Professional Documents
Culture Documents
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cabrera. Cortes
K.W.
41 year old
G5P5(5005)
Micronesian Housewife
Single
Palau
Chief Complaint
For chemoradiation therapy
OB Gyn history
LMP: November 7, 1st sexual contact: 17
2012 PMP: 1st week October, 2012 Menarche: 15 y.o. Interval: Regular Duration: 4 5 days Amount: 5-6 ppd, moderately soaked No dysmenorrhea
y.o. Age at first pregnancy: 17 y.o. 2 sexual partners No history of contraceptive use No previous hx of STI, leukorrhea, vulvar pruritus No history of cervical screening No history of recent sexual contact
OB Gyn history
G5P5 (5005)
Year
G1 1987
Outcome
LFT (F)
Manner
NSD
Institution
Hospital
G2
G3 G4 G5
1990
1993 1997 2002
LFT (M)
LFT (F) LFT (M) LFT (F)
NSD
NSD NSD NSD
Hospital
Hospital
Hospital Hospital
No diabetes
No asthma No thyroid problems No liver disease No allergies to food or drugs
Family History
No hypertension
No diabetes
No asthma No thyroid problems
housewife
Lives with partner and children History of chronic smoking (10 pack years) Non alcoholic beverage drinker Denies illicit drug use
Review of systems
No fever, changes in mental status, easy fatigability, dysphagia, DOB, chest pain, dysuria, changes in bowel habits, excessive sweating or temperature intolerance
Physical Examination
General: Alert, coherent not in respiratory distress. Anthropometrics:
Ht. 159 cm
Vital signs:
no TPC, no CLAD
Physical Examination
Cardiovascular: Adynamic precordium,
Physical Examination
Abdomen: flabby, normoactive bowel
Physical Examination
Extremities: Good skin color. Good turgor,
Physical Examination
Gynecologic Examination
Friable, bleeding fungating growths
encompassing entire cervix extending to L parametria, involvement Mixed discharges: bloody and purulent Uterus not enlarged No adnexae tenderness
SALIENT FEATURES
Do you have any questions?
Salient Features
41 y/o G5P5 (5005) 2 sexual partners No history of contraceptive use History of chronic smoking Diagnosed case of cervical cancer (squamous cell carcinoma, large cell nonkeratinizing, stage IIA) 1 year history of vaginal discharge (Mucopurulent foul-smelling, brownish (+) undocumented weight loss, poor appetite (-) fever, easy fatigability, abdominal pain, vaginal bleeding, post-coital bleeding, dyspareunia
Primary Impression
Laboratories
CBC
Hgb 118 g/L Hct 0.34 RBC 4.96 x 1012/L WBC 5.97 x 109/L
Neutrophil: 0.61 Monocyte: 0.05
Laboratories
Urinalysis
Color: light yellow Transparency: clear Erythrocytes: negative Protein: negative Glucose: negative Leucocytes: negative Ketones: negative Urobilinogen: normal Nitrites: negative WBC: 1-3/hpf RBC: 3-5/hpf Epithelial cells: 2/hpf Bacteria: Few
Cervical Cancer
third most common malignancy in women
worldwide leading cause of cancer-related death for women in developing countries patients tend to be in their 40s to 60s, with a median age of 52 years
Pathophysiology
HPV infection must be present for cervical cancer
to occur Approximately 90% of HPV infections clear on their own within months to a few years and with no sequelae Factors postulated to influence the development of CIN 3 lesions:
The type and duration of viral infection, with high-
risk HPV type and persistent infection predicting a higher risk for progression; low-risk HPV types do not cause cervical cancer Host conditions that compromise immunity (eg, poor nutritional status, immunocompromise, and HIV infection)
Gynecologic factors:
early age of first intercourse and higher number of
sexual partners.
Genetic susceptibility
symptoms:
abnormal bleeding or brownish discharge,
frequently noted following douching or intercourse and also occurring spontaneously between menstrual periods back pain, loss of appetite, and weight loss, are late manifestations
Differentials
Cervicitis
PID
Vaginitis Vaginal Cancer Primary melanoma and Paget disease
Work-up
The diagnosis is established by biopsy of the
tumor
A Kevorkian, Eppendorf, Tishler, or similar punch
invasive carcinoma with no gross lesion visible and endocervical curettage does not demonstrate carcinoma or if an adequate biopsy specimen to establish carcinoma cannot be obtained, then cervical conization should be performed.
Staging
The staging of carcinoma of the cervix depends
examination, by chest radiographic examination, by intravenous pyelography (IVP), or computed tomography (CT)
Stage I Cancer
Stage IA:
The area of invasion
< than 3 mm
(approximately 1/8 inch) deep < than 7 mm (approximately 1/3 inch) wide
Stage IA2:
The area of invasion
between 3 mm and 5
Stage I Cancer
Stage IB1:
no larger than 4 cm
Stage II
Stage IIA:
spread beyond the
cervix to the upper portion of the vagina, does not involve the lower third of the vagina
Stage IIB:
spread to the tissue
Stage III
Stage IIIA:
spread to the lower
third of the vagina but has not spread to the pelvic wall
Stage IIIB:
extends to the pelvic
Stage IV
Stage IVA:
spread to the bladder
Management
Stage 0 cancer
local ablative or excisional measures such as
conization are accepted procedures. Lymph node dissection is not required if the depth of invasion is less than 3 mm and no lymphovascular invasion is noted.
Selected patients with stage IA1 disease but no
lymphovascular space invasion who desire to maintain fertility may undergo therapeutic conization with close follow-up, including cytology, colposcopy, and endocervical curettage. Patients with comorbid medical conditions who are not surgical candidates can be successfully treated with radiation.
IB or IIA disease
For patients with stage IB or IIA disease, there
are 2 treatment options: Combined external beam radiation with brachytherapy Radical hysterectomy with bilateral pelvic lymphadenectomy
mass and thereby enable subsequent intracavitary application. Brachytherapy is delivered by means of afterloading applicators that are placed in the uterine cavity and vagina
Additionally, the results from large, well-
conducted, prospective randomized clinical trials have demonstrated a dramatic improvement in survival when chemotherapy is combined with
Radiation therapy is used alone for control of bleeding and pain, whereas systemic chemotherapy is used for disseminated disease. Treatment of pelvic recurrences after primary surgical management should include single-agent chemotherapy and radiation, and treatment for recurrences elsewhere should include combination chemotherapy. For disease recurring after chemotherapy and radiation therapy, a disease-free interval of more than 16 months is considered to designate the tumor as platinum-sensitive. The NCCN also recommends bevacizumab, docetaxel, gemcitabine, ifosfamide, 5-fluorouracil, mitomycin, irinotecan, and topotecan as possible candidates for second-line therapy (category 2B recommendation), as well as pemetrexed and vinorelbine (category 3 recommendation). In addition, bevacizumab as singleagent therapy is also acceptable.
Prognostic Factors
stage of clinical advancement(size of the tumor
and depth of infiltration, involvement of parametria, vascular invasion) histological type of the tumor grade of tumor differentiation condition of draining lymph nodes extent of surgical procedure