Cervical cancer

Cervical cancer
[Summary]



Cervical cancer occur in all parts of the world, the human body is one of the most common cancer, not only in the tumor in the female genital mutilation of the first, but most women in various malignant tumor see, but its incidence Obviously there are regional variations. The incidence of cervical cancer in the geographic distribution is characterized by a high incidence area often connect films. Cervical cancer relatively high incidence area of the provincial cities, counties often interconnected phenomena. The general trend in the rural areas than in urban, mountain above the plain. According to 29 provinces, municipalities and autonomous regions of China cervical cancer mortality survey of the total cancer mortality rate in the fourth, accounting for the second female cancer. Patients with cervical cancer, the average age of onset, the States, all over the reports also are differences, age of onset of 40 to 50 years maximum, 60 to 70 years old have a peak, rare before the age of 20.



[Diagnosis]




According to history and clinical performance, in particular in touch with the bleeding, should first think of the possibility of cervical cancer, should do a detailed inspection of the body and gynaecological examinations, and the following examinations:

(1) cervical cytology screening is scraping detection of cervical cancer precursor lesions and early cervical cancer is the main method. But attention to the correct location based and careful examination, there are 5% to l0% of the false-negative rate, it should be combined with clinical, and regular inspections as a screening method.

(B) iodine test normal vaginal or cervical squamous epithelium is rich in glycogen, as can be brown with povidone-iodine, and columnar epithelium of the cervix, cervical erosion and abnormal squamous epithelium (including squamous metaplasia, not typical hyperplasia and carcinoma in situ and invasive carcinoma district) glycogen did not exist, was not colored. Clinical use vaginal cervical Kuiqi exposed, wipe the surface mucus to povidone-iodine cervical smear and subfornical organ, such as normal iodine found negative in this area are able to take the biopsy sent pathological examination.

(C) of the cervix and cervical biopsy examination in cervical cytology for the scratch-Ⅲ ~ Ⅳ more than smear, cervical biopsy was negative but, in a column at the junction of cervical squamous Department of 6,9,12 and 3 points from 4:00 biopsy, or iodine test coloring and not suspicious cancerous parts from various organizations, and biopsy, or the application of small scraping of the cervix Saogua key will be sent scraps of pathological examination.

(D) can not be directly colposcopy colposcopy cancer diagnosis, but can assist in the selection of the site for cervical biopsy biopsy. According to statistics, such as colposcopy in the assistance of the biopsy, the diagnostic accuracy of early cervical cancer rate may be 98 percent. However, colposcopy can not replace scratch cytology examination and biopsy examination, we can not find cervical lesions.

(5) in the resection of cervical cone biopsy not sure whether invasive inspection, the cervix can be tapered resection. However, the current diagnosis of cervical cone resection has been rarely used. When cervical cancer established, in accordance with specific circumstances, which can carry out the lung X-ray film, lymphatic contrast, cystoscopy, rectal examination, in order to determine the clinical stage of cervical cancer.


[Treatment]




Cervical cancer treatment at dysplasia, carcinoma in situ, invasive endoscopic early, invasive treatment

(1) treatment principle

1. Dysplasia: biopsy such as mild dysplasia, Zanan inflammatory treatment, follow-up blow-half and, if necessary, further biopsy. Lesions can be sustained and continued observation. Diagnosed as moderate dysplasia, should be applied laser, freezers, electric iron. Severe dysplasia, and more generally advocated to hysterectomy. If an urgent demand growth, but also in close and regular cone follow-up after resection.

2. Carcinoma in situ: general to advocate more total hysterectomy, bilateral ovarian reservations there are also removed at the same time advocating vaginal 1 to 2 cm. Laser treatment useful at home and abroad in recent years, but the need for close follow-up after treatment.

3. Early invasive endoscopic: General advocated for more expansion hysterectomy, and l ~ 2cm vagina organizations. Early invasive endoscopic due to the possibility of minimal lymph node metastasis, without the elimination of pelvic lymph tissue.

4. Invasive cervical cancer: treatment should be based on clinical stage, age and general condition, as well as equipment conditions. Used radiation treatment, surgery and chemotherapy. Generally speaking, radiotherapy can be applied to all patients; Ⅰ b Ⅱ a view to the effect of surgery and radiation therapy similar to the radiation sensitivity of cervical adenocarcinoma is not good to take the surgical excision and radiotherapy treatment.

