Cervix (cervical cancer)

Cervical Cancer
The cervix is ​​the area where the top of the vagina meets the lower part of the uterus (womb). Cancers occurring in this area, namely Cervical Cancer (Cervical Ca) are one of the leading causes of cancer deaths in women all over the world. While 350 thousand new cases are detected every year in developing countries, this number is less than one hundred thousand in developed countries. This is due to the lack of effective screening programs in developing countries that aim to detect and treat cervical lesions before they progress to invasive cancer, that is, in the preinvasive period.
Early diagnosis of cervical cancer is of great importance for women’s health in our country where there is no effective and widespread screening program.
Thanks to the pap smear test, which detects precancerous changes in the cervix, death rates from cervical cancer have decreased by 50-70% in the last 50 years.
Cancerous changes start at the squamocolumnar junction and there are changes in the cervical epithelium over the years, which is important in the early diagnosis of cervical cancer. These changes are:
Normal endocervical columnar epithelium —> Squamous metaplasia —> Mild-moderate-severe dysplasia —> Carsinoma in situ —> Microinvasive carcinoma —> It is in the form of distinctly invasive carcinoma.
The terms cervical intraepithelial neoplasia (CIN) or squamous intraepithelial lesion (SIL) are used for these precancerous changes. In most women, these precancerous changes disappear or remain unchanged, however, when treated, almost all cervical cancers will be prevented.
Cervical cancer is seen between the ages of 35-55 on average, but since there is a risk of cancer development over the age of 65, all sexually active women or women over the age of 18 should be regularly screened until at least 70 years of age. A sexually transmitted virus called Human Papilloma Virus (HPV) has been detected in almost all cervical cancer lesions. For this reason, it is thought that vaccines developed against this virus will be effective in preventing cervical cancer.
Major risk factors for Cervical Cancer:
* Infection of the cervix with high-risk Human Papilloma Virus (HPV) : It is reported that 3 out of 4 people between the ages of 15-49 have HPV infection at some point in their life. The infection may not show symptoms for years, it may not always cause genital warts, but this does not mean that the person does not carry the virus. Infection may not always progress to cancer, but high-risk oncogenic HPV types cause changes that can cause cancer later. Therefore, frequent follow-up is recommended for people with HPV detected.
* Having sexual intercourse at an early age (before the age of 20), having multiple sexual partners or having sex with a person with multiple sexual partners: People who are carriers of HPV are often unaware of their condition, as cancer often does not show symptoms before it develops. For this reason, the only and sure way to prevent HPV is to be monogamous or not to have intercourse with people who are likely to be HPV carriers. Condoms do not provide protection against HPV.
* Cigaret: The risk is increased by 2 times compared to non-smoker.
* Other risk factors: diseases that weaken the immune system, chlamydia infection, low socioeconomic level, not having regular pap smear tests..
Precancerous lesions are usually asymptomatic, but when the cells turn into cancer, they begin to spread to the deep parts of the cervix and adjacent organs. In the early stages of cervical cancer, bloody and foul-smelling vaginal discharge, pain during sexual intercourse or vaginal bleeding afterwards, excessive and prolonged menstrual bleeding can be seen. These findings may also be due to reasons other than cervical cancer, but they should not be neglected and a doctor should be consulted to avoid delay in treatment.
The best way to detect cervical cancer at an early stage is to have a regular pap smear test. Pap smear test is the process of taking cells as a swab from the endocervical canal with the help of a brush during the gynecological examination and the pathologist evaluates whether these cells are suspicious under the microscope. If the test is positive, that is, if it contains abnormal cells, the doctor may recommend HPV DNA test, colposcopy.
Since the Pap smear test is a screening test, in the presence of an abnormal result, further tests such as colposcopy, biopsy, and endocervical curettage (ECC) will be required for definitive diagnosis. Colposcopy is a method of examining the cervix in more detail by a special lighted magnifying glass. During colposcopic examination, a biopsy can be taken from suspicious areas by applying 5% acetic acid and lugol solutions to the cervix surface, and biopsies are evaluated by the pathologist.
Suspicious areas detected by colposcopy are removed with techniques such as cryotherapy (freezing), LEEP or laser. These treatments are always effective in destroying pre-cancerous lesions and preventing cancer. However, regular pap smear screening should be continued to monitor for recurrence of abnormal changes.
Mild dysplasia (CIN I): Colposcopy (+/- biopsy) is performed. It is recommended to have a Pap smear every 4-6 months. Most cases regress spontaneously. If mild dysplasia (CIN I) does not regress in the follow-ups, it is recommended to repeat the colposcopy, take a biopsy, and perform cryotherapy or laser vaporization.
Moderate dysplasia (CIN II) and Severe Dysplasia (CIN III): Colposcopic biopsy and endocervical curettage are performed. If invasive cancer is ruled out as a result of the pathological examination of the biopsies, local conservative treatment is performed with cryotherapy, CO2 laser and LEEP conization. Total removal of the uterus (hysterectomy) is recommended in women who have completed their fertility.
When precancerous cell changes are detected in the cervix, the pathology is limited to the cervical epithelium. There is no possibility of spread (metastasis). In cervical cancer, cancer cells fill the entire epithelial layer and progress to the subepithelial layer. There is a possibility of distant organ metastasis via lymphatic pathways.
Histopathological type of cervical cancers are 80-85% squamous cell cancers. 15-20% of adenocarcinomas are seen. Other histological types are rare.
5-year survival rate in cervical cancer is 72%. The course and treatment of cervical cancer are determined by factors such as the histopathological type and degree of the cancer, the stage of the disease, the age of the patient, the general condition, and the rate at which the disease spreads. For this purpose, tests such as blood count, axial X-ray, intravenous pyelography, cystoscopy and rectoscopy are performed.
Generally, Radical surgical treatment, Radiotherapy or a combination of these are performed. In some cases, chemotherapy may be added to the treatment.
Radical Hysterectomy: It is the standard treatment in stage 1a2,1b and IIa cases. Radical hysterectomy and pelvic-paraaortic lymphadenectomy, called Wertheim-Meigs operation, are performed. In young women, the ovaries can be preserved because less than 1% of cervical cancers metastasize to the ovary.
Radiotherapy: It can be applied either primary or postoperatively. RT has a place in every stage of cervical cancer. An external or intracavitary high-energy beam is sent to the area of ​​the tumor.
Chemotherapy, It is a systemic drug therapy used to kill cancer cells that have spread to other parts of the body. The side effects of the treatment in cervical cancer vary depending on the type of surgical operation, whether or not RT is taken, the drugs used in LT and the duration of the treatment.
The recurrence probability of the tumor in the first 2 years after cervical cancer treatment is 74%. For this reason, patients should be checked with gynecological examination and smear every 2-4 months after treatment. At the end of the 1st year, chest X-ray and Computed Tomography are taken.

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