Cervix

General Diagnostic Procedures Radiographic studies Laboratory Studies [|Lymphatic drainage of the uterine cervix] || Cervical cancer may also spread to the lower vagina, vulva, lungs, liver and brain through the bloodstream.8 || Grade 1 is a low grade cancer which is a slower growing cancer and is less likely to spread (Poorly differentiated) Grade 2 is a moderate grade cancer which is more likely to grow and spread than a grade 1 cancer (Moderately differentiated) Grade 3 is a high grade cancer which will grow quickly and is likely to spread (Well differentiated) || Pre-cancerous conditions are completely curable when followed up and treated properly. 2 The chance of being alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area is 92%. 2 The 5-year survival rate falls steadily as the cancer spreads into other areas. 2 || Types of surgery for early cervical cancer include: 2 A hysterectomy is rarely used if there is no evidence of spread. Treatment for more advanced cervical cancer may include: Chemotherapy: Sometimes radiation and chemotherapy are used before or after surgery. 2 Radiation may be used to treat cancer that has spread beyond the pelvis, or cancer that has returned. Either external or internal or both. 2 *In the majority of patients with uterine cervix carcinoma, the treatment regimen consists of both external beam irradiation and brachytherapy. 1 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Here is a table illustrating the treatment guidelines for irradiation of the uterine cervix: <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">3 <span style="background-color: #ffffff; display: block; font-family: arial,helvetica,clean,sans-serif; text-align: left; vertical-align: baseline;"> || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">BLADDER--65 Gy <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">RECTUM--60 Gy <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">COLON---45 Gy <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">FEMORAL HEAD--52 Gy <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">SMALL INTESTINE--40Gy ||  ||   ||
 * **Epidemiolgy:** || Cervical cancer is the second most common cause of cancer death in women, with an estimated 510,000 newly diagnosed cervical cancer cases and 288,000 deaths globally. In the United States an estimated 11,150 cases of invasive cervical cancer will be diagnosed in 2012 and an estimated 3,670 women will die from this disease. Cervical cancer usually develops slowly over time. First, the calls of the cervix undergo changes known as dysplasia, where abnormal cells appear in the cervical tissue. Then, cancer cells start to grow and spread into cervix and surrounding tissues. Approximately 70 percent of cervical cancers are caused by human pappiloma virus (HPV) types 16 or 18. About 500,000 precancerous lesions (cervical intraepithelial neoplasia Grade 2 and 3; CIN2 and CIN3) are diagnosed each year in the United States, and about 50 to 60 percent are attributable to HPV16 and HPV18. 6 ||
 * **Etiology:** || * For cervical cancer, the most important risk factor is infection with a human papilloma virus (HPV).
 * Women with low socioeconomic status (less frequent screening)
 * Early sexual activity
 * Multiple sexual partners
 * Oral contraceptive
 * Smoking (women who smoke are about twice as likely to get cervical cancer as those who don't)
 * Human Immunodeficiency Virus (HIV): HIV seems to make a woman's immune system less able to fight both HPV and early cancers.
 * Young age at the time of first full-term pregnancy: Women who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who waited to get pregnant until they were 25 years or older.
 * Family history.7 ||
 * **Signs & Symptoms:** || Pre-cancers and early cancers of the cervix are usually asymptomatic; however, they can be detected by Papanicolaou (PAP) smears. Common signs and symptoms of cervical cancer are:6
 * painful intercourse
 * postoital bleeding
 * more prominent menstrual bleeding or intermenstrual bleeding
 * anemia
 * fatigue
 * vaginal discharge
 * rectal bleeding
 * hematuria ||
 * **Diagnostic Procedures:** || ** Diagnostic Work-up for Carcinoma of the Uterine Cervix ** 5
 * History
 * Physical examination
 * including bimanual pelvic and rectal examinations
 * Cytologic smears (Papanicolaou) if not bleeding
 * Colposcopy
 * Conization (subclinical tumor)
 * Punch biopsies (edge of gross tumr, four quadrants)
 * Dilation and curettage
 * Cytoscopy, rectosigmoidoscopy (stages IIB, III, and IV A)
 * Standard
 * Chest radiography
 * Intravenous pyelography
 * Barium enema (stages III and IVA and earlier stages if there are symptoms referable to colon or rectum)
 * Complementary
 * Lymphangiography
 * Computed tomography or magnetic resonance imaging
 * Positron emission tomography scan (optional)
 * Complete blood count
 * Blood chemistry
 * Urinalysis ||
 * **Histology:** || Invasive cervical cancers comprise approximately 85% of squamous cell varieties, 15% adenocarcinomas, and a rare collection of other entities. 9
 * Squamous Cell Carcinomas ** 9
 * Keratinizing
 * Nonkeratinizing
 * Verrucous
 * Papillary transitional
 * Lymphoepithelial
 * Adenocarcinomas ** 9
 * MucinousEndometroid
 * Endocervial
 * Intestinal
 * Signet ring
 * Clear cell
 * Minimal deviationPapillary villloglandular
 * Adenoma malignum
 * Serous
 * Mesonephric
 * Other types ** 9
 * Adenosquamous
 * Glassy cell
 * Adenoid cystic
 * Adenoid basal
 * Carcinoid
 * Small cell
 * Undifferentiated carcinomas ||
 * **Lymph node drainage:** || The lymphatics of the cervix course in three seperate routes. Laterally, they pass along the uterine artery to the external iliac lymph nodes. Posterolaterally, they pass behind the ureters to the internal iliac nodes, Posteriorly, they enter the common iliac and lateral sacral nodal groups. 9
 * Undifferentiated carcinomas ||
 * **Lymph node drainage:** || The lymphatics of the cervix course in three seperate routes. Laterally, they pass along the uterine artery to the external iliac lymph nodes. Posterolaterally, they pass behind the ureters to the internal iliac nodes, Posteriorly, they enter the common iliac and lateral sacral nodal groups. 9
 * **Metastatic spread:** || Cervical cancer can spread locally to the upper vagina and surrounding tissue, it may also grow into the tissue surrounding the cervix. Cervical cancer may also locally spread into the bladder and rectum. There can also be spread within the abdomen if the tumor penetrates the full thickness of the cervix.If the Cancer reaches the lymphatic system it can spread into the lymph nodes along the pelvic wall. Once there it can spread to other nodal regions in the pelvic area.