(B) Surgical treatment of a broad hysterectomy and pelvic lymph node elimination. Resection include hysterectomy, bilateral annex, the upper section of the vagina and the vagina, as well as adjacent tissues in the pelvic lymph nodes by the group (cervical beside the obturator, iliac, iliac, the common iliac lymph nodes under paragraph). Surgery called for a thorough, security, strict levy to prevent complications.

(C) surgical complications and treatment

1. Surgical complications are bleeding, postoperative pelvic infection, lymphocele, Lu stay retention, urinary tract infections and vaginal fistula, and other ureter.

2. Complications of surgery, in recent years, due to anesthesia and surgical methods to improve technology, the application of preventive antibiotics, as well as after using extraperitoneal suction drainage, and other measures, the incidence of these complications has decreased significantly.

(4) radiation therapy for the treatment of choice for cervical cancer, can be applied to the period of cervical cancer, including radiation involvement of the cervix and vagina, uterus, Gongpeng organizations and pelvic lymph nodes. Irradiation method is generally used to integrate internal and external radiation, brachytherapy for cervical main primary tumor and adjacent sites, including the uterus, vagina and the nearby upper Gongpeng Organization ( "A") points. External irradiation for pelvic lymph node was mainly the regional distribution ( "B") points. Radioactive sources used in the laser cavity (Ra) or Cesium 137 (Cs 137), the original target of cervical lesions. 60 radioactive sources used in drilling (60 Co), the original target lesion outside the metastasis, including pelvic lymph node drainage area. General dose of 60 Gy. At present more than that of early cervical cancer in the first irradiation. And the advanced cancer, in particular the partial tumor huge, active bleeding or infection while first with external irradiation suitable.

(5) chemical treatment so far the majority of cervical cancer is not sensitive anti-cancer drugs, chemotherapy efficiency does not exceed 15%, use of chemotherapy in patients with advanced, integrated radiotherapy treatment. Chemotherapy drugs can be 5 - 5-Fluorouracil, Adriamycin, such as a vein or local injection.


[Etiology:




On the reasons for the incidence of cervical cancer is not clear, a great deal of information at home and abroad confirmed, early marriage, early childbearing, fertility disorders and sexual life of women have a higher prevalence rate. Baopigou there is also the view that the role of cholesterol as bacteria can be changed for carcinogenic substances. Lead to cervical cancer is also an important incentive.

In recent years also found that sexual intercourse and cervical cancer and virus-borne some relationship to a certain extent, such as: ① human scars measles virus type Ⅱ (HSV-2), due to HSV-2 antibody in patients with invasive cervical cancer in 80% ~ 100% positive ② human papillomavirus (HPV) and cervical cancer organizations of various types of HPV-specific antigen testing, are indications that the incidence of cervical cancer and HPV infection; ③ human cytomegalovirus (CMV). Both at home and abroad, precancerous cervical dysplasia lesions in patients with CMV antibody titers were higher animal experiments proved that CMV-DNA with malignant transformation capacity. Therefore, in recent years become infected with the virus on the causes of cervical cancer one of the important topics.


[Pathological changes:




Squamous cell carcinoma of cervical squamous cell carcinoma in the main, about 90% to 95%, adenocarcinoma accounts for only 5% to 10%. However, the two do not have cancer in appearance SDT, and all happened in the cervix and vagina, or in the neck.

(1) of the concept in the development of invasive cervical cancer, eye-no special anomaly, or similar general cervical erosion. With the emergence of invasive cervical may be in the following four types:

1. Erosive: around the cervix, mouth rough granular surface erosion, or irregular Huipo face, touched easy bleeding.

2. Exogenous: also known as hyperplasia or cauliflower-type. Polypoid from papillary or uplift, and then to the development of vaginal prominent ranging from the size of the cauliflower-like vegetation, Zhicui easy bleeding.

3. Endogenous type: also known as invasive. Cervical cancer deep tissue infiltration, and cervical mast hard, but still smooth surface or only superficial ulcers.

4. Ulcer type: whether endogenous or exogenous type of further development, the cancer tissue necrosis loss, ulcer formation, or even for a whole cervical replaced by empty, often due to secondary infections, there is a stench from the secretions. Cervical cancer can be especially to the growth of the neck, cervical-barrel increase, which is a type of Health.

(2) check -

1. Dysplasia: dysplasia performance for the bottom cell hyperplasia, the underlying cells not only proliferated, and there are disordered and cell nuclei increased with concentration, such as uneven distribution of chromatin nuclear heterogeneity change.

