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What is carcinoma of cervix. It sounds like a disease thats very harmful, dangerous, and may endanger ourselves. So, here we will be discuss what is exactly it is. Generally, carcinoma is a type of cancer which starts on skin or some other surface of organs. That's mean the carcinoma refers to a cancer originated from an epithelial cell origin. Besides that, carcinoma is also can be metastasized which means it can invade surrounding tissues, organs, lymph nodes and other sites. Then, the cervix means a part of woman's reproductive system which located in the pelvis. Specifically, it is a cylindrical like-shape of organ placed at the top end of the vagina and connected with the lower end of uterus. According to Medicinenet (2012), the cervix is basically has functions which allows the flow of blood from the uterus to the outside of the body during menstrual period. Besides that, the cervix secretes mucus which necessary for the sperm to move from the vagina to the uterus. Furthermore, during pregnancy, the cervix will be closed to maintain the baby is inside the uterus and will be opened during childbirth to allow the baby to pass out through the vagina. So, we can conclude here that carcinoma of cervix is a cancer that occurs when a normal growth of cell is interrupted causing the buildup of new unneccasary extra cell called tumor which can interrupt the normal call activity.
The probability of someone to developing cancer is depends on both genetic and non-genetic factors. A cancer with genetic factor is develops inherited and unchangeable trait. While a cancer with non-genetic factor is commonly develop caused by environmental influences.
Recent researches did not yet found the factor lead to the development of cervical cancer hereditarily. However, the probability of someone to get cancer is high if their family members is already got a certain type of cancer; which known as genetic predisposition.
HPV : One of the most important risk factor of cervical carcinoma is caused by human papilloma virus (HPV). HPV is a type of infection that is sexually transmitted and will infect an individual that is sexually active. Normally, some type of HPV will caused genital warts. However, there are also some types of HPV that may infect the cervix, hence disrupt the normal function of the cell leading to cancer.
Sexual activity : According to emedicine, 2012, major risk factor linked with this type of cancer such as having sex at a young age ( before 18 ), multiple sexual partners, promiscuous male partners, and history of sexually transmitted disease. These are all the example of risky sexual practice which leading to the development of cervical carcinoma.
Smoking : A female smoker will has higher risk of getting cervical cancer, same goes to the secondary smoker. According to C.Health 2013, the risk will increase depends on the time of woman smoke and the number of cigarettes consumed per day.
Weakened immune system : Immune systems is important to fight infections in our body. Factors that may lead to the weakened of immune system are from diseases and medications. The medications that may weakened our immune system are such as chemotherapy drugs and over use of corticosteroids. Human immunodeficiency virus (HIV) is example of disease that associated to the development of cervical cervix by suppressing the immune systems.
Other risk factors : Age can be also associated with the development of cervical cancer which mostly affected woman younger than 50 years of age. Besides that, family history of cervical cancer, history of STIs, and less receive regular Pap test may also lead to the occurrence factors.
INCIDENCE IN MALAYSIA COMPARE TO OTHER COUNTRY
According to National Cancer Registry (2011), cancer cervix is the 5th most cancer cases among people in Malaysia with 4.6%. This statistic is made based on total 18,219 people who was suffered with cancer recorded in year 2007. Above cancer cervix is breast cancer which the most cancer cases with percentage of 18.1% followed by colorectal cancer (12.3%), lung cancer (10.2%), and nasopharynx cancer (5.2%). However, if the statistic is classified according to gander, cancer cervix is the 3rd most cancer cases among females with 8.4%. Breast cancer is at the top followed by colorectal cancer with 32.1% and 10.0%. The statistic also showed that the cancer is notably starts to increase at the age of 30, and has peak case at age of 60-69 years. Besides that, Chinese female is recorded as the most affected with cervical cancer followed by Indian and Malay.
