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07.05.07 (1 year ago)
#22
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CARCINOMA CERVIX.. THE LATEST STAGING.....
Histological staging:
0 - CIN III (carcinoma in situ)
IA - microinvasive carcinoma
Stage 0 - carcinoma in situ
Stage 1 - the cancer is just in the neck of the womb
Stage 2 - the cancer has begun to spread around the neck of the womb
Stage 3 - the cancer has spread into the pelvis
Stage 4 - the cancer has spread into other body organs
AJCC TNM staging classification 1
The primary tumor (T) is staged in the following way:
TX. Primary tumor cannot be assessed.
T0. No primary tumor is seen.
Tis (Carcinoma in situ). The cancer is found only in one area of the cervix and only in a few layers of cells. This type of cervical cancer is called carcinoma in situ.
T1. Cervical carcinoma is only found in the uterus.
o T1a. Invasive carcinoma diagnosed by microscopy with stromal invasion is no more than 5 mm in depth and 7 mm wide.
T1a1. Stromal invasion is 3 mm or less in depth and 7 mm or less in width. This is also called microinvasive carcinoma.
T1a2. Stromal invasion is between 3 mm and 5 mm in depth and 7 mm or less in width.
T1b. Visible tumor only on the cervix or by microscopy is larger than 5 mm in depth and 7 mm wide.
T1b1. Visible tumor is 4 cm (1.6 in.) or less in size.
T1b2. Visible tumor is more than 4 cm (1.6 in.) in size.
T2. Cancer invades beyond the uterus but not the pelvic wall or the lower third of the vagina.
o T2a. Tumor does not involve the connective tissue (parametrium) around the uterus.
o T2b. Tumor does extend into the parametrium around the uterus.
T3. The tumor extends to the pelvic wall or involves the lower third of the vagina or causes an obstructed kidney that forms a cyst or a nonfunctioning kidney.
o T3a. Tumor involves lower third of vagina but no extension into the pelvic wall.
o T3b. Tumor extends to pelvic wall or causes an obstructed kidney or nonfunctioning kidney.
T4. Tumor invades the lining of the bladder or rectum, or extends beyond the pelvis.
o M1. Distant metastasis: The cancer has spread to distant parts of the body.
After the tumor (T) is staged, the TNM system stages lymph node involvement (N) to help determine the treatment options at each stage. Lymph node involvement is staged in the following way:
NX. Lymph nodes near the primary tumor cannot be evaluated.
N0. Cancer has not spread to lymph nodes near the primary tumor.
N1. Cancer has spread to lymph nodes near the primary tumor.
The last part of staging cervical cancer is to determine whether cancer has spread to other parts of the body (metastasized). The TNM system stages metastasis (M) in the following way:
MX. Distant metastasis cannot be assessed.
M0. No distant metastasis is found.
M1. Metastasis to another part of the body has occurred.
FIGO staging of cervical carcinomas
Stage I
Stage I is carcinoma strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion.
Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
Stage IA1: Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
Stage IA2: Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.
Stage IB: Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
Stage IB1: Stage IB1: Clinical lesions no greater than 4 cm in size.
Stage IB2: Stage IB2: Clinical lesions greater than 4 cm in size.
Stage II
Stage II is carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
Stage IAB: Obvious parametrial involvement, but not into the pelvic sidewall.
Stage III
Stage III is carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.
Stage IV
Stage IV is carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.
Stage IVA: Spread of the tumour into adjacent pelvic organs.
Stage IVB: Spread to distant organs.
Stage TNM class
Stage 0 is carcinoma in situ TisN0M0
Stage I T1N0M0
Stage IA
Stage IA1
Stage IA2 T1aN0M0
T1a1N0M0
T1a2N0M0
Stage IB
Stage IB1
Stage IB2 T1bN0M0
T1b1N0M0
T1b2N0M0
Stage II
Stage IIA
Stage IIB T2N0M0
T2aN0M0
T2bN0M0
Stage III
Stage IIIA
Stage IIIB T3N0M0
T3aN0M0
T1N1M0
T2N1M0
T3aN1M0
T3b, any N, M0
Stage IVA
Stage IVB T4, any N, M0
Any T, any N, M1
Medical Care: The treatment of cervical cancer varies with the stage of the disease. For early invasive cancer, surgery is the treatment of choice. In more advanced cases, radiation combined with chemotherapy is the current standard of care. In patients with disseminated disease, chemotherapy or radiation provides symptom palliation.
