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CARCINOMA OF THE CERVIX

Female Genital Tract

CARCINOMA OF THE CERVIX
Cervical carcinoma, also known as cervical cancer, is a malignant neoplasm originating from the cervix, the lower part of the uterus that connects to the vagina. This cancer typically develops from precancerous changes in the cervix that may progress over time. The majority of cervical cancers are squamous cell carcinomas, but adenocarcinomas can also occur.
Epidemiology:
• The most common cause of cervical cancer is persistent infection with high-risk types of the Human Papillomavirus (HPV), particularly HPV-16 and HPV-18.
• It is more common in women between the ages of 35 and 44, though it can occur in any adult woman.
• Smoking, immunocompromised states (such as HIV infection), and long-term oral contraceptive use also increase the risk.
Pathogenesis:
• HPV infection: Persistent infection with HPV, especially types 16 and 18, leads to the development of cervical dysplasia, which may progress through stages from mild dysplasia (CIN 1) to moderate (CIN 2), and severe dysplasia (CIN 3), eventually progressing to carcinoma.
• Other factors: Co-infection with other STIs, genetic factors, and long-term use of oral contraceptives can also contribute.
Clinical Presentation:
• Early-stage cervical carcinoma may be asymptomatic.
• Symptoms often include abnormal vaginal bleeding (e.g., post-coital bleeding, post-menopausal bleeding), pelvic pain, or abnormal discharge. In more advanced stages, symptoms may include weight loss, leg swelling, or back pain.
Gross Features of Cervical Carcinoma:
1. Shape & Size: The tumor can be a mass or ulcer that can expand into the surrounding tissue. It may form a bulky, exophytic (outward-growing) mass or an endophytic (inward-growing) lesion.
2. Location: Most commonly, cervical carcinoma arises in the transformation zone, where squamous and columnar epithelium meet, which is the area where HPV infection usually takes place.
3. Appearance:
o Squamous Cell Carcinoma: Appears as a cauliflower-like, exophytic growth or ulcerated lesion.
o Adenocarcinoma: May present as a more glandular, infiltrating mass.
4. Color: The tumor may appear grayish, yellowish, or pale red depending on its stage and level of necrosis.

Microscopic Features:
1. Squamous Cell Carcinoma:
o Keratinization: The tumor is characterized by keratin production (keratin pearls or individual cell keratinization).
o Cellular Features: The tumor cells are usually large with pleomorphic nuclei, prominent nucleoli, and high mitotic activity.
o Infiltration: Tumor cells invade the stroma, forming nests, sheets, or cords. The stroma may show desmoplastic reaction (fibrosis).
o Dysplasia: The squamous epithelial cells exhibit a loss of normal architecture, with a high degree of nuclear atypia and abnormal mitoses.
2. Adenocarcinoma:
o Glandular Formation: These tumors consist of malignant columnar epithelial cells arranged in gland-like structures.
o Mucin Production: Often, the cells produce mucin, and glands may be lined with atypical columnar cells.
o Infiltrative Growth: Infiltrates deep into the cervical stroma.
3. Other Histologic Variants:
o Adenosquamous Carcinoma: A mixture of both squamous and glandular components.
o Small Cell Neuroendocrine Carcinoma: Characterized by small, round cells with scant cytoplasm, high mitotic activity, and neuroendocrine markers.
Staging (FIGO System):
• Stage I: Confined to the cervix.
• Stage II: Extends beyond the cervix, but not to the pelvic wall or lower third of the vagina.
• Stage III: Extends to the pelvic wall or lower third of the vagina.
• Stage IV: Extends to the bladder, rectum, or distant organs.
Diagnosis:
• Pap Smear: A routine screening test for cervical cancer that detects precancerous changes (CIN). HPV DNA testing may also be performed.
• Colposcopy and Biopsy: If abnormalities are found on a Pap smear, a colposcopy (a visual examination of the cervix) with biopsy may be performed to confirm the diagnosis.
• Imaging: In more advanced cases, imaging such as ultrasound, CT, or MRI may be used to assess the extent of the disease.

Treatment:
• Surgical: Hysterectomy (removal of the uterus) is the primary treatment for early-stage cervical cancer. Lymph node dissection may also be performed.
• Radiotherapy: Often used in conjunction with surgery or for more advanced stages.
• Chemotherapy: Can be used for advanced disease, often in combination with radiation (chemoradiation).
• Targeted Therapy: May be used in specific cases, depending on the molecular profile of the tumor.
Prognosis:
• Early-stage carcinoma has a better prognosis, with a five-year survival rate of approximately 92%.
• Advanced-stage carcinoma has a much lower survival rate, particularly when it has spread to distant organs.
Cervical carcinoma has a well-established prevention and early detection program, mainly through the use of HPV vaccination and regular screening programs (Pap smears, HPV testing), which can significantly reduce the incidence and mortality rates.

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