cervical cancer

Synonyms in the broader sense

Synonyms in the broader sense: cancer at the entrance to the uterus, uterine cesarean
English: cervical cancer / cervix cancer

definition

This tumor is the second most common cancer in women after breast cancer. 20% of all new cancers are cervical cancer.
It is believed that cervical cancer is caused by wart viruses ( human papilloma viruses ).

HPV virus

HPV viruses belong to the Papillomaviridae family. These unencumbered DNA viruses are by no means all the same. There are over 100 different types that can trigger different clinical pictures. The spectrum of possible diseases ranges from benign warts to malignant cancers such as cervix cancer or penile carcinoma.

There are so-called low-risk types, including HPV types 11 and 6, among the high-risk viruses, which include types 16, 18 and 33, for example. High-risk viruses can lead to the development of malignant diseases of the genital area, such as cervix, penile / vulvar and anal cancers. But also cancers in the mouth and throat area can be caused by these viruses.
Low-risk viruses favor the development of benign warts.

The transfer takes place mainly via sexual intercourse. Condoms do not protect against infection because skin contact is sufficient for transmission. The virus remains in the body after infection and can lead to disease after several years. However, especially in young women, an infection can also heal.

Occurrence in the population (epidemiology)

Cervical carcinoma accounts for 20% of women's malignant cancers. Previously, he was one of the most common cancers.
Today, this cancer, which affects about half a million women worldwide, is the second most common site of malignant tumors.
Every year, ten to twenty new cases among 100, 000 inhabitants in the Federal Republic of Germany are added. The frequency of occurrence is greatest between the 35th and the 60th year of life. At a younger age precursors may already occur.

Anatomy and histology

Figure uterus
  1. Uterus -
    uterus
  2. Cervix -
    Fundus uteri
  3. Uterine lining -
    Tunica mucosa
  4. Uterine cavity -
    Cavitas uteri
  5. Peritoneal cover -
    Tunica serosa
  6. Cervix -
    Ostium uteri
  7. Uterine body -
    Corpus uteri
  8. Uterus -
    Isthmus uteri
  9. Vagina - vagina
  10. Cervix - Cervix uteri
  11. Ovary - ovary
  12. Fallopian tubes - tuba uterina
Fig. Position and shape of the uterus in the female pelvis
  1. Uterus - uterus
  2. Cervix - Fundus uteri
  3. Uterine lining -
    Tunica mucosa
  4. Cervical cavity - Cavitas uteri
  5. Peritoneal cover - Tunica serosa
  6. Cervix - ostium uteri
  7. Uterine body - corpus uteri
  8. Uterus - isthmus uteri
  9. Vagina - vagina
  10. Pubic symphysis -
    Symphysis pubica
  11. Bladder - Vesica urinaria
  12. Rectum - rectum

The cervix represents the part of the uterus leading from the vagina into the uterine body. The portion of this cervix protruding into the vagina (ie the portion further away from the uterine body is called the portio and is the most frequent place of origin of cervix cancer.
Natural changes in the cervical mucosa are responsible for this at sexual maturity: Hormone-controlled, mucous membrane of the cervix grows (it contains small glands that form an antibacterial mucus) in the direction of the vagina to protect against ascending infections.
Before puberty, the vagina is covered only by flat, superimposed superficial cells (so-called squamous epithelium). Due to these remodeling processes, the mucosa of the anterior cervix (the portio, see above) is particularly sensitive to bacterial, mechanical, and other stimuli.
Frequent inflammation therefore favors the development of tumors on the floor of previously damaged cells.

The various previous injuries (collectively referred to as cervical intraepithelial neoplasms, CIN for short, ie as a superficial cell formation limited neoplasms of the cervix, and classified according to the extent of cell changes in stages from I to III) initially grow not yet in the surrounding tissue ( = invasive growth), but are detectable by smear examination and colposcopy (see below)

reason

The cause of cervical cancer is still unclear

The exact genesis of cervical cancer is not known in every detail. However, according to the current state of knowledge, the disease is an example of a virus-induced cancer.
Extensive studies have shown that human papillomavirus (HPV) infection is a prerequisite for disease. The virus is transmitted through sexual intercourse. Two of the approximately 200 different types of human papillomavirus (HPV) present a particularly high risk ( types 16 and 18 ); other types of virus ( types 6 and 11 ) are caused by genital warts of the genitalia (so-called condyloma acuminata ).

Human papillomaviruses are in the broadest sense viruses that trigger warts on the skin.
However, human papillomavirus infection is not necessarily linked to cervical cancer. Self-healing powers of the body prevent the onset of the disease in about 80% of all those infected with the virus.
Poor hygiene and frequent partner changes increase the likelihood of disease, while male circumcision and childlessness lower the risk.

