screening programs has reduced the incidence of invasive cervical cancer by 50% or more.[citation needed] Human papillomavirus (HPV) infection is a necessary factor in the development of almost all cases of cervical cancer.[1][2] HPV vaccines effective against the two strains of HPV that currently cause approximately 70% of cervical cancer have been licensed in the U.S, Canada, Australia and the EU.[3][4] Since the vaccines only cover some of the cancer causing ("high-risk") types of HPV, women should seek regular Pap smear screening, even after vaccination.[5]

Cervix in relation to upper part of vagina and posterior portion of uterus.

Cervical cancer seen on a T2 weighted saggital MR image of the pelvis. The cervix is the narrow portion of the uterus where it joins with the top of the vagina. Most cervical cancers are squamous cell carcinomas, arising in the squamous (flattened) epithelial cells that line the cervix. Adenocarcinoma, arising in glandular epithelial cells is the second most common type. Very rarely, cancer can arise in other types of cells in the cervix.

Signs and symptoms

The early stages of cervical cancer may be completely asymptomatic.[1][6] Vaginal bleeding, contact bleeding or (rarely) a vaginal mass may indicate the presence of malignancy. Also,

moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs or elsewhere. Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or faeces from the vagina,[7] and bone fractures.

Causes
Human papillomavirus (HPV) infection with high-risk types has been shown to be a necessary factor in the development of cervical cancer.[8] HPV DNA may be detected in virtually all cases of cervical cancer.[1][8][2] Not all of the causes of cervical cancer are known. Several other contributing factors have been implicated.[9]

Human papillomavirus infection

In the United States each year there are more than 6.2 million new HPV infections in both men and women, according to the CDC, of which 10 percent will go on to develop persistent dysplasia or cervical cancer. That is why HPV is known as the "common cold" of the sexually transmitted infection world. It is very common and affects roughly 80 percent of all sexually active people, whether they have symptoms or not. The most important risk factor in the development of cervical cancer is infection with a high-risk strain of human papillomavirus. The virus cancer link works by triggering alterations in the cells of the cervix, which can lead to the development of cervical intraepithelial neoplasia, which can lead to cancer. Women who have many sexual partners (or who have sex with men who had many other partners) have a greater risk.[10][11] More than 150 types of HPV are acknowledged to exist (some sources indicate more than 200 subtypes). Genital warts are caused by various strains of HPV which are usually not related to cervical cancer. However, it is possible to have multiple strains at the same time, including those that can cause cervical cancer along with those that cause warts. The medically accepted paradigm, officially endorsed by the American Cancer Society and other organizations, is that a patient must have been infected with HPV to develop cervical cancer, and is hence viewed as a sexually transmitted disease (although many dispute that, technically, it is the causative agent, not the cancer, that is a sexually transmitted disease), but most women infected with high risk HPV will not develop cervical cancer.[16] Use of condoms reduces, but does not always prevent transmission. Likewise, HPV can be transmitted by skin-to-skin-contact with infected areas. In males, there is no commercially available test for HPV, although HPV is thought to grow preferentially in the epithelium of the glans penis, and cleaning of this area may be preventative.[citation needed]

Cofactors

The American Cancer Society provides the following list of risk factors for cervical cancer: human papillomavirus (HPV) infection, smoking, HIV infection, chlamydia infection, stress and stress-related disorders, dietary factors, hormonal contraception, multiple pregnancies, exposure to the hormonal drug diethylstilbestrol, and family history of cervical cancer.[10] Early age at first intercourse and first pregnancy are also considered risk factors, magnified by early use of oral contraceptives.[17] There is a possible genetic risk associated with HLA-B7.[citation needed] There has not been any definitive evidence to support the claim that circumcision of the male partner reduces the risk of cervical cancer, although some researchers say there is compelling epidemiological evidence that men who have been circumcised are less likely to be infected with HPV.[18] However, in men with low-risk sexual behaviour and monogamous female partners, circumcision makes no difference to the risk of cervical cancer.[19]

Diagnosis
Biopsy procedures
While the pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix.[1] Colposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the diagnosis. Further diagnostic and treatment procedures are loop electrical excision procedure (LEEP) and conization, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe cervical intraepithelial neoplasia.

This large squamous carcinoma (bottom of picture) has obliterated the cervix and invaded the lower uterine segment. The uterus also has a round leiomyoma up higher.

