Cervical Cancer

Cabrera. Cortes

K.W.
41 year old

G5P5(5005)
Micronesian Housewife

Single
Palau

Chief Complaint
For chemoradiation therapy

History of Present Illness

1 year history PTC (+) vaginal discharge Mucopurulent foul-smelling, brownish 8 months PTC Sought consult and was diagnosed to have cervical cancer Biopsy: squamous cell carcinoma, large cell nonkeratinizing, stage IIA Initial workup (CBC, LFT: Normal, UA: WBC 8/hpf): treated for UTI Advised chemotherapy (+) undocumented weight loss, poor appetite (-) abdominal pain, vaginal bleeding, post-coital bleeding, dyspareunia

Referral subsequent admission

OB Gyn history
LMP: November 7, 1st sexual contact: 17

2012 PMP: 1st week October, 2012 Menarche: 15 y.o. Interval: Regular Duration: 4 5 days Amount: 5-6 ppd, moderately soaked No dysmenorrhea

y.o. Age at first pregnancy: 17 y.o. 2 sexual partners No history of contraceptive use No previous hx of STI, leukorrhea, vulvar pruritus No history of cervical screening No history of recent sexual contact

OB Gyn history
G5P5 (5005)
Year
G1 1987

Outcome
LFT (F)

Manner
NSD

Institution
Hospital

G2
G3 G4 G5

1990
1993 1997 2002

LFT (M)
LFT (F) LFT (M) LFT (F)

NSD
NSD NSD NSD

Hospital
Hospital

Hospital Hospital

No complications feto-maternal complications

Past Medical History

No hypertension

No diabetes
No asthma No thyroid problems No liver disease No allergies to food or drugs

Family History
No hypertension

No diabetes
No asthma No thyroid problems

Personal Social History

Highshool graduate

housewife
Lives with partner and children History of chronic smoking (10 pack years) Non alcoholic beverage drinker Denies illicit drug use

Review of systems
No fever, changes in mental status, easy fatigability, dysphagia, DOB, chest pain, dysuria, changes in bowel habits, excessive sweating or temperature intolerance

Physical Examination
General: Alert, coherent not in respiratory distress. Anthropometrics:

Ht. 159 cm
Vital signs:

Wt. 102 kg BMI 47 kg/m2

BP= 130/80 Temp: 36.7 RR= 20 HR= 72

HEENT: Anicteric sclerae, pink conjunctivae

no TPC, no CLAD

Physical Examination
Cardiovascular: Adynamic precordium,

normal rate regular rhythm, good S1 S2, no heaves, no murmurs

Respiratory: equal chest expansion,

clear breath sounds

Physical Examination
Abdomen: flabby, normoactive bowel

sounds, soft, nontender, no masses, no organomegaly

Physical Examination
Extremities: Good skin color. Good turgor,

no cyanosis, no edema. Full and equal pulses. Good capillary refill.

Physical Examination
Gynecologic Examination
Friable, bleeding fungating growths

encompassing entire cervix extending to L parametria, involvement Mixed discharges: bloody and purulent Uterus not enlarged No adnexae tenderness

SALIENT FEATURES
Do you have any questions?

Salient Features

41 y/o G5P5 (5005) 2 sexual partners No history of contraceptive use History of chronic smoking Diagnosed case of cervical cancer (squamous cell carcinoma, large cell nonkeratinizing, stage IIA) 1 year history of vaginal discharge (Mucopurulent foul-smelling, brownish (+) undocumented weight loss, poor appetite (-) fever, easy fatigability, abdominal pain, vaginal bleeding, post-coital bleeding, dyspareunia

Obese Gynecologic Examination

Friable, bleeding fungating growths encompassing entire cervix extending to L parametria, involvement Mixed discharges: bloody and purulent Unremarkable IE

Primary Impression

G5P5 (5005) Cervical Cancer Plan: Chemotherapy, Radiotherapy, Brachytherapy

Laboratories
CBC
Hgb 118 g/L Hct 0.34 RBC 4.96 x 1012/L WBC 5.97 x 109/L
Neutrophil: 0.61 Monocyte: 0.05

NV = 120-160 NV = 0.36-0.47 NV = 4.20-5.40 NV = 4.50-10.00

Lymphocyte: 0.32 Eosinophil: 0.01

MCH 30 pg MCHC 0.34 MCV 90 fl RDW 12.8 Platelet 290 x 109/L

NV = 27-31 NV = 0.32-0.36 NV = 80-96 NV = 11.5-16.0 NV = 140-440

Laboratories
Urinalysis
Color: light yellow Transparency: clear Erythrocytes: negative Protein: negative Glucose: negative Leucocytes: negative Ketones: negative Urobilinogen: normal Nitrites: negative WBC: 1-3/hpf RBC: 3-5/hpf Epithelial cells: 2/hpf Bacteria: Few

Cervical Cancer
third most common malignancy in women

worldwide leading cause of cancer-related death for women in developing countries patients tend to be in their 40s to 60s, with a median age of 52 years