Symptoms and signs of cervical cancer

At first, complaints rarely occur. Sometimes a sweet-smelling discharge and spotting (especially after sexual contact) may be the first evidence of cervical cancer. In the advanced stage, the tumor spreads further into the wall of the cervix as well as into the vagina, pelvic wall, rectum, and the connective tissue supporting apparatus of the uterus in the pelvis (the so-called parametria).

Dislocations (metastases) of the tumor can initially spread through the lymphatic system, later also by ingrowth into blood vessels in the liver, brain, lungs and bones (so-called hematogenous metastasis, ie removal by the blood) with severe pain.

diagnosis

In a doctor's discussion, the necessity of preventive care is explained in addition to possible risk factors.

From the age of 20, annual check-ups are recommended because infection with the cancer-causing virus can occur very early. The detection of precancerous lesions is possible by means of smear tests. The cells thus obtained are stained for visualization (the method was developed by George Nicolas Papanicolaou, a Greek physician and pathologist who lived from 1883-1962 and is still being carried out in a modified form). The assessment is carried out in classes PAP (Papanicolaou) from I to V, according to a normal finding up to cell changes, the urgent tumor suspicion prove with necessity immediate clarification by taking a tissue sample.

Classification according to Papanicolaou

  • PAP I - Normal Cell Image
    • The finding is normal, there are no abnormalities, control after one year as part of the cancer screening examination.
  • PAP II - Inflammatory and metaplastic changes
    • The cell changes are not suspect, usually caused by bacteria or other germs, if necessary, examination after 3 months and a possible treatment of the inflammation.
  • PAP III - Severe inflammatory or degenerative changes, an assessment of whether the
    Changes are malignant, is not sure possible
    • The finding is unclear; if necessary, antibiotic or hormonal treatment; short-term control after approx. 2 weeks; with persistent Pap III, a histologic (histological) clarification is important.
  • PAP III D cells show mild to moderate untypical cell changes
    • The finding is unclear; usually this change is related to the common HPV infection. Control after 3 months is sufficient, histological clarification required only after repeated occurrence.
  • PAP IV a - severe cell dysplasia or carcinoma in situ (cancer precursor)
    • Fine tissue (histological) clarification with the help of a curettage (scarring) and a colonoscopy / hysteroscopy.
  • PAP IV b - severe cell dysplasia or carcinoma in situ (early stage of a cancer), cells
    of a malignant cancer can not be ruled out
    • Requires histologic clarification by conization (see below) or biopsy (extraction of tissue sample), therapy according to the patient's findings and family planning.
  • PAP V - cells of a suspected malignant cancer (malignant tumor), tumor is clearly malignant
    • Require histologic clarification by conization (see below) or biopsy (extraction of tissue sample). Therapy: uterine removal (hysterectomy).

In the gynecological examination of the cervix is ​​by means of colposcopy (literally: "reflection of the vagina" of Greek kolpo = scabbard, skopie = peek / consider) accessible. Already in the 1920s Hans Hinselmann introduced this diagnostic device, which was used for the early detection of cervical cancer. The cervix is ​​observed with a special microscope ( colposcope ) under optimal illumination with six to twenty times magnification.

The acetic acid sample can be used to visualize precursors ( precancerous lesions ) and mucosal abnormalities associated with increased cancer risk (eg metaplasia - transformation of endometrium into vaginal mucosa as a result of recurrent inflammation, but to some extent this mucosal transformation is normal and in all women) to prove puberty).
However, since normal mucosa is also stained by the acetic acid sample, the dark brown to black staining of exclusively healthy cells in the context of the so-called Schiller's iodine sample is helpful in distinguishing between healthy and diseased tissue.
The basis for this detection is the chemical reaction of the glycogen contained in normal cells (a giant molecule consisting of several thousand sugar building blocks) with iodine to form a brown reaction product.
Diseased mucous membrane (so-called caused by inflammation metaplastic mucous membrane or precancerous lesions), however, contains little glycogen and therefore stains little or not at.

The colposcope itself is not inserted into the vagina, but positioned in front of it. To unfold the vaginal walls, the gynecologist uses a speculum (Latin: hand mirror, for introduction into natural body cavities tube, funnel, or spatulate). With a special small pliers, it is possible to remove small pieces of tissue and examine them under the microscope. In addition to mere viewing, a colposcope also allows the creation of photos and video recordings for documentation purposes.

