Table 18.1 Nomenclature of bone tumors

Cervical cancer

BASIC INFORMATION
DEFINITION
Cervical cancer is penetration of the basement membrane and infiltration of the stroma of the uterine cervix by malignant cells.
EPIDEMIOLOGY & DEMOGRAPHICS
INCIDENCE: There are approximately 15,000 new cases annually, with 4000 to 5000 associated deaths. The U.S. has an age-adjusted mortality of 2.6 cases/100,000 persons for cervical cancer.
PREDOMINANCE: Higher incidence rates occur in developing countries. Among the U.S. population, Hispanics have a higher incidence than African-Americans, who likewise have a higher incidence than whites.
RISK FACTORS: Smoking, early age at first intercourse, multiple sexual partners, immunocompromised state, nonbarrier methods of birth control, infection with high-risk HPV (types 16 and 18), multiparity.

PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Unusual vaginal bleeding, particularly postcoital
• Vaginal discharge and/or odor
• Advanced cases may present with lower extremity edema or renal failure
• In early stages there may be little or no obvious cervical lesion, more advanced cases may present with large, bulky, friable lesions encompassing the majority of the vagina
ETIOLOGY
• Dysplastic cells progress to invasive carcinoma.
• Thought to be linked to the presence of HPV types 16, 18, 45, and 56 via interaction of E6 oncoproteins on p53 gene product.
• There may be an association between past infection with Chlamydia trachomatis.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Cervical polyp or prolapsed uterine fibroid
• Preinvasive cervical lesions
• Neoplasia metastatic from a separate primary
WORKUP
• Thorough history and physical examination
• Pelvic examination with careful rectovaginal examination
• Colposcopy with directed biopsy and endocervical curettage
• Clinically staged, not surgically staged
LABORATORY TESTS
• CBC, chemistry profile
• Squamous cell carcinoma (SCC) antigen in research setting
• Carcinoembryonic antigen (CEA)
IMAGING STUDIES
• Chest x-ray examination
• IVP
• Depending on stage, may need cystoscopy, sigmoidoscopy or BE, CT scan or MRI, lymphangiography
TREATMENT
Screening with Papanicolaou smears decreases cervical cancer mortality. The cervical cancer mortality rate has fallen substantially since the widespread use of the Pap smear. Most screening guidelines recommend regular Pap testing for all women who are or have been sexually active for 3 years or have reached the age of 21. With the onset of sexual activity comes the risk of sexual transmission of HPV, the most common etiologic factor for cervical cancer.

The recommended interval for Pap screening varies from 1-3 years. At age 30, women who have had three normal test results in a row may get screened every 2-3 years. An upper age limit at which screening ceases to be effective is not known, but women ≥70 years with no abnormal results in the previous 10 years may choose to stop screening.
NONPHARMACOLOGIC THERAPY
• FIGO stage Ia: cone biopsy or simple hysterectomy
• FIGO stage Ib or IIa: type III radical hysterectomy and pelvic lymphadenectomy or pelvic radiation therapy
• Advanced or bulky disease: multimodality therapy (radiation, chemotherapy, and/or surgery); platinum use prior to radiation therapy as a fertizer
ACUTE GENERAL Rx
Cervical cancer may present with massive and acute vaginal bleeding requiring volume and blood replacement, vaginal packing or other hemostatic modalities, and/or high-dose local radiotherapy.
CHRONIC Rx
• Physical examination with Pap smear every 3 months for 2 years, every 6 months during the third to fifth year, and annually thereafter
• Chest x-ray examination annually
DISPOSITION
Five-year survival varies by stage:
• Stage I 63% to 93%
• Stage II 43% to 83%
• Stage III <63%
• Stage IV <13%
Early detection by Pap smear imperative to long-term improvements in survival.