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Cervical cancer

Cervical cancer (CC) will become with time a rare disease, since a vaccine has already been found for its cause that must be used before the onset of sexual activity, that is, before a possible infection with human papillomavirus. In the meantime, the disease can be detected at an early stage under one condition, undergoing regular gynecological examinations.

Cervical cancer stages

The stage is established prior to start of treatment during clinical and standard examination with radiography, any endoscopy, curettage and other necessary gynecological interventions. Findings of high-tech examinations such as CT, MRI, ultrasound, PET or laparoscopy are not involved in determining the process stage, but are always taken into account when planning therapy. This principle of stage determination is observed exclusively in respect of malignant pathologies of the uterine cervix.

  1. Stage I has several gradations from a microscopically detected tumor to a visually detectable formation exceeding 4 cm, the main thing here is that the lesion has not yet emerged from the cervix;
  2. Stage II signals that the cancer has left the uterus, but without affecting the pelvic tissue, the vagina is free only in the lower part, and the formation size may be different;
  3. Stage III informs about cancer infiltration into the pelvis, the tumor has completely occupied the vagina or disrupted the urine flow through the compressed ureter, causing the renal pelvis to swell, and the kidney function is reduced if not completely blocked;
  4. Stage IV has two options, one being involvement of the urinary bladder or rectum into the conglomerate, and the other being already existing distant metastases.

Treatment of dysplasia and early cervical cancer

Severe CIN III dysplasia and the most initial cancer in situ, when the cells not only haven’t yet penetrated into other cervical layers, but have not even overcome the basement membrane of the mucosal lining, togerther with microinvasive carcinoma that has penetrated no deeper than 7 millimeters and the neoplasm I stage are treated the same and only way, surgically.

The organ is preserved as much as possible, and a conical piece of tissue is «cut out», the central part of which becomes the cervical canal. The excision process is called cervix conization; in the future, it does not exclude the possibility of carrying a pregnancy. For women who are not planning childbirth or have incurable gynecological conditions, the extirpation (uterus removal) is recommended.

In certain cases, conization is performed twice due to discovery of cancer cells in the margin of a previously excised piece. If malignant cells are found inside the vessels of the tissue removed, the question is raised about removing the entire uterus to reduce the risk of spreading metastases.

Cervical cancer causes

The cause of the disease is human papillomavirus (HPV) infection which leads to precancerous processes of the vaginal part of the cervix. Not all HPVs, and there are dozens of their types known, but only types 11, 16, and 18 can lead to cancer.

In itself, infection without mucosal pathology does not lead to a malignant tumor, the virus that resides free in mucous membrane cells is not dangerous, having lived for some time, it will disappear along with the cell that «sheltered» it. Over three years, almost half of the damaged cells die, but every fifth infected woman develops a cervical pathology — dysplasia or cervical intraepithelial neoplasia (CIN).

The main starting point that leads to the transformation of a normal cell into a pathological one is virus insertion into the cell’s genome. The symbiosis of cellular and viral genomes leads to the loss of the normal structure, the nuclei enlarge and change their shape, the reproduction process is accelerated, the life of cells is reduced and their function changes. With the accumulation atypia, that is, immaturity signs, a transformation into cancer occurs.

Cervical dysplasia

Dysplasia is the appearance of defective cells in the mucous membrane that are unable to perform a protective function. Changes are localized in the transition zone of one type of multilayer epithelium cells into another cell type, which lies only in one layer.

Cervical dysplasia is a precancerous change of the mucous membrane, which with further development runs the risk of becoming a full-fledged malignant tumor, but after passing certain stages of development, from the minimum degree I, through degree II to III, which is very difficult to separate from intracellular cancer (cancer in situ).

Malignization does not occur in 100% of cases, however, the likelihood of such transformation is quite high. With a light degree I, 6 out of 10 women can self-cure within 3 years, one woman goes into a more severe degree II, and another one will develop cervical cancer.

In the absence of drugs effective for HPV, however, intraepithelial neoplasia can be successfully treated. Severe CIN III is subject to surgical removal. Young women planning a pregnancy undergo an organ-sparing intervention called cryodestruction (burning-out with liquid nitrogen), a laser destruction or an excision with a special loop (loop electrosurgical excision), a photodynamic therapy.

Cervical cancer (CC) will become with time a rare disease, since a vaccine has already been found for its cause that must be used before the onset of sexual activity, that is, before a possible infection with human papillomavirus. In the meantime, the disease can be detected at an early stage under one condition, undergoing regular gynecological examinations.

Cervical cancer diagnostics is divided into several successive stages starting with a routine gynecological examination and continuing in a small operating and diagnostic rooms, where the spread of the process is determined. The goal is to choose the best cancer treatment.

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Primary diagnostics of cervical cancer

To establish the cervical cancer diagnosis, it is not enough just to detect a tumor lesion. It is necessary to verify the process, that is, to confirm its cancer nature during morphological examination. To do this, scrapings and pieces of tissue are taken and examined under a microscope.

Unlike other malignant neoplasms, the process stage is established exclusively according to the findings of clinical diagnostics.

During a gynecological examination, the spread of the process is determined. This includes a rectovaginal examination used to establish the involvement of the rectum into the cancer node.

