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子宮頸癌

Cervical Cancer

* The depth of incvasion should not be more than 5 mm taken from the base of the epithelium, either surface or glandular, from which it originate. Vascular space involveme,ent, either venous or lymphatic, should not alter the staging

Stages of Cervical Cancer Staging System
I	Strictly confined to cervix
IA.	Preclinical carcinomas of cervix diagnosed only by microscopy. All gross lesions even with superficial invasion are stage IB cancers. Invasion is limited to measured stromal invasion with maximum depth of 5.0 mm and no wider than 7.0mm*.
IA1	Stromal invasion no greater than 3.0 mm and no wider than 7.0 mm
IA2	Maximum depth of invasion of stroma greater than 3 mm and no greater than 5 mm taken from base of epithelium, either surface or glandular, from which it originates; horizontal invasion not more than 7 mm
IB	Clinical lesions confined to the cervix or preclinical lesions greater than stage IA.
IB1	Clinical lesion no longer than 4.0 cm in size
IB2	Clinical lesion greater than 4.0 cm in size
II	Extension beyond cervix but not to pelvic wall. Involves vagina, but not the lower third.
IIA	Involves vagina, but not lower third. No obvioius extension to parametria.
IIB	Involves vagina, but not lower third. Obvious parametrial involvement.
III	Extension to pelvic wall. On rectal exam, no cancer-free space between tumor and pelvic wall. Involves lower third of vagina.
IIIA	No extension to pelvic side wall.
IIIB	Extension to pelvic side wall.
IV	Extension beyond true pelvis or involvement of bladder or rectal mucosa. Bullous edema does not permit a case to be assigned to Stage IV.

Notes

Diagnosis of both Stages IA1 and IA2 is based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion. The lower limit of Stage IA2 should be measurable macroscopically (even if dots need to be placed on the slide prior to measurement). The upper limit of IA2 is determined by measurement of the two largest dimensions in any given section.

Revised staging - adopted in 1988 - varies from the previous staging primarily in the stage I category. These changes have occasioned a good deal of controversy and a substantial body of opposition from some gynecologic oncologists. The defined limits of the 1a2 often appear impractical in clinical practice. Multiple foci of invasion may be present, the cone biopsy may not include the entire lesion, and prior colposcopic biopsies which encroach on the lesion may alter the volumetric dimensions. A major concern is that clinicians will interpret the stage Ia2 lesion as one that can be approached in a more conservative manner such as simple hysterectomy. Taken as a group, a retrospective study done here suggested that such lesions carry a risk of nodal metastases in excess of 4% and a recurrence rate of 6% even when treated by radical hysterectomy. The G.O.G. previously had described "microinvasion" as a lesion with less than 3 mm of invasion, no vascular space involvement and no areas of confluence. as possibly suitable for conservative treatment. It has been suggested that this guideline be substituted in treatment planning.

Cervical cancer remains the one remaining major gynecologic cancer that is subjected to "clinical" staging as opposed to surgical staging. This decision, of course, reflects an appreciation that a large number of cases - perhaps a majority - are treated with radiation therapy without surgical intervention. It is generally agreed that the most experienced clinician involved in the case should stage the lesion and if there is a doubt as to which stage applies, the earlier stage is mandatory.

Examination for clinical staging permits palpation, inspection, colposcopy, hysteroscopy, curettage, cystoscopy, proctoscopy and roentgen examinations to include X-rays of the lungs and skeleton and intravenous urography. Other procedures such as laparoscopy or lymphography may not be employed. A conization of the cervix is regarded as a clinical examination. An IVP revealing hydronephrosis or a nonfunctioning kidney attributable to stenosis of the ureter by cancer permits the allotment of a case to Stage III regardless of other factors.

After cervical cancer has been diagnosed, tests are done to find out if cancer cells have spread within the cervix or to other parts of the body.

The process used to find out if cancer has spread within the cervix or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan the best treatment. The following tests and procedures may be used in the staging process:

Chest x-ray: Brief exposure of the chest to radiation to produce an image of the chest and its internal structures.

CT scan (CAT scan): A CT scan creates a series of detailed pictures of areas inside the body, taken from different angles. The pictures are created by a computer linked to an x-ray machine. This test is also called computed tomography, computerized tomography, or computerized axial tomography.

Lymphangiography: An x-ray is made of the lymph system. A dye is injected into a lymph vessel and travels through the lymph system. The dye outlines the lymph vessels and organs on the x-ray. This test helps determine whether cancer has spread to the lymph nodes.