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A statistic of worldwide case of cervical carcinoma shown that the cervical carcinoma is the 2nd most cases recorded among female (Chiang n.d.). The statistic also shown that about 465,000 new cases were recorded every year involving industrial and developing nations. Basically, the occurrence of cervical cancer among country is depends on environmental factor and socioeconomic status of the country. The higher socioeconomic status of the country, the less occurrence of diagnosed cervical cancer. This is proven as Globocan (2008) recorded that nations of low socioeconomic status such as Africa, South America, South-Central Asia, Melanesia, and also Caribbean are among the highest incidence of cervical cancer. In contrast, developing countries such as Northern, Southern, and Western Europe, Northern Africa, Australia, New Zealand and Western Asia recorded as the least incidence of cervical cancer.
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MORTALITY / MORBIDITY
There are many factors that lead to functional changes of the cervix which mostly resulting from Human Papilloma Virus (HPV) infection. Generally, when the HPV infected the cervix, woman's immune system will prevent this HPV from doing any harm. But for some woman with weak immune system will allow the HPV to infect the cervix and increase the probability for cancer. Later, as the cancer starts to occurs, the virus will change the normal cell of the cervix into cancerous cell. Besides that, for woman living with HIV infection also will increase the probability of cancer cervix as the HIV will weakens the immune system and thus helping the HPV to become active (Cecelia n.d.). In fact, there are many other factors which all of them will help increase the activities of HPV. According to Jayaraman (2009), the cervical cancer is occurs at the active site of squamocolumnar junction which normally will develop into invasive cancer in several years if not getting any early treatment. However, if the woman getting early treatment, probability of occurrence cervical cancer will be diminish. Furthermore, Jayaraman (2009) also stated that cervical carcinoma will be irreversible it the basement membrane and cervical stroma was invade. As the cancer become invasive, it will harm the cervix in certain pattern (Jayaram 2009). Exophytic pattern usually arise at the exocervix in a polyp form that will cause bleeding at the superficial site of the cervix. In contrast, nodular pattern will affect the endocervix and later will develop into cervical stroma resulting a mass that will expand the cervix. Tumor will also infect the endocervical canal originating from the cancerous endocervix. Next, the infiltrative pattern will result a mass that infect either endocervical or exocervical. When the endocervical lesion occurs it will harm the vagina fornices and any other superficial part of the vagina. On the other hand, the exocervical lesion will harm the corpus and lateral papametrium. Lastly, the ulcerative pattern will cause the formation of cavity which lately result seropurulent discharge. All of this growth pattern will be increasingly severe depends on its stage of cancer.
SIGN & SYMPTOMS
Normally, the early stage of cervical carcinoma will be asymptomatic. Later, when the cancer became invasive, the woman will experience many symptoms such as:
Vaginal bleeding between regular menstrual periods.
Pain during sexual intercourse following bleeding after intercourse.
Periods become heavier and longer than normal.
Unusual amount of vaginal discharge which will be pale, clear, watery, brown, bloody, of foul-smelling.
When the cancer progress, tumor will be further grow and invade the surrounding organs such as bladder, lung, liver and intestine. As the tumor become severe, patience will experience:
Pelvic and back pain
Bone pain or fractures
Bleeding during urinate (hematuria)
Shortness of breath (anemia)
Loss of appetite
Blood in the feaces
Swollen and leg pain
Loss of weight
Carcinoma of cervix is one of the most common dangerous gynecologic malignancy affected among women. This cancer will become severe if it is not treated at the early stage. So, when the cell cancer is recognized, a preventable step should be taken before the developing cancer become invasive. As a measure to identify the staging of this carcinoma, the imaging modalities will definitely assist. The most common imaging modalities used are magnetic resonance imaging (MRI), computed tomography (CT), and ultrasonography (US). Besides that, imaging like physical examination, chest radiography, intravenous urography (IVU), invasive procedures, nuclear imaging and others will be done depends on specific case of the pathology.
