Cervical Carcinoma

Cervical carcinoma

Early Detection and Prevention

Cervical cancer is particularly suitable for early detection tests. Effective early detection requires regular participation in the cancer screening program, especially for women with a history of risk.

Patient Information – Early Detection/Prevention

Effective early detection of cervical cancer and its precursors requires regular participation in the cancer screening program. This should include a colposcopic assessment of the cervix and a targeted cytological smear from the cervical surface and the cervical canal. If abnormal findings are found, a colposcopically targeted biopsy should be taken.

Diagnosis

Diagnosis in Asymptomatic Patients

A mirror adjustment and a targeted cytological smear sampling, if possible under colposcopic control from the portio surface and the cervical canal, are required.

In recent years, the diagnosis of HPV infection using PCR or hybrid capture II assay (HC II assay) has made it possible to detect patients with persistent HPV infections. HPV detection enables identification of patients at risk for developing high-grade dysplasia. HPV detection currently has no significance in screening for precancerous lesions of cervical cancer.

Necessary Examinations:

• Inspection of the vagina and portio uteri by mirror adjustment during gynecological examination
• Bimanual vaginal and rectovaginal examination
• Colposcopy of the vagina and portio uteri
• Endocervical curettage of the cervix
• Confirmation of the suspected diagnosis by colposcopically targeted tissue sampling in the case of conspicuous findings or macroscopically visible tumor

Preoperative Examination Procedures

• Diagnosis of tumor spread preferably by magnetic resonance imaging (MRI)
• Chest X-ray
• Transvaginal sonography, sonography of the kidneys and liver
• Cystoscopy and rectoscopy to exclude tumor invasion into the bladder or rectum
• Endocervical curettage of the uterus, possibly with hysteroscopy

Patient Information – Diagnostic Measures

The diagnosis and staging of cervical cancer is primarily made through a gynecological examination. An MRI or CT scan is not always necessary, but may be useful for advanced tumors. The diagnosis is confirmed by histological examination of a sample from the tumor. Tumor markers are of little importance, but if elevated at the time of primary diagnosis, they can be useful in follow-up care.

Patient Information – Tissue Examination

When treating precancerous lesions of cervical cancer, it is important that the affected lesion is removed in healthy tissue. Clear written information should be available about the size, extent of the lesion, the resection margins, and any invasive lesions present.

Therapy

The decision on the appropriate treatment modality is made in an interdisciplinary manner, involving gynecological oncology, radiotherapy, anesthesiology, and pathology. This includes a discussion of the short- and long-term consequences of various treatment options.

The treatment decision must be made individually and together with the patient, considering the patient's general condition, life situation, disease stage, and risk factors.

Surgical Therapy

• Conization: Can be performed as a knife conization, with an electric loop, or as a laser conization. The conization should remove premalignant or microinvasive changes with tumor-free margins. In 2-3% of cases, post-conization bleeding occurs. If conization is performed during pregnancy, the risk of post-conization bleeding is significantly increased and premature births are more likely.
• Operational Staging: Staging laparoscopy (laparoscopy)/laparotomy (open surgery) and intraoperative findings are essential for treatment planning and assessment of the disease extent.
• Radical Abdominal Surgery: Performed depending on the stage in accordance with the recommendations of Wertheim, Meigs, Latzko, Okabayashi (various techniques).
• Lymphadenectomy (Lymph Node Removal): Systematic pelvic lymphadenectomy involves the removal of all lymph nodes and fatty tissue in the area of the pelvic vessels.

Patient Information – Therapy

In the early stages of cervical cancer, surgery, radiotherapy, or chemoradiotherapy, alone or in combination, are possible treatment options, depending on the tumor stage and risk factors. The therapy should be adapted to the patient's life situation and general condition. In the case of clinically borderline surgical findings, a surgical assessment of the tumor stage (ideally through minimally invasive measures) should support the choice of therapy.

Radiotherapy and Radiochemotherapy

• Primary Radio- or Radiochemotherapy: Typically consists of a combination of intracavitary contact and percutaneous high-voltage irradiation. Combining radiotherapy with simultaneous chemotherapy significantly improves healing results compared to radiotherapy alone.

Chemotherapy

Chemotherapy is effective in treating cancer of the cervix uteri.

Stage-Dependent Therapy

Classification of Precancerous Lesions

The definition of dysplasia (syn. cervical intraepithelial neoplasia - CIN) includes cellular atypia of the (squamous) epithelium with disruption of the tissue structure, referred to as precancerous lesions. Depending on the severity of the cellular atypia and the extent of the change, three grades are distinguished:

• CIN I: Low-grade dysplasia
• CIN II: Moderate-grade dysplasia
• CIN III: High-grade dysplasia and carcinoma in situ (CIS)

Therapy of Histologically Confirmed Cervical Intraepithelial Neoplasia (CIN)

• CIN I: If the finding is limited to the ectocervix (confirmed by colposcopy), check every 3 months. In case of persistence and ectocervical location, biopsy or CO2 laser vaporization is possible. In the case of endocervical location, generous indication for conization.
• CIN II: Colposcopic and cytological examination every three months. If persisting for more than one year, treatment as CIN III.
• CIN III: Treatment by loop excision or conization. Invasive carcinomas are treated surgically according to the FIGO stage.

Rehabilitation

Rehabilitation in the somatic and psychosocial areas results from the determination of disorders resulting from the disease and treatment, in accordance with the classification principles of the ICF classification of the WHO (2001). Rehabilitation can be started in a suitable clinic within two weeks of the end of primary therapy or regular treatment can be applied for and approved within two years of primary therapy.

Aftercare

Follow-up care focuses on individual orientation with an informative conversation, a detailed, structured medical history, and a clinical, symptom-oriented examination. One possible scheme provides for follow-up examinations quarterly during the first three years, half-yearly in the fourth and fifth years, and annually thereafter.

Diagnosis Without Suspicion of Recurrence

The gynecological mirror and palpation examination (vaginal/rectal) is the most important form of searching for a recurrence. Early detection of urinary retention can be achieved through sonography of the urinary tract. Determination of tumor markers is part of the follow-up.

Diagnostics With Suspected Recurrence

If loco-regional recurrence is suspected, histological confirmation and assessment of previous therapies and removability must be examined. Extensive diagnostics are required, including local findings through gynecological examination, vaginal sonography, MRI of the pelvis, cystoscopy, and rectoscopy. Exclusion of distant metastases through whole-body computed tomography and histological confirmation of metastases or supraclavicular lymph node metastases.

Patient Information – Aftercare/Rehabilitation/Psychosocial Care

Aftercare serves to identify problems caused by the illness and therapy. The main goals of aftercare are psychological stabilization, reintegration into working life, and restoring the best possible quality of life.

Palliative treatment decisions are individual, depending largely on the patient’s personal life plans and should be made together with her. In addition to sufficient symptom control (pain, nausea, constipation, ileus, etc.), medical care also includes psychosocial and religious-ethical support for the patient and her relatives.