Stage 0: Treatment options for stage 0 cancer include loop electrosurgical excision procedure (LEEP), laser therapy, conization, and cryotherapy.
Stage IA: The treatment of choice for stage IA disease is surgerytotal hysterectomy, radical hysterectomy, and conization are accepted procedures. Intracavitary radiation is an option for selected patients.
Stage IB or IIA
o For patients with stage IB or IIA disease, treatment options are either combined external beam radiation with brachytherapy or radical hysterectomy with bilateral pelvic lymphadenectomy.
o Most retrospective studies have shown equivalent survival rates for both procedures, although such studies usually are flawed due to patient selection bias and other compounding factors. However, a recent randomized study showed identical overall and disease-free survival rates.
o Quality-of-life data, particularly in the psychosexual area, is relatively scant.
o Postoperative radiation to the pelvis decreases the risk of local recurrence in patients with high-risk factors (positive pelvic nodes, positive surgical margins, and residual parametrial disease).
o A recent randomized trial showed that patients with parametrial involvement, positive pelvic nodes, or positive surgical margins benefit from a postoperative combination of cisplatin-containing chemotherapy and pelvic radiation.
Stage IIB-IVA
o For locally advanced cervical carcinoma (stages IIB, III, and IVA), radiation therapy was the treatment of choice for many years. However, the results from large randomized clinical trials demonstrated a dramatic improvement in survival with the combined use of chemotherapy and radiation.
o For treatment with radiation alone, 5-year survival rates reportedly are 65-75%, 35-50%, and 15-20% for stages IIB, III, and IVA, respectively.
o Radiation therapy begins with a course of external beam radiation to reduce tumor mass to enable subsequent intracavitary application. Brachytherapy is delivered using afterloading applicators that are placed in the uterine cavity and vagina.
o The results of prospective, randomized, well-conducted studies of concurrent chemoradiation changed the standard of care in this group of patients.
o In the Radiation Therapy Oncology Group trial, 403 patients with bulky IB and IIB-IVA cancers were randomized to either radiotherapy to a pelvic and paraaortic field or pelvic radiation with concurrent cisplatin and fluorouracil. Rates of both disease-free survival and overall survival were significantly higher in the group that received combination treatment.
o Rose and associates conducted a Gynecologic Oncology Group (GOG) trial for patients with stage IIB, III, or IVA cancer, comparing the combination of radiation with 3 different chemotherapy regimens (cisplatin alone, cisplatin/5-fluorouracil/hydroxyurea, and hydroxyurea alone). Overall survival rates were significantly higher in the 2 groups that received cisplatin-containing regimens.
o In another GOG trial, patients with bulky stage IB disease were randomized to either radiation alone or a combination of weekly cisplatin and radiation. All patients had adjuvant hysterectomy. Both disease-free survival and overall survival rates were significantly higher in the combined-therapy group at 4 years of follow-up.
o Based on the aforementioned study results, using cisplatin-based chemotherapy in combination with radiation for patients with locally advanced cervical cancer represents the standard of care.
Stage IVB and recurrent cancer
o These patients are treated with chemotherapy. For many years, single agent cisplatin represented the standard of care. Recently, the combined use of cisplatin and topotecan was shown to significantly improve survival compared with single-agent cisplatin.
o Palliative radiation is often used individually to control bleeding, pelvic pain, or urinary or partial large bowel obstructions from pelvic disease.
o Total pelvic exenteration may be considered in patients with an isolated central pelvic recurrence.
Surgical Care:
Carcinoma in situ (stage 0) is treated with local ablative measures such as cryosurgery, laser ablation, and loop excision.
o Hysterectomy should be reserved for patients with other gynecologic indications to justify the procedure.
o After local treatment, these patients require lifelong surveillance.
o Palliative radiation often is used individually to control bleeding, pelvic pain, or urinary or partial large bowel obstructions from pelvic disease.
o Invasive procedures such as nephrostomy or diverting colostomy sometimes are performed in this group of patients to improve their quality of life.
o Special effort should be made to ensure comprehensive palliative care, including adequate pain control for these patients.
The standard treatment for microinvasive disease (stage IA) is total hysterectomy.
o Lymph node dissection is not required if the depth of invasion is less than 3 mm and no lymphovascular invasion is noted.
o Selected patients with stage IA1 disease but no lymphovascular space invasion who desire to maintain fertility may have a therapeutic conization with close follow-up, including cytology, colposcopy, and endocervical curettage.
o Patients with medical comorbidities who are not surgical candidates can be successfully treated with radiation.
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