Atypical hyperplasia can be divided into mild, moderate and severe. ① mild dysplasia (change as Level I): epithelial cells are slightly disordered, cells mild atypia, dysplasia epithelial occupy the lower third of the cortex. ② moderate dysplasia (change as Ⅱ): epithelial cells arranged disorder, marked atypia, dysplasia epithelial occupy two-thirds of the cortex. ③ severe atypical hyperplasia (Ⅲ inter-change): almost all of epithelial polarity polar disorder or disappeared, significantly heterotypic cell carcinoma in situ and have been difficult to distinguish.

2. Carcinoma in situ: carcinoma in situ (CIS) also known as epithelial carcinoma. Epithelial polarity layer disappeared, significantly different types of nuclear, deeply stained, uneven distribution of chromatin, mitotic rate. However, the disease remains confined to the cortex, did not penetrate the basement membrane, continuous infiltration. Heterotypic cell cervical glands along the cavity can also enter the transitional zone opening the cervical glands, glands caused the original multi-columnar cells squamous cells of different types of alternative, but still maintain integrity of the basement membrane gland, which said Cervical carcinoma in situ for involving glands.

3. Early invasive endoscopic: microscope in the early invasive carcinoma in situ on the basis of a cancer cell can be found occasionally small corporation has pierced the basement membrane, it is teardrop-shaped intrusive basement membrane in the vicinity of interstitial, the depth of invasion less than 5 mm , no more than 7 mm wide, and no integration between foci phenomenon, and no violations of mesenchymal signs of the vessel, there is no clinical characteristics.

4. Squamous cell carcinoma: When cancer cells penetrate epithelial basement membrane, violations of mesenchymal depths exceeding 5 mm, known as squamous cell carcinoma. In between, there may be dendritic quality, cord-like, diffuse, or in lumpish cancer nest.

Under pathological biopsy, the cancer cell differentiation can be divided into three: ① I level: good differentiation. Cancer nest in a considerable number of keratosis phenomenon, we can see that significant cancer beads. ② Ⅱ level: moderately differentiated (middle of cervical cell differentiation), no significant cancer nest keratosis phenomenon. ③ Ⅲ level: the small cell undifferentiated (at the bottom of the cervix undifferentiated cells).

5. Cancer: adenocarcinoma of the cervix from the coating surface and the glands in the neck of the columnar epithelium. Microscope, we can see the structure glands, and even gland cavity papillary processes. Glandular epithelial hyperplasia is a multi-level, low cells, atypia obviously, we can see that mitotic rate. If cancer cells with adenovirus cavity, which can not find the original gland structure, it was often difficult to poorly differentiated adenocarcinoma and squamous cell carcinoma of the distinction. If both adenocarcinoma and squamous cell carcinoma of cervix, called adenovirus, and squamous cell carcinoma. Gland, a high degree of malignant squamous cell carcinoma, early metastasis, and poor prognosis.


[Clinical]




(A) When vaginal bleeding stromal tumor invasion and vascular when bloodshed. The first performance for women of any age, sex or double after a consultation after a small amount of bleeding or vaginal discharge, increased. Especially after menopause in a small number of intermittent irregular bleeding more advanced, and even larger vessels were due to erosion caused fatal bleeding. General exogenous cancer earlier bleeding, blood volume also more than endogenous cancer hemorrhage late.

(2) of the general vaginal discharge in vaginal bleeding occurred after the initial level is low, no foul. With cancer Huipo can flow serous secretion; advanced cancer tissue necrosis, while a large number of pyogenic infection or Mitang Leucorrhea like odor.

(C) with advanced cancer pain. When the cervix adjacent tissues obvious infiltration, and has involved Penbi, obturator nerve, lumbar nerve, and so on, there may be serious or sustained lumbosacral sciatic nerve pain. Extensive pelvic lesions, venous and lymphatic can return blocked, resulting in the affected leg swelling and pain.


[Complications]




Uterine cancer with pregnancy is rare, the total number of domestic reports of cervical cancer 0.92% ~ 7.05%, foreign reported in the literature of 1.01%. Patients may or threatened abortion attending antenatal bleeding, vaginal smear and biopsy examination can confirm the diagnosis, early pregnancy if vaginal bleeding women should be routinely check Kuiqi cervix, as well as for cervical cytology examination scratch.

Pregnancy the impact of cervical cancer, pregnancy because of the blood supply and pelvic lymph flow increased, the transfer may promote cancer; and delivery will occur in the proliferation of cancer, serious postpartum hemorrhage and infection. Because of the pregnancy hormones influence cervical cell proliferation active transitional zone, similar to carcinoma in situ lesions, but there are directional differentiation, polar also maintained that these changes could resume after childbirth. Pregnancy may also be combined carcinoma in situ, and post can not be restored. Should be carefully differentiated.