Pathophysiology
HPV infection must be present for cervical cancer

to occur Approximately 90% of HPV infections clear on their own within months to a few years and with no sequelae Factors postulated to influence the development of CIN 3 lesions:
The type and duration of viral infection, with high-

risk HPV type and persistent infection predicting a higher risk for progression; low-risk HPV types do not cause cervical cancer Host conditions that compromise immunity (eg, poor nutritional status, immunocompromise, and HIV infection)

 Gynecologic factors:
early age of first intercourse and higher number of

sexual partners.
Genetic susceptibility

 abnormal Papanicolaou (Pap) test result

symptoms:
abnormal bleeding or brownish discharge,

frequently noted following douching or intercourse and also occurring spontaneously between menstrual periods back pain, loss of appetite, and weight loss, are late manifestations

 early-stage cervical cancer

physical examination findings can be relatively normal

cervix may become abnormal in appearance

gross erosion, ulcer, or mass

Bimanual pelvic examination

pelvic or parametrial metastasis

Differentials
Cervicitis

PID
Vaginitis Vaginal Cancer Primary melanoma and Paget disease

Work-up
The diagnosis is established by biopsy of the

tumor
A Kevorkian, Eppendorf, Tishler, or similar punch

biopsy instrument is convenient to use.

If the patient's cytologic smear is suggestive of

invasive carcinoma with no gross lesion visible and endocervical curettage does not demonstrate carcinoma or if an adequate biopsy specimen to establish carcinoma cannot be obtained, then cervical conization should be performed.

Staging
The staging of carcinoma of the cervix depends

primarily on the pelvic examination

designation may be modified by general physical

examination, by chest radiographic examination, by intravenous pyelography (IVP), or computed tomography (CT)

Stage I Cancer
Stage IA:
The area of invasion

< than 3 mm

(approximately 1/8 inch) deep < than 7 mm (approximately 1/3 inch) wide

Stage IA2:
The area of invasion

between 3 mm and 5

mm (approximately 1/5 inch) deep < than 7 mm

Stage I Cancer
Stage IB1:
no larger than 4 cm

(approximately 1 and 3/5 inches)

Stage IB2:
larger than 4 cm

(approximately 1 and 3/5 inches)

Stage II
Stage IIA:
spread beyond the

cervix to the upper portion of the vagina, does not involve the lower third of the vagina
Stage IIB:
spread to the tissue

next to the cervix (the parametrial tissue)

Stage III
Stage IIIA:
spread to the lower

third of the vagina but has not spread to the pelvic wall
Stage IIIB:
extends to the pelvic

wall and/or blocks urine flow to the bladder

Stage IV
Stage IVA:
spread to the bladder

or rectumorgans close to the cervix.

Stage IVB:
spread to distant

organs beyond the pelvic area, such as the lungs

Management

Stage 0 cancer
local ablative or excisional measures such as

cryosurgery, laser ablation, and loop excision.

Stage IA1 Cancer

The treatment of choice is surgery.
Total hysterectomy, radical hysterectomy, and

conization are accepted procedures. Lymph node dissection is not required if the depth of invasion is less than 3 mm and no lymphovascular invasion is noted.
Selected patients with stage IA1 disease but no

lymphovascular space invasion who desire to maintain fertility may undergo therapeutic conization with close follow-up, including cytology, colposcopy, and endocervical curettage. Patients with comorbid medical conditions who are not surgical candidates can be successfully treated with radiation.

IB or IIA disease
For patients with stage IB or IIA disease, there

are 2 treatment options: Combined external beam radiation with brachytherapy Radical hysterectomy with bilateral pelvic lymphadenectomy

Stage IIB, III, or IVA cancer

radiation therapy was the treatment of choice for

many years. Radiation

course of external beam radiation to reduce tumor

mass and thereby enable subsequent intracavitary application. Brachytherapy is delivered by means of afterloading applicators that are placed in the uterine cavity and vagina
Additionally, the results from large, well-

conducted, prospective randomized clinical trials have demonstrated a dramatic improvement in survival when chemotherapy is combined with

Stage IVB and recurrent cancer

Individualized therapy is used on a palliative basis.

Radiation therapy is used alone for control of bleeding and pain, whereas systemic chemotherapy is used for disseminated disease. Treatment of pelvic recurrences after primary surgical management should include single-agent chemotherapy and radiation, and treatment for recurrences elsewhere should include combination chemotherapy. For disease recurring after chemotherapy and radiation therapy, a disease-free interval of more than 16 months is considered to designate the tumor as platinum-sensitive. The NCCN also recommends bevacizumab, docetaxel, gemcitabine, ifosfamide, 5-fluorouracil, mitomycin, irinotecan, and topotecan as possible candidates for second-line therapy (category 2B recommendation), as well as pemetrexed and vinorelbine (category 3 recommendation). In addition, bevacizumab as singleagent therapy is also acceptable.

Prognostic Factors
stage of clinical advancement(size of the tumor

and depth of infiltration, involvement of parametria, vascular invasion) histological type of the tumor grade of tumor differentiation condition of draining lymph nodes extent of surgical procedure