 * **Grading:** || Standard grading is applied for cervical cancer:
 * **Staging:** || [[image:uwlmedicaldosimetry2012/staging cervix.JPG]] ||
 * **Radiation side effects:** || * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Several radiosensitive organs are located around this treatment area, and ways to decrease side effects to these critical structures need to be taken. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">1
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">One of the most severe complications is rectovaginal or vesicovaginal fistulas <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">1
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Caused when the vaginal wall is destroyed leaving an opening between either the bladder and vagina or the rectum and bladder
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Other side effects include: <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">1
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Proctitis, cystitis, urethral stricture, rectal ulcer, sigmoid stricture, small bowel obstruction and pelvic abscess.
 * Late complications include:
 * Chronic cystitis( 6 mths post tx at doses above 50-60Gy)
 * Contracture/ hemorrhagic cystitis( dose above 65Gy)
 * Bowel obstruction ( at doses above 45Gy). ||
 * **Prognosis:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">How well the patient does depends on many things, including: <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">2
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The type of cancer
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The stage of the disease
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The woman's age and general physical condition
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">If the cancer comes back after treatment
 * **Treatments:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Treatment of cervical cancer depends on: <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">2
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The stage of the cancer
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The size and shape of the tumor
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The woman's age and general health
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Her desire to have children in the future
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Cryotherapy -- freezes abnormal cells
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Laser therapy -- uses light to burn abnormal tissue
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Radical hysterectomy
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Pelvic exenteration
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Traditional radiation fields consist of the four-field box technique, with anterior, posterior, right and left lateral fields. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">1
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Anterior field extends cephalad from L5-S1 in early disease, and L4-L5 for advanced stages
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Caudal margins extend to the midobturator foramen if no vaginal involvement. If there is vaginal involvements, the inferior margins are extended with about 1.5-2.0 cm
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Lateral margins are 1.5-2.0 cm past the widest section of the bony pelvis
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Anterior marginincludes the symphysis pubis
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Posterior margin includes S2-S3 interspace
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">There is now a prevelance of Intensity Modulated Radiation Therapy for treating these lesions due to the increase in the therapeutic ratio3
 * **TD 5/5:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">TD 5/5 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">4
 * **References** || # <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Bentel GC. //Radiation Therapy Planning//. 2nd ed. The McGraw-Hill Companies; 1996: 445-450, 458
 * 1) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Cervical Cancer. PubMed Health. Available at: []. Accessed: June 2, 2012.
 * 2) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Chao KC, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. 3rd ed. Philadelphia, PA; Lippincott Williams & Wilkins. 2011: 565-571.
 * 3) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: []. Accessed: June 2, 2012.
 * 4) Perez CA, Brady LA, Halpern EC, Schmidt-Ullrich RK. //Principles and Practice of Radiation Oncology//. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004.
 * 5) Chao KC, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. 3rd ed. Philadelphia, PA; Lippincott Williams & Wilkins. 2011: 565-571
 * 6) American Cancer Society. Cervical Cancer Overview. Available at: []. Accessed at: June 18, 2012.
 * 7) Women’s cancer information center-Cervix, Stern J. L. []. Accessed June 21, 2012
 * 8) <span style="background-color: #ffffff; color: #800080; font-family: Arial,Helvetica,sans-serif;">Hoppe RT, Phillips TL, Mack III M. //Leibel and Phillips Textbook of Radiation Oncology//. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010. ||
 * 1) <span style="background-color: #ffffff; color: #800080; font-family: Arial,Helvetica,sans-serif;">Hoppe RT, Phillips TL, Mack III M. //Leibel and Phillips Textbook of Radiation Oncology//. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010. ||

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