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Cervical Cancers

by

Thomas Ind

Consultant Gynaecological Surgeon

St George's & Royal Marsden Hospitals

 

Prevalence

There are about 2500 new cases of cervical cancer every year in the UK with about 1000 deaths

 

Onset

There are two peaks in the age of onset (thirties and fifties).

 

The highest incidence of cervical cancer occurs in South America. The incidence is increasing in Africa as cervical cancer is an AIDS related illness.

 

Causes

With the exception of the rare clear cell cancers it is caused by Human Papilloma Virus. There are over 100 types of HPV virus and not all are related to carcinoma of the cervix. The most common are types 16, 18, 31, 33, and 45. The virus alters the genes in the cells allowing them to make proteins (called E6 and E7) that promote cancer. Almost any woman who has been sexually active can develop cancer of the cervix. However, it is more frequent in women who have had more partners. It is also more common in women whose husbands / boyfriends have had more sexual partners. Immunodeficient women (such as those with AIDS, after an organ transplant, or those on steroids) are also more likely to develop cervix cancer.

 

Symptoms

Cervix cancer can cause a number of symptoms. Sometimes it is detected after treatment for ‘CIN’. Sometimes cervix cancer presents with abnormal vaginal bleeding, discharge, or bleeding after intercourse. When advanced, cervix cancer can present by causing back ache from a blockage of the tubes from the kidneys to the bladder (ureters).

 

Staging

Staging is a clinical staging. For this reason the presence of lymph  node involvement is not included in the staging but it is an important prognostic marker.

 

Stage I              Limited to cervix

        IA             Those which can be seen microscopically only.

All others are 1b.

Iai            <3mm deep and <7mm wide

Iaii            3 – 5mm deep and <7mm wide

                       

        IB             Clinically visible lesion confined to the cervix.

        Ibi            <4cm

        Ibii            >4cm

       

Stage II        Local extension

        IIA            To upper 2/3 vagina

        IIB            To parametrium but not pelvic sidewall

       

Stage III        Extensive local extension

IIIA           To lower 1/3 vagina

        IIIB           To pelvic sidewall

 

Stage IV        Distant metastases

 

 

Treatment

Stage 1ai           Cone biopsy or standard hysterectomy

 

Stage 1aii*         Radical Hysterectomy and lymphadenectomy

                or

                        Radical trachelectomy and lymphadenectomy

 

Stage 1b**         Radical hysterectomy and lymphadenectomy

                        or

                        Radical trachelectomy and lymphadenectomy

                        or

                        Chemoradiotherapy

 

Stage 2a**         Radical hysterectomy and lymphadenectomy

                        or

                        Chemoradiotherapy

 

Stage 2b***       Chemoradiotherapy

 

* The management of stage 1aii lesions is controversial. Some would advocate a more conservative approach. The risk of lymph node involvement is 4.8% so a lymphadenectomy is recommended. A radical hysterectomy has varying degrees of radicality. Some would advocate a hysterectomy of limited or no radicality for stage 1aii lesions. Likewise, for fertility sparing procedures, some would advocate a large cone biopsy rather than a trachelectomy.

 

** The efficacy of chemoradiotherapy is as good as surgery so if adjuvant chemoradiotherapy is likely then this is normally offered instead to reduce the complications. An example might be someone with positive pelvic lymph nodes on MRI scan. Another example might be someone with a large tumour which is poorly differentiated and has lymphvascular space involvement.

 

*** Sometimes it is necessary to perform a laparoscopic para-aortic lymphadenectomy to determine how high a radiotherapy field should go.

 

Recurrence

Recurrent cervix cancer has a poor prognosis. If it returns at the top of the vagina and is only local, an operation called ‘exenteration’ is sometime appropriate. This operation may involve removal of the vagina, bowel and even bladder and is assoicated with a high complication and mortality rate. Some recurrent tumours respond slightly to chemotherapy (PMB) but the prognosis is poor.

 

Survival

The aim of treatment for early stage cervical cancer is curative. For stage 1 disease with negative lymph nodes this can be achieved in 19 out of 20 cases. When lymph nodes are involved this reduces to 70%.

 

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