Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Chapter 3 and documented in the case record with a descriptive diagram whenever an invasive cervical cancer is discovered. The investigations and procedures, on the basis of which the staging assessment was carried out, should also be described. Treatment and prognosis The standard treatment of cervical cancer may involve surgery or radiotherapy or a combination of both. Early cervical cancers (stage I and IIA) may be treated by either procedure. Radiotherapy is the treatment of Lateral pelvic wall Bladder Rectum Parametrium Upper 2/3 vagina Lower 1/3 vagina Invasive cancer STAGE I STAGE II A STAGE II B STAGE III A STAGE III B STAGE IV A FIGURE 3.10: A schematic diagram of clinical stages of invasive cancer of the cervix 26
An introduction to invasive cancer of the uterine cervix choice once the disease has spread beyond the confines of the cervix and vaginal fornices, when surgery is not effective. The management of cervical cancer with radiotherapy may often involve a combination of external radiotherapy (for the entire pelvis) and intracavitary irradiation (to the central part of the disease). The addition of intracavitory irradiation to external beam radiotherapy is associated with improved disease control and survival, as compared to external radiotherapy alone for locally advanced disease such as stage IIB and III. Women with microinvasive cancer (stage IA) may be treated with conization or total hysterectomy or extended hysterectomy. Those with stage IB and IIA cancer may be treated with radical (Wertheim’s) hysterectomy, and pelvic lymphadenectomy or with intracavitary radiotherapy, or with a combination of external radiotherapy and intracavitary radiotherapy. In selected cases of small (< 2 cm) stage IB carcinoma, radical trachelectomy combined with laparoscopic lymphadenectomy, to salvage the reproductive function of the patient, can be performed. Radiotherapy and surgery produce similar results for early invasive cancer (stages IB and IIA). Stage IIB and III cancers are treated with a combination of external and intracavitary radiotherapy. Women with stage IV disease are treated palliatively with external radiotherapy and/or with chemotherapy. Concomitant chemotherapy with cisplatin has improved the results of radiotherapy in advanced cervical cancer. Randomized clinical trials have shown a significant gain in overall and disease free survival for cisplatin-based therapy given concurrently with radiotherapy (Thomas, 2000; Green et al., 2001). A significant benefit of chemo-radiation on both local and distant recurrence has been observed. The absolute benefit with combined therapy in overall survival was 16%. Based on this evidence, concurrent chemotherapy with radiotherapy is emerging as the new standard of care for advanced cervical cancer. Clinical stage of disease at presentation is the single most important predictor of long-term survival; survival rates also decline with advancing age. Other factors influencing survival include general health and nutritional status. Anaemic patients respond poorly to treatment; as do those with HIV-seropositive disease. Several clinical and population-based studies have demonstrated consistently high five-year survival associated with stage I disease (> 75%), with rapidly decreasing survival with advanced stages of disease (< 10% in stage IV) (Delgado et al., 1990; Fagundes et al., 1992; Kosary et al., 1994; Gatta et al., 1998; Sankaranarayanan et al., 1998; Denton et al., 2000). In a large series of cervical cancer patients treated by radiation therapy, the frequency of distant metastases (most frequently to para-aortic lymph nodes, lung, abdominal cavity, liver and gastrointestinal tract) was shown to increase with increasing stage of disease from 3% in stage IA to 75% in stage IVA (Fagundes et al., 1992). In a study of 1028 patients treated with radical surgery, survival rates correlated consistently with tumour volume (Burghardt et al., 1992). Five-year survival rates ranged between 91% for patients with tumours of < 2.5 cm 3 and 70% for those with tumours of 10-50 cm 3 . The three-year disease-free survival ranged from 94.6% for stage I tumours 5 mm to 59.5% for stage I tumours 21 mm (Delgado et al., 1990). Advanced clinical stages are associated with increasing frequency of vascular invasion and spread to pelvic and para-aortic lymph nodes and distant metastases. 27
Page 1 and 2: Colposcopy and Treatment of Cervica
Page 3 and 4: INTERNATIONAL AGENCY FOR RESEARCH O
Page 5 and 6: Published by the International Agen
Page 7 and 8: Contents 11 Management that provide
Page 9 and 10: Acknowledgements The authors gratef
Page 11 and 12: Preface Health care providers have
Page 13 and 14: Chapter 1 An introduction to the an
Page 15 and 16: An introduction to the anatomy of t
Page 25 and 26: Chapter 2 An introduction to cervic
Page 27 and 28: An introduction to cervical intraep
Page 33 and 34: Chapter 3 An introduction to invasi
Page 35 and 36: An introduction to invasive cancer
Page 37: An introduction to invasive cancer
Page 41 and 42: Chapter 4 Table 4.1: Indications fo
Page 43 and 44: Chapter 4 FIGURE 4.2: Colposcope wi
Page 45 and 46: Chapter 4 FIGURE 4.6: Endocervical
Page 47 and 48: Chapter 4 Table 4.2: Preneoplastic
Page 49 and 50: Chapter 5 between the two ocular le
Page 51 and 52: Chapter 5 Obtain specimens for labo
Page 53 and 54: Chapter 5 FIGURE 5.2: Biopsy techni
Page 55 and 56: Chapter 5 tissue tends to mimic inv
Page 57 and 58: Chapter 6 invasive carcinoma. Even
Page 59 and 60: Chapter 6 ages (Figures 1.7d, 1.7e,
Page 61 and 62: Chapter 6 FIGURE 6.7: The colour ch
Page 63 and 64: Chapter 6 Crypt openings Immature s
Page 65 and 66: Chapter 6 a FIGURE 6.17: An area of
Page 67 and 68: Chapter 7 The colposcopic diagnosis
Page 69 and 70: Chapter 7 appears as individual sma
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74: Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76: Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78: Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80: Chapter 7 We recommend that the stu
Page 81 and 82: Chapter 8 highlights this responsib
Page 83 and 84: Chapter 8 Appearance before applica
Page 85 and 86: Chapter 8 diagnosis of AIS and aden
Page 87 and 88: Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90:
Chapter 9 Inflammatory lesions of t
Page 91 and 92:
Inflammatory lesions of the uterine
Page 93 and 94:
Inflammatory lesions of the uterine
Page 95 and 96:
Chapter 10 Table 10.1: Common sourc
Page 97 and 98:
Chapter 10 Table 10.2 (cont.): A su
Page 99 and 100:
Chapter 11 FIGURE 11.1: Flow chart
Page 101 and 102:
Chapter 11 treatment policies for p
Page 103 and 104:
Chapter 11 Vaginal delivery can be
Page 105 and 106:
Chapter 12 involvement increases wi
Page 107 and 108:
Chapter 12 Table 12.1: Eligibility
Page 109 and 110:
Chapter 12 a b c d e f FIGURE 12.6:
Page 111 and 112:
Chapter 12 during the follow-up in
Page 113 and 114:
Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116:
Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118:
Chapter 13 Once the specimen has be
Page 119 and 120:
Chapter 13 in the endocervical cana
Page 121 and 122:
Chapter 14 Decontamination, cleanin
Page 123 and 124:
Decontamination, cleaning, high-lev
Page 125 and 126:
References Herrero, R. (1997) Preva
Page 127 and 128:
Further reading Suggestions on furt
Page 129 and 130:
Appendix Leukoplakia Condylom
Page 131 and 132:
Appendix regardless of your pregnan
Page 133 and 134:
Appendix Monsel’s paste Ingredien
Page 135 and 136:
Appendix 5 The modified Reid colpos
Page 137 and 138:
Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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