Principles and Practice II
Chapters 32:
Perineum: the area between the change to vagina to anus in women, and scrotum to anus in men
Perimetrium: connective tissue immediately lateral to the uterine cervix
CERVICAL:
3rd most common malignancy in women
Pap smear preventive screening
(younger than 50 years old, rare under age 20)
Classified histologically by their tissue of origin: (primary types)
1) Squamous (80%-90%), exocervix
2) Adeno (10%-20%), worse prognosis, endocervix, bulky, high rate of distant mets,
difficult to detect
3%-5% of cervical cancers are composed of both cell types, called adenosquamous carcinomas
Increased risk:
- Sex at young age
- Multiple sex partners
- Herpes simplex type 2
- HPV (most common STI in the U.S, responsible for 90% of cervical cancers, specifically
HPV 16 and 18, HPV needs 10-20 years to progress into cervical cancer)
Slow-growing, early stages are asymptomatic
Advanced-stages symptoms:
- Abnormal vaginal bleeding (most common symptom)
- Abnormal vaginal discharge
- Pelvic or back pain
- Painful urination
- Hematuria
- Hematochezia (bloody stool)
Bowel symptoms may suggest spread into the rectum
Edema or pain may suggest lymphatic obstruction or nerve involvement
Clinical exams:
1) Visualize cervix
2) Obtain Pap smear
3) Colposcopy (if unusual Pap smear results)
-punch biopsy (abnormal tissue, forceps) or cone biopsy (when tumor is suspected
endocervically, LEEP or cold knife biopsy)
4) Palpate cervix
Pap smear every 3 years for women starting at age 21 (no need after total hysterectomy)
, Imaging test for the staging (lymph node involvement) of cervical cancer: PET-CT
Parametrial and vaginal extension: MRI (contradiction is patients with pacemaker or internal
metallic objects)
FIGO and AJCC TNM staging (FIGO doesn’t have stage 0)
Staging is the most important prognostic factor of cervical cancer
May directly invade adjacent tissues, spread through hematogenous routes (lung, liver, bone),
and spread lymphatically (orderly)
Lymphatic spread:
1) Parametrial
2) Pelvic
3) Common iliac
4) Periaortic
5) Supraclavicular (35% with periaortic)
Cryotherapy: freezes cervix with liquid nitrogen
Laser therapy: targets and kills abnormal cells
Radiation and surgery are the treatment modalities
Typical treatment for early-stage cervical carcinoma:
1) Total abdominal hysterectomy (TAH) with or without a small amount of vaginal tissue
called the vaginal cuff (women can no longer receive children and menstruation ceases)
2) Brachytherapy treatment because risk of nodal mets is low
3) Radical trachelectomy (cervix is removed but the uterus remains in place, patients
maintain their fertility)
4) Radiation therapy (when surgery is not possible or adequate)
-should be considered when tumor is confined to cervix
Post-op radiation for:
-patients with negative nodes
-patients with a combination of deep stromal invasion
-lymphovascular space involvement (LVSI)
-large tumor diameter
Advanced-stage disease:
Radiation with or without chemo
70Gy for low volume disease, 85Gy for bulky
Excessive doses (like from brachytherapy) may cause fibrosis, vaginal stenosis, or atrophy
Chapters 32:
Perineum: the area between the change to vagina to anus in women, and scrotum to anus in men
Perimetrium: connective tissue immediately lateral to the uterine cervix
CERVICAL:
3rd most common malignancy in women
Pap smear preventive screening
(younger than 50 years old, rare under age 20)
Classified histologically by their tissue of origin: (primary types)
1) Squamous (80%-90%), exocervix
2) Adeno (10%-20%), worse prognosis, endocervix, bulky, high rate of distant mets,
difficult to detect
3%-5% of cervical cancers are composed of both cell types, called adenosquamous carcinomas
Increased risk:
- Sex at young age
- Multiple sex partners
- Herpes simplex type 2
- HPV (most common STI in the U.S, responsible for 90% of cervical cancers, specifically
HPV 16 and 18, HPV needs 10-20 years to progress into cervical cancer)
Slow-growing, early stages are asymptomatic
Advanced-stages symptoms:
- Abnormal vaginal bleeding (most common symptom)
- Abnormal vaginal discharge
- Pelvic or back pain
- Painful urination
- Hematuria
- Hematochezia (bloody stool)
Bowel symptoms may suggest spread into the rectum
Edema or pain may suggest lymphatic obstruction or nerve involvement
Clinical exams:
1) Visualize cervix
2) Obtain Pap smear
3) Colposcopy (if unusual Pap smear results)
-punch biopsy (abnormal tissue, forceps) or cone biopsy (when tumor is suspected
endocervically, LEEP or cold knife biopsy)
4) Palpate cervix
Pap smear every 3 years for women starting at age 21 (no need after total hysterectomy)
, Imaging test for the staging (lymph node involvement) of cervical cancer: PET-CT
Parametrial and vaginal extension: MRI (contradiction is patients with pacemaker or internal
metallic objects)
FIGO and AJCC TNM staging (FIGO doesn’t have stage 0)
Staging is the most important prognostic factor of cervical cancer
May directly invade adjacent tissues, spread through hematogenous routes (lung, liver, bone),
and spread lymphatically (orderly)
Lymphatic spread:
1) Parametrial
2) Pelvic
3) Common iliac
4) Periaortic
5) Supraclavicular (35% with periaortic)
Cryotherapy: freezes cervix with liquid nitrogen
Laser therapy: targets and kills abnormal cells
Radiation and surgery are the treatment modalities
Typical treatment for early-stage cervical carcinoma:
1) Total abdominal hysterectomy (TAH) with or without a small amount of vaginal tissue
called the vaginal cuff (women can no longer receive children and menstruation ceases)
2) Brachytherapy treatment because risk of nodal mets is low
3) Radical trachelectomy (cervix is removed but the uterus remains in place, patients
maintain their fertility)
4) Radiation therapy (when surgery is not possible or adequate)
-should be considered when tumor is confined to cervix
Post-op radiation for:
-patients with negative nodes
-patients with a combination of deep stromal invasion
-lymphovascular space involvement (LVSI)
-large tumor diameter
Advanced-stage disease:
Radiation with or without chemo
70Gy for low volume disease, 85Gy for bulky
Excessive doses (like from brachytherapy) may cause fibrosis, vaginal stenosis, or atrophy