MRI is commonly used as the modality in imaging cervical cancer. With its superior soft-tissue contrast resolution, it is also preferences for preoperative staging and evaluation for local recurrence. According to ScienceDirect (2008) in compare to CT and US, the MRI is superiorly valuable in identifying primary tumor stage which capable in assessing the tumor size, the depth of cervical invasion, and tumoral invasion toward surrounding organ of the cervix. Besides that, MRI is also usable in treatment monitoring and also involve in planning radiotheraphy. Furthermore, according to PubMed (2009) the MRI also plays an important role for fertility-sparing surgery in the early age woman of cervical cancer. The evaluation of lymph-node spreading beyond the cervix is also clearly visualized. However, recent gynecology study stated that the MRI is not suitable as CT scan for pretreatment evaluation of cervical cancer because the extra information provided by high soft tissue-contrast resolution did not give any benefit for the treatment that will be decided (Faysal,n.d). Besides that, MRI cannot accurately measure the size of cervical tumor with size of less than 2cm in diameter which normally at the early stage of disease. The MRI also has limited ability to evaluate the morphologic alteration of organ that involved with tumor. Next, if the is the present of large tumor in the cervix, the MRI will not be able to clearly visualize the remaining normal cell especially the cervical stromal stripe and vaginal fornix shape (Faysal,2011). Furthermore, a studied was conducted and proven that the MRI is the most superior modality in producing the best valuable image for cervical cancer including a better evaluation of lymph-node which improved the accuracy of International Federation of Gynecology and Obstetrics (FIGO) staging about 96% (Sankar S, cited in Rajaram 2010).
The CT Scanning capabilities in analyzing cancer cervix cannot be denied. This is proven as most gynecologic study prefered the use CT Scan compare to MRI for pretreatment evaluation of cervical cancer (Faysal ,2011). Besides that, the CT Scanning also has better capability than Ultrasound in diagnosing enlarged lymph nodes and for staging purpose. Besides the ability of CT Scanning in tracing enlarged lymph nodes, it is also important for guiding biopsy of those nodes (Faysal, 2011). Moreover, in certain case such as urinary obstruction, CT Scanning is preferable than IVU because it has the ability to detecting the probability of gross tumor that presence in the urinary tract (Faysal, 2011). However, besides the advantage of CT Scanning, it also has the disadvantage which its accuracy of clinical staging is not as accurate as MRI. According to Medscape (2011), the clinical staging by experienced gynecologic oncologist is more accurate than using the CT Scanning when it is at the early stage of disease which at stage I and stage II. In contrast when the disease entering stage III and IV, the capability of CT Scanning increases and the accuracy of CT Scanning in detecting enlarge lymph nodes become better. Other than that, CT Scanning cannot accurately measure the size of cervical tumor with size of less than 2cm in diameter which normally at the early stage of disease. This is because during the early stage of disease, there is only small tumor confined in the cervix, so that the CT Scanning cannot clearly diagnose the disease (Faysal, 2011).
The role of Ultrasound in diagnosing cervical cancer is not as good as MRI and CT Scanning. Generally, the ultrasound is used to assess the size and local region of tumor. However, the Ultrasound is rarely used for diagnostic purpose in cervical cancer because of certain limitations (Faysal, 2011). Firstly, according to Medscape (2011), it is because of its low contrast resolution, it is difficult to distinguish between primary tumor and normal tissues of cervical stroma, uterine corpus, vagina, and parametrium. Besides that, the ultrasound also cannot adequately depict all possible sites of metastasis and anatomic area that has lymph nodes. Furthermore, even the superiority of transvaginal and transrectal ultrasonography, it is still cannot provide the best diagnostic value, (Annals,n.d). Moreover, patient's body habitus and operator dependency is also affect the limitation of ultrasound.