The aim of colposcopy is the classification of the degree of severity on detection of a pathological change. Decisive factors include color, surface texture, and the dyeability by iodine of the suspected tissue component. Superficial white staining of the mucosa (they are called leukoplakia) may be harmless or give evidence of an underlying precancerous lesion. Red dots or bars (called "mosaics") correspond to the vessels reaching the surface, and are always suspicious of a malignant change.
So far, a positive effect in the context of cancer screening has not yet been proven. However, a colposcopy seems very useful to us as a precautionary measure. The colposcopy is not included in the scope of the GKV (statutory health insurance).

Therapy of cervical cancer

There are different treatment levels:

  1. Prevention (prophylaxis)
  2. conization
  3. Uterine destruction (hysterectomy)

pension options

There are very good precautionary measures against cervical cancer, so that in recent years there has been a marked decline in this disease in the industrialized nations. Primary prevention is to prevent infection with HPV viruses. For this purpose, the HPV vaccine exists (see below).

The secondary prevention is realized by the annual check-up at the gynecologist. This study should be performed by every woman, whether she is vaccinated or not. The examination is recommended from the age of 20 years. This check-up involves assessing the cervix by the gynecologist and taking a smear (cervical smear). This smear is taken at 2 points with a wooden spatula / cotton swab. The sample is then spread evenly on a microscope slide and stained according to the Papanicolaou staining method. Therefore, the test is also colloquially referred to as PAP test. This swab can detect cancer precursors and pre-existing cancer early, allowing rapid therapy.

Vaccination against cervical cancer

The vaccine protects against the most common viruses that can cause cervical cancer, but does not replace the necessary preventive medical check-ups.

After promising results in animal experiments, scientists have now been able to prove in the context of clinical trials that a newly developed vaccine is characterized by great efficacy and minimal side effects.
The vaccine consists of proteins corresponding to those from the envelope of the human papillomavirus. By vaccination, the immune system is stimulated to produce even protective proteins (so-called antibodies) against the cancer-causing viruses, comparable to a workout. The effect of the vaccine is enhanced by an additional activating agent acting on the immune system (a so-called adjuvant). An effective protection over 4.5 years could be proven for women from 25 to 55 years.
First, the vaccine was approved in the US in 2006.
A vaccine against cervical cancer has been possible since 2007 in Germany.
However, as this does not provide 100% protection, it can not replace precautionary smear tests (the vaccine currently only counters the two most dangerous high-risk types of the cervix responsible for about 70% of all cervical cancers).
There are plans for broad-based vaccination programs in the population, since the prevalence of human papillomavirus is high: Between 70% and 80% of all women in Germany, Austria and Switzerland become infected with HPV during their lifetime.
Usually, the infection heals by itself within 12 to 18 months, so that, for example, a positive test for the virus is by no means linked to an existing or emerging cancer. However, it is important to note that a vaccine has only preventive character: An infection with the virus can not be cured.
Therefore, it is planned to vaccinate especially the age group of nine to twelve-year-olds (puberty) before the first sexual contact. Not only girls, but also boys would benefit from the vaccine: The vaccine, which was introduced in Germany at the beginning of 2007, is also intended to protect against the benign genital warts of genital warts (which are harmless in terms of cervical cancer and are therefore referred to as low-risk types).,
The future goal is to limit the cervical cancer and all precursors to a minimum that can no longer be reduced by the vaccinations.

Cost of vaccination

For the prevention of cervical cancer, three vaccines are currently approved in Germany that protect against various HPV viruses. The vaccine Cervarix protects against the virus strains HPV 16 and 18, while Gardasil protects against the HPV types 16, 18, 11 and 6. The new approved vaccine Gardasil9 additionally protects against the virus strains 31, 33, 45, 52 and 58.

The cost per injection is about 155 Euro. With three injections for the primary immunization, the costs amount to 465 euros. With only two necessary injections, it is 310 euros. The cost of the vaccine will be covered by the health insurance for girls between the ages of 12 and 17 years. However, many health insurances also take the vaccine until the age of 26. Therefore, it is advisable to ask the health insurance.

conization

Tissue lesions suspected of causing cancer should be cut out of the cervix in a conical shape (so-called conization). At present, an estimated 50, 000 of these surgical interventions are performed each year in Germany.
A general conization is not always necessary, but a stadienabhängiges procedure according to the individual findings according to the current guidelines.

Uterine removal (hysterectomy)

Surgery of cervical cancer

In more advanced stages, removal of the entire uterus (medial hysterectomy) including the connective tissue attachment, a vaginal cuff, and the surrounding lymph nodes is the drug of choice (so-called Wertheim radical surgery). Sometimes radiotherapy and / or chemotherapy is required.
As with any cancer, consistent follow-up care is important: every three months for the first three years, every four months for a further two years, and every six months after five years.


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