Micrograph of a (cervical) adenosquamous carcinoma, a type of cervical cancer. H&E stain.

Precancerous lesions
Cervical intraepithelial neoplasia, the potential precursor to cervical cancer, is often diagnosed on examination of cervical biopsies by a pathologist. For premalignant dysplastic changes, the CIN (cervical intraepithelial neoplasia) grading is used. The naming and histologic classification of cervical carcinoma percursor lesions has changed many times over the 20th century. The World Health Organization classification[20][21] system was descriptive of the lesions, naming them mild, moderate or severe dysplasia or carcinoma in situ (CIS). The term, Cervical Intraepithelial Neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardise treatment.[21] It classifies mild dysplasia as CIN1, moderate dysplasia as CIN2, and severe dysplasia and CIS as CIN3. More recently, CIN2 and CIN3 have been combined into CIN2/3. These results are what a pathologist might report from a biopsy. These should not be confused with the Bethesda System terms for Pap smear (cytopathology) results. Among the Bethesda results: Low-grade Squamous Intraepithelial Lesion (LSIL) and High-grade Squamous Intraepithelial Lesion (HSIL). An LSIL Pap may correspond to CIN1, and HSIL may correspond to CIN2 and CIN3,[21] however they are results of different tests, and the Pap smear results need not match the histologic findings.

Cancer subtypes
Histologic subtypes of invasive cervical carcinoma include the following:[22][23] Though squamous cell carcinoma is the cervical cancer with the most incidence, the incidence of adenocarcinoma of the cervix has been increasing in recent decades.[1]

squamous cell carcinoma (about 80-85%[citation needed]) adenocarcinoma (about 15% of cervical cancers in the UK[20])

Note that the FIGO stage does not incorporate lymph node involvement in contrast to the TNM staging for most other cancers.

For cases treated surgically, information obtained from the pathologist can be used in assigning a separate pathologic stage but is not to replace the original clinical stage.

Staging
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and cervical conization.

Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would

be disregarded)

Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina Stage III The tumour extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidney Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous oedema, as such, does not permit a case to be allotted to Stage IV

Prevention
Vaccination
Main article: HPV vaccine Gardasil, is a vaccine against HPV types 6, 11, 16 & 18 which is up to 98% effective.[24] Cervarix has been shown to be 92% effective in preventing HPV strains 16 and 18 and is effective for more than four years.[25] Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases. HPV types 6 and 11 cause about 90% of genital wart cases. HPV vaccines have also been shown to prevent precursors to some other cancers associated with HPV.[26][27] HPV vaccines are targeted at girls and women of age 9 to 26 because the vaccine only works if given before infection occurs; therefore, public health workers are targeting girls before they begin having sex. The vaccines have been shown to be effective for at least 4[5] to 6[28] years, and it is believed they will be effective for longer,[29] however the duration of effectiveness and whether a booster will be needed is unknown.

The use of the vaccine in men to prevent genital warts, anal cancer, and interrupt transmission to women or other men is initially considered only a secondary market. The high cost of this vaccine has been a cause for concern. Several countries have or are considering programs to fund HPV vaccination.

Condoms
Condoms offer some protection against cervical cancer.[30] Evidence on whether condoms protect against HPV infection is mixed, but they may protect against genital warts and the precursors to cervical cancer.[30] They also provide protection against other STDs, such as HIV and Chlamydia, which are associated with greater risks of developing cervical cancer. Condoms may also be useful in treating potentially precancerous changes in the cervix. Exposure to semen appears to increase the risk of precancerous changes (CIN 3), and use of condoms helps to cause these changes to regress and helps clear HPV.[31] One study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women may benefit from the use of condoms.[32][33]

Smoking
Carcinogens from tobacco increase the risk for many cancer types, including cervical cancer, and women who smoke have about double the chance of a nonsmoker to develop cervical cancer.[34][35]

Nutrition
Fruits and vegetables Higher levels of vegetable consumption were associated with a 54% decrease risk of HPV persistence.[36]

Screening
The widespread introduction of the Papanicolaou test, or Pap smear for cervical cancer screening has been credited with dramatically reducing the incidence and mortality of cervical cancer in developed countries.[6] Pap smear screening every 35 years with appropriate follow-up can reduce cervical cancer incidence by up to 80%.[46] Abnormal Pap smear results may suggest the presence of cervical intraepithelial neoplasia (potentially premalignant changes in the cervix) before a cancer has developed, allowing examination and possible preventive treatment. If premalignant disease or cervical cancer is detected early, it can be monitored or treated relatively noninvasively, with little impairment of fertility. Cervical cancer screening is typically recommended starting three years or more after first sex, or starting at age 21 to 25.[47][48][citation needed] Recommendations for how often a Pap smear should be done vary from once a year to once every five years, in the absence of abnormal results.[46]