Pretreatment surgical staging: Surgery (an operation) is done to find out if the cancer has spread within the cervix or to other parts of the body. In some cases, the cervical cancer can be removed at the same time. Pretreatment surgical staging is usually done only as part of a clinical trial.

Ultrasound: A test that uses sound waves to create images of body tissues.

MRI (magnetic resonance imaging): A procedure in which a magnet linked to a computer is used to create detailed pictures of areas inside the body. This test is also called nuclear magnetic resonance imaging (NMRI).

The results of these tests are viewed together with the results of the original tumor biopsy to determine the cervical cancer stage.

TREATMENT OPTION OVERVIEW

How cancer of the cervix is treated

There are treatments for all patients with cancer of the cervix. Three kinds of treatment are used:

surgery (removing the cancer in an operation)
radiation therapy (using high-dose x-rays or other high-energy rays to kill cancer cells)
chemotherapy (using drugs to kill cancer cells)

A doctor may use one of several types of surgery for carcinoma in situ to destroy the cancerous tissue:

Cryosurgery kills the cancer by freezing it.

Laser surgery is the use of a narrow beam of intense light to kill
cancerous cells.

A doctor may remove the cancer using one of these operations:

Conization is the removal of a cone-shaped piece of tissue
where the abnormality is found. Conization may be used to take out a piece of tissue for biopsy, but it can also be used to treat early cancers of the cervix.

Alternatively, a doctor may perform a loop electrosurgical excision
procedure (LEEP) to remove the abnormal tissue. LEEP uses an electrical current passed through a thin wire loop to act as a knife.

A laser beam can also be used as a knife to remove the tissue.

A hysterectomy is an operation in which the uterus and cervix are taken out along with the cancer. If the uterus is taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus is taken out through a cut (incision) in the abdomen, the operation is called a total abdominal hysterectomy. Sometimes the ovaries and fallopian tubes are also removed, which is called a bilateral salpingo-oophorectomy.

A radical hysterectomy is an operation in which the cervix, uterus, and part of the vagina are removed. Lymph nodes in the area are also removed. This is called lymph node dissection. (Lymph nodes are small bean-shaped structures that are found throughout the body. They produce and store cells that fight infection).

If the cancer has spread outside the cervix or the female organs, a
doctor may take out the lower colon, rectum, or bladder (depending on where the cancer has spread) along with the cervix, uterus, and vagina. This is called an exenteration and is rarely needed. Plastic surgery may be needed to make an artificial vagina after this operation.

Radiation therapy is the use of x-rays or other high-energy rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found (internal radiation). Radiation may be used alone or in addition to surgery.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle inserted into a vein. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells outside the cervix.

Treatment by stage

Treatments for cancer of the cervix depend on the stage of the disease, the size of the tumor, and the patient's age, overall condition, and desire to have children.

Treatment of cervical cancer during pregnancy may be delayed depending on the stage of the cancer and how many months a patient has been pregnant.

STAGE 0 CERVICAL CANCER

Stage 0 cervical cancer is sometimes called carcinoma in situ.

Treatment may be one of the following:

1. Conization.

2. Laser surgery.

3. Loop electrosurgical excision procedure (LEEP).

4. Cryosurgery.

5. Surgery to remove the cancerous area, cervix, and uterus (total abdominal or vaginal hysterectomy) for those women who cannot or no longer want to have children.

Hysterectomy for women who cannot or no longer want to have children. Internal radiation therapy for women who cannot have surgery.

STAGE I CERVICAL CANCER

Treatment may be one of the following depending on how deep the tumor cells have invaded into the normal tissue:

For stage IA cancer:

1. Surgery to remove the cancer, uterus, and cervix (total abdominal hysterectomy). The ovaries may also be taken out (bilateral salpingo- oophorectomy), but are usually not removed in younger women.

2. Conization.

3. For tumors with deeper invasion (3-5 millimeters): Surgery to remove the cancer, the uterus and cervix, and part of the vagina (radical hysterectomy) along with the lymph nodes in the pelvic area (lymph node dissection).

4. Internal radiation therapy.

For stage IB cancer:

1. Internal and external radiation therapy.

2. Radical hysterectomy and lymph node dissection.

3. Radical hysterectomy and lymph node dissection followed by radiation therapy plus chemotherapy.

4. Radiation therapy plus chemotherapy.

Treatment of stage IB cervical cancer may include the following:

A combination of internal radiation therapy and external radiation therapy.

Radical hysterectomy and removal of lymph nodes.

Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.

Radiation therapy plus chemotherapy.

A clinical trial of high-dose internal radiation therapy combined with external radiation therapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site.

STAGE II CERVICAL CANCER