Cervical Cancer 2
What is the workup before we go ahead with treatment of cervical cancer? Well obviously a history and a physical examination which includes a pelvic and a rectal examination, a complete blood count, blood chemistry with attention to the patient’s creatinine, then consider HIV testing, cervical cancer is an AIDS defining illness and patient’s at risk. The treatment of the cervical cancer will be positively influenced and affected by treatment of their HIV status and their AIDS at the same time, so this is important to consider. A chest x-ray is important, an IVP, skeletal x-rays and barium enema are helpful in patient’s with advanced disease. These are the studies that are also allowed for clinical staging purposes.
Examination under anesthesia, in my opinion, remains an important component of the pretreatment workup because it allows one to examine a relaxed patient, to have a better understanding of the local extent of the disease, it also allows examinations with multiple examiners including radiation oncologist at that time. Cystoscopy, proctoscopy again are useful in patient’s with locally advanced disease where there is a positive finding to be expected.
Other studies which are increasingly used are imaging studies such as CT scan, MRI scan, in order to more accurately try to determine the extent of the disease, if one finds that findings are accessible to fine needle aspiration and that should be attempted under CT guidance. As a reminder, the staging of cervical cancer is purely clinical and information is allowed from the following sources, from the clinical examination preferably conducted under anesthesia, x-rays of the chest, the kidneys, the bone, no information of the CT scan or the MRI scan is allowed, so if you do a CT scan basically for clinical staging purposes, only the information with respect to the presence or absence of hydronephrosis can be used for clinical staging, not the presence of an enlarged, periaortic node for instance. Biopsy of suspected bladder or rectal invasion, it can further be used to complete the clinical staging.
I will review the stages of cervical cancer with you. Stage I is confined to the cervix and then identified microinvasive carcinoma as follows: These are invasive lesions which by definition can only be identified under the microscope. Stage IAI includes lesions with invasion up to 3 mm and with a width not exceeding 7 mm, when invasion reads more than 3 mm, the stage is IAII, less than 5 mm width not exceeding 7 mm. Stage IB are clinically visible lesions or preclinical tumors which are more than 5 mm invasive. They are in terms further subdivided in lesions than are less than 4 cm or equal to 4 cm stage IBI or tumors that are larger than 4 cm in diameter, stage IBII. Stage II tumors involve either the vagina or the parametrium, stage IIA extends into the upper vagina, not in the lower one-third and not in the parametrium, stage IIB remains parametrium extension, but not to the side wall. Stage III disease, stage IIIA lower third of the vagina, stage IIIB is extension to the pelvic side wall and the presence of hydronephrosis. Stage IV disease is extension outside the reproductive tract, either involving the mucosa of the bladder or rectum, stage IVA or distant metastases outside the pelvis stage IVB. These stages do correlate with survival, this is experience of Anderson which are still very applicable in patient’s with invasive carcinoma of the cervix treated with radiation therapy, five year survival in stage I cases, 91% is excellent, stage IIA 83%, stage IIB 66.5%, and approximately 45% for patient’s with stage IIIA. In carcinoma of the cervix, treatment controversies continue to persist and they predictably continues to exist at both ends of the spectrum, so there are still substantial difficulties at the present time in finding the correct and ideal treatment for patient’s with either very small tumors or the patient with very large tumors. I will go over that in the next couple of minutes.