Guidelines vary on how long to continue screening, but well screened women who have not had abnormal smears can stop screening about age 60 to 70.[47][48][49] To take a Pap smear, the vagina is held open with a speculum, the loose surface cells on the cervix are scraped using a specially shaped spatula and a brush, and the cells are spread on a microscope slide. At a laboratory the slide is stained, examined for abnormal cells and findings are reported. Until recently the Pap smear has remained the principal technology for preventing cervical cancer. However, following a rapid review of the published literature, originally commissioned by NICE,[50] liquid based cytology has been incorporated within the UK national screening programme. Although it was probably intended to improve on the accuracy of the Pap test, its main advantage has been to reduce the number of inadequate smears from around 9% to around 1%.[51] This reduces the need to recall women for a further smear. Automated technologies have been developed with the aim of improving on the interpretation of smears, normally carried out by cytotechnologists. Unfortunately these on the whole have proven less useful; although the more recent reviews suggest that generally they may be no worse than human interpretation.[52] The HPV test is a newer technique for cervical cancer triage which detects the presence of human papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false negative results), but less specific (more likely to produce false positive results) and its role in routine screening is still evolving. Since more than 99% of invasive cervical cancers worldwide contain HPV, some researchers recommend that HPV testing be done together with routine cervical screening.[15] But, given the prevalence of HPV (around 80% infection history among the sexually active population) others suggest that routine HPV testing would cause undue alarm to carriers, more unnecessary follow-up testing and treatment. HPV testing along with cytology significantly increases the cost of screening. VIA/cryo, for visualization of the cervix with acetic acid (vinegar) and treatment with cryotherapy,[53] sometimes with special lights (speculoscopy), or taking pictures for expert evaluation (cervicography) have been evaluated as adjuncts to or replacements for Pap smear screening, especially in countries where Pap smear screening is prohibatively expensive. There are efforts to develop low cost HPV tests which might be used for primary screening of older women in less developed countries.

Treatment
When using the visual methods, the lesions to be treated are the VIA /VILI positive lesions and those suspicious for cancer. A biopsy of the specimen can be taken and sent for histology. All clients with VIA/VILI positive need to be referred to a gynecologist for further treatment.

Some of the treatment options available include: 1. Cryotherapy; involves is-application of a low temperature metal probe to freeze the abnormal lesion 2. Loop electrosurgical excision procedure (LEEP)/ Large loop excision of the transformation zone (LLETZ) is an excisional method, using a thin electric wire to remove the entire transformation zone (TZ) and thus remove the affected tissue.

Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.[54] If a cone biopsy does not produce clear margins,[55] one more possible treatment option for patients who want to preserve their fertility is a trachelectomy.[56] This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care,[57] as few doctors are skilled in this procedure. Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown. If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the patient has given prior consent. Due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the uterus for pathologic evaluation. A radical trachelectomy can be performed abdominally[58] or vaginally[59] and there are conflicting opinions as to which is better.[60] A radical abdominal trachelectomy with lymphadenectomy usually only requires a two to three day hospital stay, and most women recover very quickly (approximately six weeks). Complications are uncommon, although women who are able to conceive after surgery are susceptible to preterm labor and possible late miscarriage.[61] It is generally recommended to wait at least one year before attempting to become pregnant after surgery.[62] Recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomy.[57] Yet, it is recommended for patients to practice vigilant prevention and follow up care including pap screenings/colposcopy, with biopsies of the remaining lower uterine segment as needed (every 34 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to conceive. Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). Patients treated with surgery who have high risk features found on pathologic examination are given radiation therapy with or without chemotherapy in order to reduce the risk of relapse.

Larger early stage tumors (IB2 and IIA more than 4 cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy. Advanced stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy. On June 15, 2006, the US Food and Drug Administration approved the use of a combination of two chemotherapy drugs, hycamtin and cisplatin for women with late-stage (IVB) cervical cancer treatment.[63] Combination treatment has significant risk of neutropenia, anemia, and thrombocytopenia side effects. Hycamtin is manufactured by GlaxoSmithKline.