Atlas of pathophysiology, 2 Edition

Part II - Disorders

Genital Diseases

Cervical Cancer

The third most common cancer of the female reproductive system, cervical cancer is classified as either microinvasive or invasive. Precancerous dysplasia, also called cervical intraepithelial carcinoma or cervical carcinoma in situ, is more frequent than invasive cancer and occurs more often in younger women.

Causes

Cause unknown

Predisposing factors include

·   Frequent intercourse at a young age (under age 16)

·   Multiple sexual partners

·   Multiple pregnancies

·   Sexually transmitted diseases (particularly genital human papillomavirus [HPV])

·   Smoking

Pathophysiology

Preinvasive disease ranges from mild cervical dysplasia, in which the lower third of the epithelium contains abnormal cells, to carcinoma in situ, in which the full thickness of epithelium contains abnormally proliferating cells. Other names for carcinoma in situ include cervical intraepithelial neoplasia and squamous intraepithelial lesion. Preinvasive disease detected early and properly treated is curable in 75% to 90% of cases. If preinvasive disease remains untreated (and depending on the form in which it appears), it may progress to invasive cervical cancer.

In invasive carcinoma, cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by lymphatic routes.

In almost all cases of cervical cancer (95%), the histologic type is squamous cell carcinoma, which varies from well-differentiated cells to highly anaplastic spindle cells. Only 5% are adenocarcinomas.

Age Alert

Usually, invasive carcinoma occurs in women between ages 30 and 50; rarely, in those under age 20.

Signs and symptoms

Preinvasive disease

·   Often produces no symptoms or other clinically apparent changes

Early invasive cervical cancer

·   Abnormal vaginal bleeding

·   Persistent vaginal discharge

·   Postcoital pain and bleeding

Advanced disease

·   Pelvic pain

·   Vaginal leakage of urine and stool from a fistula

·   Anorexia, weight loss, and anemia

Diagnostic test results

·   Papanicolaou (Pap) test screens for abnormal cells.

·   Colposcopy shows the source of the abnormal cells seen on the Pap test.

·   Cone biopsy is performed if endocervical curettage is positive.

·   Vira-Pap test permits examination of the specimen's deoxyribonucleic acid structure to detect HPV.

·   Lymphangiography and cystography detect metastasis.

·   Organ and bone scans show metastasis.

Treatment

Preinvasive lesions

·   Loop electrosurgical excision procedure

·   Cryosurgery

·   Laser destruction

·   Conization (with frequent Pap smear follow-up)

·   Hysterectomy

Invasive carcinoma

·   Radical hysterectomy

·   Radiation therapy (internal, external, or both)

·   Chemotherapy

·   Combination of the above procedures

P.307

CERVICAL CANCER

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Clinical Tip: Pap smear findings

Normal

·   Large, surface-type squamous cells

·   Small, pyknotic nuclei

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Mild dysplasia

·   Mild increase in nuclear:cytoplasmic ratio

·   Hyperchromasia

·   Abnormal chromatin pattern

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Severe dysplasia, carcinoma in situ

·   Basal type cells

·   Very high nuclear:cytoplasmic ratio

·   Marked hyperchromasia

·   Abnormal chromatin

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Invasive carcinoma

·   Marked pleomorphism

·   Irregular nuclei

·   Clumped chromatin

·   Prominent nucleoli

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