Colposcopy serves to determine the site for taking a sample of tissue for microscopy and, for the same purpose, diagnostic curettage of the cervical canal is prescribed. If it is difficult to interpret the material obtained during curettage and biopsy, it may be necessary to perform conization, that is, excision of the tissue cone with the cervical canal in its center. With minor cancer, conization is a manipulation that is simultaneously diagnostic and therapeutic.

Clarifying examination

At this examination stage, a tumor lesion of the abdominal and retroperitoneal lymph nodes is detected, since the cells spread mainly through lymphatic vessels, and very little of them are carried by the bloodstream.

It may also be necessary to perform endoscopic examination of the urinary bladder and rectum. In case of a cervical mass formation, a ureter compression with urination disruption is possible, therefore, an excretory urography is performed, that is, an X-ray examination of the urinary system condition with a contrast agent.

High-tech diagnostics of the disease

Nowadays, this is not an exclusive examination anymore, but a routine practice to study the cervix condition using CT, or better, MRI. The method enables extremely accurate determination of the cancer penetration depth into the cervical tissue, the tumor spread throughout the cellular tissue of the lesser pelvis, adjacent organs and the uterus itself.

Abdominal and retroperitoneal CT is useful to clarify the extent of tumor damage to the lymph nodes, because ultrasound resolution is somewhat lower.

It should be noted that the information obtained by CT and MRI is not used to establish the cancer degree, but is always taken into account in developing the optimal treatment strategy.

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Cervical cancer stages

The stage is established prior to start of treatment during clinical and standard examination with radiography, any endoscopy, curettage and other necessary gynecological interventions. Findings of high-tech examinations such as CT, MRI, ultrasound, PET or laparoscopy are not involved in determining the process stage, but are always taken into account when planning therapy. This principle of stage determination is observed exclusively in respect of malignant pathologies of the uterine cervix.

  1. Stage 1 has several gradations from a microscopically detected tumor to a visually detectable formation exceeding 4 cm, the main thing here is that the lesion has not yet emerged from the cervix;
  2. Stage 2 signals that the cancer has left the uterus, but without affecting the pelvic tissue, the vagina is free only in the lower part, and the formation size may be different;
  3. Stage 3 informs about cancer infiltration into the pelvis, the tumor has completely occupied the vagina or disrupted the urine flow through the compressed ureter, causing the renal pelvis to swell, and the kidney function is reduced if not completely blocked;
  4. Stage 4 has two options, one being involvement of the urinary bladder or rectum into the conglomerate, and the other being already existing distant metastases.

Treatment of dysplasia and early cervical cancer

Severe CIN 3 dysplasia and the most initial cancer in situ, when the cells not only haven’t yet penetrated into other cervical layers, but have not even overcome the basement membrane of the mucosal lining, togerther with microinvasive carcinoma that has penetrated no deeper than 7 millimeters and the neoplasm I stage are treated the same and only way, surgically.

The organ is preserved as much as possible, and a conical piece of tissue is «cut out», the central part of which becomes the cervical canal. The excision process is called cervix conization; in the future, it does not exclude the possibility of carrying a pregnancy. For women who are not planning childbirth or have incurable gynecological conditions, the extirpation (uterus removal) is recommended.

In certain cases, conization is performed twice due to discovery of cancer cells in the margin of a previously excised piece. If malignant cells are found inside the vessels of the tissue removed, the question is raised about removing the entire uterus to reduce the risk of spreading metastases.

Medical approaches to stages 2 and 3

The oncology principle assumes that if it is possible to remove a tumor-affected organ, it is necessary to remove it. Cancer stage 2 is the indication for removal of the uterus together with appendages and ovaries, supplemented by removal of altered lymph nodes. If there are contraindications for surgical treatment, irradiation and chemotherapy are chosen instead, which entails a high relapse likelihood.

Modern practice does not recommend to supplement surgery with irradiation unless absolutely necessary, since too many complications would spoil the woman’s life in the future, yet preventive chemotherapy is indicated.

What treatment will be performed after the uterus is removed is decided by the estimated probability of the risk of progression in the future, and the risk is determined by the morphological study and the detection of metastases during the operation. With a low probability, preventive treatment is not performed, with a moderate degree, irradiation will be offered, and with high risk, chemotherapy and radiation exposure are advisable.

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Treatment of an advanced stage 4 process

Standard treatment involves remote and intracavitary radiation therapy against the background of chemotherapy for 6–7 weeks, but the matter of surgery is decided individually, because only removal of the main malignant process can increase a woman’s life expectancy and save her from the inevitable complications associated with conservative therapy.

Essentially, surgery can become technically feasible after several courses of chemotherapy, a quite extensive operation will be offered, sometimes with a single block removal of the vagina, rectum and bladder called pelvic exenteration. The same intervention is applied if fistulas emerge on the background of post-radiation tissue changes.

Removal of a cancer conglomerate is not an end in itself for the operating oncologist, but an urgent need. If possible, a young and childless woman will be offered preservation of the ovaries with their temporary relocation from the irradiation zone, together with maximum possible preservation of elasticity of the genital tissues.

With distant metastases, treatment options are very few limited to chemotherapy, but again, a lot depends on the specialists and the medical institution. At the Clinic Medicine 24/7, virtuosic oncogynecologists and oncologists have great opportunities and, most importantly, a desire to help with an undoubted ability.

This text is based on the materials of NCCN (National Cancer Comprehensive Network).