Pemeriksaan Kanker Serviks

Histopatologi

Dapat diklasifikasikan sebagai kanker serviks bila pertumbuhan primernya

berasal dari serviks. 85% merupakan karsinoma sel skuamosa, 10%

adenokarsinoma, dan 5% adenoskuamosa, sel jernih, sel kecil, sel verukosa.

Secara histopatologik, kanker serviks dibagi menjadi:

Neoplasia intraepitel serviks, derajat III, Karsinoma skuamosa insitu, Karsinoma

skuamosa (berkeratinisasi, tidak berkeratinisasi, verukosa), Adenokarsinoma

insitu, Adenokarsinoma insitu tipe endoservikal, Adenokarsinoma endometrioid,

Adenokarsinoma sel jernih, Karsinoma adenoskuamosa, Karsinoma kistik

adenoid, Karsinoma sel jernih dan Karsinomsa undifferentiated.

Derajat histopatologik : diferensiasi baik, diferensiasi sedang, diferensiasi buruk.

Diagnosis

Diagnosis kanker serviksdiperoleh melalui pemeriksaan klinis berupa

anamnesis, pemeriksaan fisis dan ginekologis, termasuk evaluasi kelenjar getah

getah bening, pemeriksaan panggul dan pemeriksaan rektal.

Tes Pap pada saat ini merupakan alat skiring yang diandalkan. Tes Pap Smear ini

direkomendasikan pada saat mulai melakukan aktifitas seksual atau telah

menikah. 3 kali dilakukan berturut-turut setiap tahun, kemudian tiap 3 tahun

sekali.

Untuk yang beresiko tinggi (infeksi HPV, HIV, dan kehidupan seksual yang

beresiko) dianjurkan melakukan tes setiap tahun.

Pemanstian diagnosis dapat dilakukan biopsi jaringan.

Pemeriksaan radiologi berupa foto paru, pielografi intravena atau CT-scan

merupakan pemeriksaan penunjang untuk melihat perluasan penyakit, serta

menyingkirkan adanya obstruksi ureter.

Untuk menentukan jenis pengobatan maka perlu dilakukan pemeriksaan

laboratorium klinik berupa pemeriksaan darah tepi, tes fungsi ginjal, dan tes

fungsi hati.

DIAGNOSIS Symptoms

A large portion of women diagnosed with cervical cancer may be asymptomatic.

For those with symptoms, however, early stage cervical cancer may create a

watery, blood-tinged vaginal discharge. Intermittent vaginal bleeding that

follows coitus or douching may also be noted. As a malignancy enlarges, bleeding

typically intensifies and occasionally a woman may present to an emergency

room with uncontrolled hemorrhage from a tumor bed. With parametrial

invasion and extension to the pelvic sidewall, a tumor may compress adjacent

organs to produce symptoms. For example, lower extremity edema and low back

pain, often radiating down the posterior leg, may reflect compression of the

sciatic nerve root, lymphatics, veins, or ureter by an expanding tumor. With

ureteral obstruction, hydronephrosis and uremia can follow and may

occasionally be initial presenting symptoms. Additionally, with tumor invasion

into the bladder or rectum, women may note hematuria and/or symptoms of

vesicovaginal or rectovaginal fistula.

Physical Examination

Most women with cervical cancer have normal general physical examination

findings. However, with advancing disease, enlarged supraclavicular or inguinal

lymphadenopathy, lower extremity edema, ascites, or decreased breath sounds

with lung auscultation may indicate metastases.

In those with suspected cervical cancer, a thorough external genital and vaginal

examination should be performed, looking for concomitant lesions. Human

papillomavirus is a common risk factor for cervical, vaginal, and vulvar cancers.

With speculum examination, the cervix may appear grossly normal if cancer is

microinvasive. Visible disease displays varied appearances. Lesions may appear

as exophytic or endophytic growth; as a polypoid mass, papillary tissue, or

barrel-shaped cervix; as a cervical ulceration or granular mass; or as necrotic

tissue (Fig. 30-9). A watery, purulent, or bloody discharge may also be present.

For this reason, cervical cancer may mirror the appearance of different diseases.

These include cervical leiomyoma, cervical polyp, prolapsing uterine sarcoma,

vaginitis, cervical eversion, cervicitis, threatened abortion, placenta previa,

cervical pregnancy, condyloma acuminata, herpetic ulcer, and chancre.

FIGURE 30-9Photograph of invasive cervical cancer originating from the

endocervix. (Courtesy of Dr. David Miller.)

