Carcinoma of Cervix

Overview

The cervix is the most common site for female genital cancer. Among women dying from malignant disease of all kinds, the cervix is the organ primarily involved in 5%. Statistics vary considerably from country to country and from race to race.

So, in African and Asian women living in poor conditions the incidence and relative mortality rate of carcinoma of the cervix may be four or five times higher than those seen in developed countries. With the modern shifts in populations and migrations, the extent of the problem may fluctuate in the same area from time to time.

Ratio:

It used to be said that for every case of carcinoma of the endometrium there are three or four of invasive carcinoma of the cervix.

But in western communities this is no longer true and the ratio is approaching 1:1. One explanation of this is that more women are living to a later age which gives them more chance of developing carcinoma corporis.

Cancer cervix is the most common cancer in women of the developing countries where screening facilities are inadequate.

Social and Economic Factors i.e.: –                                            

• women living in poor conditions, with a low income and indifferent education.
• Invasive carcinoma of the cervix is 20 times more common amongst the wives of unskilled laborer’s than it is in those of professional men.

The possible operating factors are i.e.: –

• Low standards of cleanliness
• Coitus or marriage at an early age
• Frequency of sexual intercourse
• Promiscuity of both partners 

Coitus i.e.: –

• The sexually active woman is 2–4 times more likely to develop cancer of the cervix than is the sexually inactive woman.
• The earlier the age of first intercourse, the more the partners, and the more promiscuous the partners, the greater the risk.
• To account for the relationship of cervical cancer to sexual activity, it was once postulated that smegma lying beneath the prepuce of the male phallus is carcinogenic, and this concept was linked with the possible protection offered by circumcision and the increased danger due to poor hygiene.
• Yet smegma was never shown to be carcinogenic, and the male phallus exposed to it continually did not develop malignant disease.

Childbearing i.e.: –

• Invasive cancers occur in multipara.
• High parity means frequent coitus during many years, starting at a young age, and is often associated with poor socioeconomic conditions.

Cervical Irritation and Infection i.e.

• Cervical trauma,
• Chronic cervicitis and ectopy

 Oestrogen i.e.                                                                                               

• While excessive and unbalanced oestrogen stimulation favours the development of cancer of the cervix.
• the disease occurs commonly after ovarian activity has ceased — even after surgical removal of both ovaries.

 Predisposing Histological States i.e.

• Certain histological changes in the cervix which have alleged to be “precancerous”, or which sometimes confused with cancer, include basal cell hyperplasia, squamous cell metaplasia and CIN. Of these, only CIN II-III are likely to be significant forerunners of invasive carcinoma.

Squamous Cell Carcinoma i.e.

• Squamous cell carcinoma usually starts in the area of the squamous-columnar junction (transformation zone) as described above. Occasionally, however, it arises in the endocervix, sometimes deep to the lining.
• Even if not all squamous cell growths begin in reserve cells, those developing in the endocervix almost certainly do. Squamous cell carcinoma of the cervix seen in the micro invasive and invasive forms.
• Some invasive cancers of the cervix are hypertrophic or exophytic, producing a cauliflower-like mass; others are mainly eroding and ulcerative or infiltrative an early growth can simulate an erosion. The squamous cell carcinoma has histological features similar to those of an epithelioma in any site except that pearl formation is unusual.

Proportion

• About 20% of the tumours of the well-differentiated type (often known as “large cell keratinising tumours”). Moderately differentiated tumours (large cell nonkeratinizing tumours) constitute about 60% of the total. The remaining 20% are poorly differentiated (small cell non keratinising tumours).
• However, biopsies taken from different areas of the same tumor often show different degrees of differentiation and different predominant cell types. Two distinctive histological variants of cervical squamous cell carcinoma merit mention; some, usually of the well differentiated type, have cells which contain abundant glycogen and thus appear as “clear” cells, whilst occasionally the poorly differentiated tumours assume a spindle-shaped cell form and so resemble a sarcoma.

Spreading of Carcinoma of Cervix

• By this mechanism the growth spreads to the body of the uterus, the vaginal wall, the bladder, and the cellular tissues of the broad and uterosacral ligaments. Direct invasion of the rectum is rare because the pouch of Douglas intervenes.
• In the broad ligament the growth surrounds and constricts the lower ends of the ureters but does not invade them. Similarly, when it reaches the pelvic wall and the sacral plexus, it causes sciatic pain but the nerves and their sheaths are never demonstrably penetrated.

Lymphatic Permeation and Embolism i.e.

• Spread by the lymphatics in the bases of the broad ligaments and in the uterosacral ligaments is an early feature, the nodes most commonly involved being the obturator, external iliac and those at the bifurcation of the common iliac vessels. Others are the internal iliac, common iliac, sacral and ultimately the para-aortic nodes.

Bloodstream i.e.

• This route much less frequently use but embolic metastases are occasionally seen in the ovary, brain, bones and lungs.
• The occurrence of distant metastases without simultaneous involvement of the lungs explain by the transfer of cancer cells by the vertebral venous plexus

Sign and symptoms of Carcinoma of Cervix

Women with early cervical cancers and pre-cancers usually have no symptoms.

Symptoms often do not begin until the cancer becomes larger and grows into nearby tissue.

The most common symptoms i.e.

• Abnormal vaginal bleeding, such as bleeding after vaginal sex, bleeding after menopause, bleeding and spotting between periods, or having (menstrual) periods that are longer or heavier than usual. Bleeding after douching may also occur.
• An unusual discharge from the vagina − the discharge may contain some blood and may occur between your periods or after menopause.
• Pain during sex
• Pain in the pelvic region

Signs and symptoms seen with more advanced disease can i.e.:

• Swelling of the legs
• Problems urinating or having a bowel movement
• Blood in the urine.

• Pyometra
• Vesicovaginal
• Vesicocervical fistulas
• Rectovaginal fistula
• Hydro nephrosis and Pyonephrosis
• Uraemia

Diagnosis of Carcinoma of Cervix

• Cervical Biopsy-

The diagnosis can only made for certain by microscopic examination of cervical tissue. The site of biopsy is usually clear when the disease is clinically evident.

• Cytodiagnosis-

Although the findings on routine Cytodiagnosis can a means of stimulating the investigation which reveals an early symptomless invasive carcinoma, cytology is not a diagnostic method.

• Colposcopy and Colpomicroscopy-

These techniques can, in the hands of experts, reveal cancer which is not apparent to the naked eye. The diagnosis, however, still has to be confirmed by biopsy, so their chief value is to indicate the sites from which tissue can most profitably be taken for histological examination.

1] Cervical Screening

• Data from many countries have shown that screening with cervical cytology reduces the incidence and mortality from cervical cancer.
• The purpose of a cervical screening programme is to reduce the incidence and mortality of cervical cancer.
• Cervical cytology is the most used method of screening.

2] Screening Guidelines

• This depends on the particular age distribution of deaths from cervical cancer and may be “country specific”. Deaths from cervical cancer are rare before age of 25 years.
• Women can be discharged from the screening programme at the age of 65 if they have had two negative smears in the previous 10.

3] Refer for colposcopy:

For moderate or severe dyskaryosis, query invasive disease or query glandular neoplasia.

• Pap smear has reduced the incidence of cervical cancer by nearly 80 percent and death by 70 percent. Cervical cancer is an entirely preventable disease as the different screening, diagnostic and therapeutic procedures are effective.

• Maintaining a diet rich in fruits and vegetables
• High levels of carotenoids
• Foods high in folate like legumes, whole grains, fruits, and vegetables
• Avoiding multiple sexual partners
• Vaccinating both children for HPV