Positron emission tomography (PET) scanning is one of nuclear imaging that used fluorodeoxyglucose (FDG) to detect any disease in the body. According to Medscape (2011), the advantage of PET scanning is it has the ability to diagnose any nodal metastatic disease and any probability of recurrence carcinoma of cervix. Besides that, PET scanning also superior in diagnosing advance cervical cancer that cannot be detected by using CT scanning. Moreover, the survival of cancer cervix patient also can be predict by using PET scanning. According to PubMed (2009), PET scanning is helped in diagnosing whole body study in advance cancer cervix. However, the ability of PET scanning is inferior than invasive procedures which cannot able to diagnose microscopic nodal diseases. In contact of diagnostic accuracy, the PET scanning is superior than MRI for scanning nodal staging which has sensitivity of 91% and sensitivity of 100% compared to MRI which has sensitivity of 73% and specificity of only 83%.
IMAGE FEATURES OF PATHOLOGY
The treatment of cervical cancer is very important in order to help people with the cancer to stay alive. So, before any treatment is taken, several factors should be considered first. According to National Cancer Institute (2012), the factors include the stage of cancer, size of tumor, patient's desire to have children, and the patient's age. After considering for all these factors, doctor will choose the best treatment for the patients. Generally, the treatments that used in cervical cancer are surgery, chemotherapy, and radiation therapy.
The surgery is an option that often taken by doctors to treat cervical cancer. There are 3 surgical treatments that commonly used which are Lymphadenectomy, Radical Trachelectomy, and Hysterectomy. First, the Lymphadenectomy is a method of surgery which the lymph nodes is removed from the affected area (American Cancer Society 2012). The purpose of removing the lymph nodes is because to prevent the cancer from being metastasized through the lymph nodes. By removing the lymph nodes, doctors can specify the area where cancer has spread (Surgeryencyclopedia n.d.). Next, Radical Trachelectomy is a method of surgery which the cervix and pelvic lymph nodes is removed, while the uterus is left untouched (Healthtalkonline 2011). In fact, if the Radical Trachelectomy is performed, the possibility for a woman to pregnant is still there even though some problems or complications may occur (Healthtalkonline 2011). Lastly, Hysterectomy can be classified into simple and radical Hysterectomy. Simple Hysterectomy usually will be performed at the early stages of cancer which the cervix and uterus is removed. In contrast, Radical Hysterectomy will be performed for invasive cancer which the cervix, uterus, lymph nodes, and part of vagina are removed (Mayoclinic 2012). The patients who have been doing their Hysterectomy will not be able to conceive anymore (Wikipedia n.d.). in some cases, Bilateral Salpingo-Oophorectomy is done along with Hysterectomy to remove both ovaries and fallopian tubes.
Basically, Chemotherapy is performed to kill the cancer cells and prevent them from metastasized. This is done by injecting drugs into patients body (Mayoclinic 2012). Low doses produced by Chemotherapy will merge with radiation therapy to produce high quality radiation. On the other hand, high doses of Chemotherapy act by controlling invasive cervical cancer which cannot be curable (Mayoclinic 2012). However, Chemotherapy can give side effect to the patient such as nausea, vomiting and infertility (WebMD 2011).
Basically, Radiation Therapy produces high energy beam to destroy cancer cells. It is usually effective to be done at the early stages of cervical cancer. Radiation Therapy is performed in two ways, namely by means of internally and externally therapy. If the therapy is performed internally, radioactive materials will be placed in the uterus, while external therapy is perform by radiation therapy machine. In certain cases, Radiation Therapy is perfectly combined with Chemotherapy to fight against invasive cancer and to stops the growing of tumor (Mayoclinic 2012). However, this therapy will cause infertility to the patient (Mayoclinic 2012).
There are different prognosis factor among cervical cancer sufferers which related to factors such as the stage of cervical cancer, size of tumor, type of cervical cancer, individual commitment to therapy, age of the individuals, and individual general health (M Ananya n.d.). In order to know person's prognosis, 5-year survival rate is used as the baseline study of patient who survive at least 5 years after being diagnosed with cervical cancer. According to HealthGuide (2011), as the stage of cervical cancer is increase from localized to regional and then to metastasized cervical cancer, the survival rate is decreasing from 92%,58% and 17%. This shown that as the cancer become invasive the possibility of the patient to survive is low.