Cervical cancer | Diagnosis | Symptoms | Treatment | NCCN Guidelines

Cervical cancer is epithelial cancer that forms in the uterine cervix. It is the fourth most common cancer in the world.

Cervical cancer can be prevented through human papillomavirus vaccination, screening, and treatment of precancerous lesions. The earliest symptoms are watery discharge from the vagina, post-coital bleeding, or intermittent spotting.

Stages of the disease

  • Stage I: Carcinoma is restricted to the cervix

  • Stage IA: Invasive carcinoma, maximum depth of invasion ≤5 mm

  • Stage IA1: Maximum depth of invasion ≤3 mm

  • Stage IA2: Maximum depth of invasion >3 and ≤5 mm

  • Stage IB: Maximum depth of invasion >5 mm

  • Stage IB1: Maximum depth of invasion >5 mm and ≤2 cm

  • Stage IB2: Maximum depth of invasion >2 cm and ≤4 cm

  • Stage IB3: Maximum depth of invasion >4 cm

  • Stage II cancer: Cancer has not extended onto the lower part of the vagina or pelvic wall

  • Stage IIA: Only the upper two-thirds of the vagina was involved

  • Stage IIB: Cancer spreads to the parametrial region but not the pelvic wall

  • Stage III: The lower third of the vagina and pelvic wall gets impacted

  • Stage IIIA: The lower third of the vagina was involved but not the pelvic wall

  • Stage IIIB: Extended to the pelvic wall

  • Stage IIIC: Pelvic region and para-aortic lymph nodes are involved

  • Stage IIIC1: Pelvic lymph node is only impacted

  • Stage IIIC2: Para-aortic lymph nodes are impacted

  • Stage IV: Other organs beyond the pelvis are impacted

  • Stage IVA: Cancer was spread to pelvic organs

  • Stage IVB: Cancer was spread to distant organs

Symptoms

  • Bleeding between or following periods

  • Excess bleeding than normal during menstruation

  • Pain after intercourse

  • Pelvic or back pain

  • Increased vaginal discharge

Diagnosis

Patients cannot diagnose the disease in the early stages.

Patients with symptoms should undergo a medical examination, which includes

  • History and physical

  • Complete blood count

  • Cervical biopsy

  • Liver function test

  • Renal function studies

  • Imaging

The extent of the disease can be determined using

  • CT scan

  • PET scan

  • Cystoscopy

  • Laparoscopy

  • Ultrasonography

  • Magnetic resonance imaging

Treatment


Treatment

Stage IA Cervical Cancer Treatment

Conization:

Conization is a procedure in which abnormal cone-shaped tissue is removed from the cervix. If the invasion is less than 3mm, and the cancer has not spread to vascular or lymphatic channels, conization can be done for those patients who want to retain fertility.

Total hysterectomy:

Oophorectomy should not be an option for younger women.

Stage IA2 Cervical Cancer

Modified radical hysterectomy with lymphadenectomy

If the tumor invasion is between 3mm to 5mm, it is recommended to treat with modified radical hysterectomy with pelvic-node dissection. Radical hysterectomy with node dissection for patients in whom the depth of tumor invasion was uncertain.

Radical trachelectomy

Radical trachelectomy is recommended in patients with stages IA2 to IB disease who want to retain fertility. Cervix and lateral parametrial tissues are removed, but the uterus and ovaries are retained.

Intracavitary radiation therapy

Intracavitary radiation therapy is ideal for patients for whom medical conditions and surgery are not considered.

Stages IB and IIA Cervical Cancer Treatment

Radiation therapy with concomitant chemotherapy

Radiation therapy plus cisplatin-based chemotherapy is recommended for patients who require radiation therapy.

Radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy

Radical hysterectomy and bilateral pelvic lymphadenectomy is an option for patients with stages IB to IIA disease.

Stages IIB, III, and IVA Cervical Cancer Treatment

Standard Treatment Options for Stages IIB, III, and IVA Cervical Cancer

The size of the primary tumor is essential for determining the therapy. Treatment options for stage IIB, stage III, and stage IVA includes radiation therapy with concomitant chemotherapy

Lymph Node Management

Patients with small-volume para-aortic nodal disease and controllable pelvic disease can be cured with para-aortic radiation therapy.

Other Treatment Options

  • Interstitial brachytherapy

  • Neoadjuvant chemotherapy

Stage IVB Cervical Cancer Treatment

Standard Treatment Options for Stage IVB Cervical Cancer

  • Palliative radiation therapy.

  • Palliative chemotherapy and other systemic therapy

Cisplatin in Combination with Other Drugs

50 mg/m² every three weeks is recommended treatment option

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