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Patients with CIN II/III should be referred to an experienced colposcopist Patients requiring conization biopsy should be referred to a gynecologist
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American College of Obstetricians-Gynecologists ACOG Committee Opinion Evaluation and management of abnormal cervical cytology and histology in the adolescent Number 330, April 2006 Obstet Gynecol 2006 Apr;107(4):963 8 [PMID: 16582143] Spitzer M et al Management of histologic abnormalities of the cervix Am Fam Physician 2006 Jan 1;73(1):105 12 [PMID: 16417073] Temte JL HPV vaccine: a cornerstone of female health Am Fam Physician 2007 Jan 1;75(1):28, 30 [PMID: 17225700]
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Treatment varies depending on the degree and extent of CIN Biopsies should always precede treatment
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CARCINOMA OF THE CERVIX
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Abnormal uterine bleeding and vaginal discharge Cervical lesion may be visible on inspection as a tumor or ulceration
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A Cauterization or Cryosurgery
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The use of either hot cauterization or freezing (cryosurgery) is effective for noninvasive small lesions visible on the cervix without endocervical extension
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Vaginal fistulas to the rectum and urinary tract are severe late complications Hemorrhage is the cause of death in 10 20% of patients with extensive invasive carcinoma
Vaginal cytology usually positive; must be confirmed by biopsy
General Considerations
Cervical cancer can be considered a sexually transmitted disease Both squamous cell and adenocarcinoma of the cervix are etiologically related to infection with HPV, primarily types 16 and 18 Smoking and possibly dietary factors such as decreased circulating vitamin A appear to be cofactors While squamous cell carcinoma (SCC) accounts for 85% of cervical cancers, the incidence of SCC is decreasing while the incidence of adenocarcinoma of the cervix is increasing SCC appears first in the intraepithelial layers (the preinvasive stage, or carcinoma in situ) Preinvasive cancer (CIN III) is a common diagnosis in women 25 40 years of age Two to 10 years are required for carcinoma to penetrate the basement membrane and invade the tissues After invasion, death usually occurs within 3 5 years in untreated or unresponsive patients
Prevention
In 2006, the FDA approved a quadrivalent HPV 6/11/16/18 L1 virus-like-particle vaccine, known as Gardisil, to prevent cervical cancer caused by HPV types 16, and 18, and to protect against low-grade and precancerous lesions and genital warts caused by HPV types 6, 11, 16, and 18
Treatment
A Emergency Measures
Vaginal hemorrhage originates from gross ulceration and cavitation in stage II IV cervical carcinoma Ligation and suturing of the cervix are usually not feasible, but ligation of the uterine or hypogastric arteries may be lifesaving when other measures fail Styptics such as Monsel s solution or acetone are effective, although delayed sloughing may result in further bleeding Wet vaginal packing is helpful Emergency irradiation usually controls bleeding
Clinical Findings
A Symptoms and Signs
The most common signs are metrorrhagia, postcoital spotting, and cervical ulceration Bloody or purulent, odorous, nonpruritic discharge may appear after invasion Bladder and rectal dysfunction or fistulas and pain are late symptoms
B Specific Measures
1 Carcinoma in situ (stage 0) In women who have completed childbearing, total hysterectomy is the treatment of choice In women who wish to retain the uterus, acceptable alternatives include cervical conization or ablation of the lesion with cryotherapy or laser Close follow-up with Papanicolaou smears every 3 months for 1 year and every 6 months for another year is necessary after cryotherapy or laser 2 Invasive carcinoma Microinvasive carcinoma (stage IA) is treated with simple, extrafascial hysterectomy Stage IB and stage IIA cancers may be treated with either radical hysterectomy with concomitant radiation and chemotherapy or with radiation plus chemotherapy alone Stage IIB and stage III and IV cancers are treated with radiation therapy plus concurrent cisplatin-based chemotherapy
B Cervical Biopsy and Endocervical Curettage, or Conization
These procedures are necessary steps after a positive Papanicolaou smear to determine the extent and depth of invasion of the cancer Even if the smear is positive, treatment is never justified until definitive diagnosis has been established through biopsy
C Staging, or Estimate of Gross Spread of Cancer of the Cervix
The depth of penetration of the malignant cells beyond the basement membrane is a reliable clinical guide to the extent of primary cancer within the cervix and the likelihood of metastases It is customary to stage cancers of the cervix under anesthesia Further assessment may be carried out by abdominal and pelvic CT scanning or MRI
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