During bimanual examination, a clinician may palpate an enlarged uterus

resulting from tumor invasion and growth. Alternatively, hematometra or

pyometra may expand the endometrial cavity following obstruction of fluid

egress by a primary cervical cancer. Advanced cervical cancer cases may have

vaginal involvement, and the extent of disease can be appreciated on

rectovaginal examination. In such cases, palpation of the rectovaginal septum

between the index and middle finger of an examiner's hand reveals a thick, hard,

irregular septum. The proximal posterior vaginal wall is most commonly

invaded. In addition, during digital rectal examination, parametrial, uterosacral,

and pelvic sidewall involvement can be palpated. Either one or both parametria

may be invaded and involved tissues feel thick, irregular, firm, and less mobile. A

fixed mass indicates that tumor has probably extended to the pelvic sidewalls.

However, a central lesion can become as large as 8 to 10 cm in diameter before

reaching these sidewalls.

Papanicolaou Smear

Histologic evaluation of cervical biopsy is the primary tool used to diagnose

cervical cancer. Although Papanicolaou (Pap) smears are performed extensively

to screen for this cancer, this test does not always detect cervical cancer.

Specifically, Pap smear testing has only a 55- to 80-percent sensitivity for

detecting high-grade lesions on any given single test (Benoit, 1984; Soost, 1991).

Thus, the preventive power of Pap smear testing lies in regular serial screening

as outlined in Table 29-3. Moreover, in women who have stage I cervical cancer,

only 30 to 50 percent of single cytologic smears obtained are read as positive for

cancer (Benoit, 1984). Hence, the use of Pap smear alone for evaluation of

suspicious lesions is discouraged. Importantly, these lesions should be directly

biopsied with Tischler biopsy forceps or a Kevorkian curette (see Fig. 29-11).

Colposcopy and Cervical Biopsy

If abnormal Pap smear findings are noted, colposcopy is performed as described

in Chapter 29, Colposcopy. During this evaluation, the entire transformation zone

ideally is identified, and adequate cervical and endocervical biopsies are

obtained. Cervical punch biopsies or conization specimens are the most accurate

for allowing assessment of cervical cancer invasion. Both sample types typically

contain underlying stroma and enable differentiation between invasive and in

situ carcinomas. Of these, conization specimens provide a pathologist with a

larger tissue sample and are most helpful in diagnosing in situ cancers and

microinvasive cervical cancers.

Tumor Spread

Survival rate

Management during PregnancyThere is no difference in survival between pregnant and nonpregnant women with cervical cancer when matched by age, stage, and year of diagnosis. As with nonpregnant women, clinical stage at diagnosis is the single most important prognostic factor for cervical cancer during pregnancy. Overall survival is slightly better for cervical cancer in pregnancy because an increased proportion of patients have stage I disease.

DIAGNOSISA Pap smear is recommended for all pregnant patients at the initial prenatal visit. Additionally, clinically suspicious lesions should be directly biopsied. If Pap test results reveal HSIL or suspected malignancy, then colposcopy is performed and biopsies are obtained. However, endocervical curettage is excluded. If Pap testing indicates malignant cells and colposcopic-directed biopsy fails to confirm malignancy, then diagnostic conization may be necessary. Conization is recommended only during the second trimester and only in patients with inadequate colposcopic findings and strong cytologic evidence of invasive cancer. Conization is deferred in the first trimester, as this surgery is associated with abortion rates of 30 percent in this part of pregnancy.

STAGE I CANCER IN PREGNANCYWomen with microinvasive squamous cell cervical carcinoma measuring 3 mm or less and containing no LVSI may deliver vaginally and be re-evaluated 6 weeks postpartum. Moreover, for those with stage IA or IB disease, studies find no increased maternal risk if treatment is intentionally delayed to optimize fetal maturity regardless of the trimester in which the cancer was diagnosed. Given the outcomes, a planned treatment delay is generally acceptable for women who are 20 or more weeks' gestational age at diagnosis with stage I disease and who desire to continue their pregnancy. However, a patient may be able to delay from earlier gestational ages if she wishes.

ADVANCED CERVICAL CANCER IN PREGNANCYWomen with advanced cervical cancer diagnosed prior to fetal

viability are offered primary chemoradiation. Spontaneous

abortionof the fetus tends to follow whole-pelvis radiation therapy. If

cancer is diagnosed after fetal viability is reached and a delay until

fetal pulmonary maturity is elected, then a classical cesarean

delivery is performed. A classical cesarean incision minimizes the

risk of cutting through tumor in the lower uterine segment, which

can cause serious blood loss. Chemoradiation is administered after

uterine involution. For patients with advanced disease and

treatment delay, pregnancy may impair prognosis. Women who

elect to delay treatment, to provide quantifiable benefit to their

fetus, will have to accept an undefined risk of disease progression.