Treatment must be in accordance with the development of cancer and the number of months of pregnancy may be. Phase I and Phase Ⅱ a merger early pregnancy, can be radical mastectomy; or to radiotherapy, to be excluded natural fetal death after radical operation again, or continue to radiotherapy. Viable pregnancy, cesarean section from fetal and radical operation. The merger of advanced cervical cancer or labor, cesarean section should be OK, after further surgery or radiotherapy.


[Prognosis]




Carcinoid tumor after treatment with clinical symptoms and signs disappeared, but after more than six months and those that levy a cancer recurrence. 3 ~ after treatment within six months of cancer there are still investigations should be classified as recovered.

(1) the prognosis of recurrent cancer recurrence after radiotherapy for treatment of patients died within one year after the largest number of deaths of patients accounts for about 1 / 2, that is, more than half of patients relapse in the treatment of symptoms after 1 year. About 88 per cent of the cases in the treatment of relapse within three years after a recurrence of symptoms. Mortality is declining after no regularity, usually in the five years the total number of deaths accounted for 93% of deaths, in the treatment of 5 to 10 years after the death of recurrence and 5 per cent.

(2) cervical cancer patients after relapse survival time, with the recurrence vary depending on location, such as vaginal stump or local recurrence, the survival time may be earlier, according to a hospital abroad analysis of 200 cases of recurrence survival time of patients, and a half months to a year to 50 per cent, 1 year to 2 years 32%, over two years of 18 per cent.

(3) recurrent parts stubborn cases recurrent always recovered in the original site. The location of cancer recurrence was more difficult decision. About recurrence after radiotherapy for cervical cancer sites, according to statistics 426 cases in the vagina or uterus, 1 / 3, l12 patients (26%); vaginal under 2 / 3 of 54 patients (6%); Gongpeng and Penbi 18 patients (43%); distant 68 cases (14%); unknown 34 cases (8%).

(D) clinical manifestations of the main symptoms of cancer recurrence for the case of lower limb pain, abdominal and pelvic pain, vaginal bleeding and the stench Leucorrhea. Another site with a recurrence of different manifestations, such as cough, chest pain, hematuria, rectal bleeding. With: In addition to the lesion site, most can be next to the abdomen or Penbi palpable mass, lower extremity edema.

(5) in the diagnosis of the above symptoms, signs as a general recurrence of the cancer diagnosis. Where the side of cervical cancer after treatment with lower extremity pain or lower extremity edema, indicates that there are recurrent pelvic nerve and lymphatic cancer oppression or blocked due to venous return. Case recurrence after surgery easier diagnosis. But sometimes not absorb the lymphatic cyst or pelvic inflammatory disease and easy to confuse the block as soon as possible for local puncture sent to pathology and cytology smear for a check to clear diagnosis. Other physical inspection of the site is also very important. Supraclavicular should pay attention to whether or inguinal lymph node metastasis, such as the lymph nodes that should be cut hard for pathological examination. Fashion should be necessary chest x-radiography and gastrointestinal barium meal examination.

(6) in the treatment of diagnosed cases of recurrence after treatment is surgery, chemotherapy or radiotherapy. First analysis of past treatment is reasonable, appropriate and thorough, according to local and systemic recurrence, a suitable choice of therapy or combination therapy, the treatment of advanced cases should. Postoperative radiotherapy for recurrent cases of the option.

(7) the prevention of first diagnosis before treatment should be clearly formulated so far as reasonably practicable treatment programmes, and strictly enforced. Regular follow-up after treatment. In this way, even if there are also early detection of recurrent disease, and early treatment.

[Transfer and proliferation --




Cervical cancer development process in recent years, a substantial amount of research has made clear that precancerous lesions of atypical hyperplasia, dysplasia, carcinoma in situ and invasive cervical cancer is a group of continuity and disease; surface by early atypical hyperplasia lesions , the causes continue to exist, will gradually progress to invasive carcinoma. The study also shows that the overwhelming majority of cervical cancer is gradual rather than sudden, precancerous lesions often in a fairly long period of time is reversible, then entered the surface of "carcinoma in situ" stage, this period is sustainable for many years, In this period of no clinical symptoms, the availability of the cervix and cervical cytology examination revealed scratch films, and the biopsy method that diagnosis. In the pre-cancerous stage, abnormal non-infringement of mesenchymal cells, the transfer does not occur, if at this point in time that a plot and given treatment, the opportunity to cure it is very high. But after invasive cervical cancer has become, it developed very quickly, and if not treated, the patient may be 2 to 5 years in the death.