Recommendations of the Polish Gynecological Oncology Society for the diagnosis and treatment of cervical cancer 25

© Medical Communications Sp. z o.o. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (CC BY-NC-ND). Reproduction is permitted for personal, educational, non-commercial use, provided that the original article is in whole, unmodified, and properly cited. Zalecenia Polskiego Towarzystwa Ginekologii Onkologicznej dotyczące diagnostyki i leczenia raka szyjki macicy Recommendations of the Polish Gynecological Oncology Society for the diagnosis and treatment of cervical cancer


ETIOLOGY/ETIOPATHOGENESIS
C ervical cancer (CC) is currently the third most common cancer among women and the fourth leading cause of cancer-related death in women worldwide (1) .In Poland in 2013, CC accounted for 3.7% of all newly registered tumor cases among women, and was the sixth most common female malignancy.At the same time, CC is the seventh leading cause of cancer-related death among Polish women (2) .Epidemiological indicators differ depending on patient's age.CC is responsible for 8% of cancer-related cases and 11% of cancer-related deaths among young women (aged between 20 and 44 years).Persistent human papillomavirus (HPV) infection is the most important factor in the development of cervical neoplasm.The incidence of CC is associated with the occurrence of HPV in a given population.In countries with a high incidence of this cancer, persistent HPV infection affects approximately 10-20% of the population, while the same rate is 5-10% in countries with lower incidence.Vaccination against HPV prevents infection with certain types of viruses, and consequently the development of cancer induced by a given type of virus.Other risk factors that increase the probability of disease include smoking tobacco, multiple vaginal deliveries, the use of oral contraceptives by women smokers, early sexual initiation, multiple sexual partners, positive history for sexually transmitted diseases, certain autoimmune diseases and chronic immunosuppression (3) .

DIAGNOSIS
The presented recommendations relate to cervical squamous cell carcinoma, squamous adenocarcinoma and adenocarcinoma.Neuroendocrine cancers, small cell cancers, glassy cell carcinomas, sarcomas and other histological types of cancers were not included in this paper.
According to current recommendations of the International Federation of Gynecology and Obstetrics (FIGO), procedures such as colposcopy, biopsy, cervical conization, cystoscopy and sigmoidoscopy are recommended for clinical staging.
The use of imaging is necessary in patients starting with stage IA2 CC.Cystoscopy and rectoscopy are only recommended if cancer infiltration of these organs is suspected and necessary in the case of neoplastic infiltration within the anterior or posterior vaginal wall.Diagnostic methods such as magnetic resonance imaging (MRI), computed tomography (CT) or positron emission tomography -computed tomography (PET-CT) may be used for treatment planning; however, they are not necessary for the official clinical staging.

Cancer strictly limited to the cervix (patients with the infiltration of the uterine body cannot be qualified to this stage)
Stage IA: only microscopic assessment of neoplastic invasion is possible (infiltration depth ≤5 mm, diameter ≤7 mm): • stage IA1: stromal invasion ≤3.0 mm in depth and ≤7.0 mm in diameter; • stage IA2: stromal invasion 3.0-5.0mm in depth and ≤7.0 mm in diameter; • stage IB1: clinically visible lesion ≤4 cm in diameter in greatest dimension; • stage IB2: clinically visible lesion >4 cm in diameter in greatest dimension.

STAGE II
CC spreading beyond the cervix, but without the involvement of the lower 1/3 of vagina or pelvic walls

STAGE III
Cancer has spread to pelvic walls (with or without the involvement of the lower 1/3 of vagina) and/or the presence of hydronephrosis or kidney dysfunction • Stage IIIA: the cancer has spread to the lower 1/3 of the vagina but not to the walls of the pelvis.• Stage IIIB: pelvic wall involvement and/or hydronephrosis or kidney dysfunction.

STAGE IV
Cancer has spread beyond the pelvis or it invades the bladder or rectal mucosa (as confirmed by biopsy) (Bladder edema is not sufficient to classify the tumor as T4).
• Stage IVA: infiltration or spread to adjacent organs.
• Stage IVB: spread to distant organs.
Copyright 2009, with the permission of FIGO.

TREATMENT
Treatment of CC involves surgery, radiation therapy, chemoradiation and chemotherapy.In accordance with evidence-based medicine (EBM), the contribution of surgery, chemotherapy and radiation therapy in the treatment of primary CC is 45%, 51.4% and 58%, respectively (1)(2)(3)5) .

RSM -FIGO STADIUM IIB-IV (ryc. 4)
Konieczne badania: • badanie przez pochwę i odbytnicę, biopsja lub wyłyżeczkowanie kanału szyjki macicy; Recommended follow-up: Every 3 months for the first 3 years after treatment completion, every 6 months for up to 5 years, then once a year.Gynecological examination.Additional evaluation should be performed depending on the symptoms, examination findings and general condition of the patient.
CC -FIGO STAGE IIB-IV (Fig. 4) used to reduce the size of large tumors before concurrent chemoradiation (CCRT).

Recommended follow-up:
Every 3 months for the first 3 years after treatment completion, every 6 months for up to 5 years, then once a year.Gynecological examination.Additional evaluation should be performed depending on the symptoms, examination findings and general condition of the patient.

Recommended follow-up:
Every 3 months for the first 3 years after treatment completion, every 6 months for up to 5 years, then once a year.Gynecological examination.Additional evaluation should be performed depending on the symptoms, examination findings and general condition of the patient (6) .

The diagnosis is based on histopathological findings from the specimen collected under colposcopic guidance! Recommended follow-up:
Every 3 months for the first 3 years after treatment completion, every 6 months for up to 5 years, then once a year.Gynecological examination.Cytology and colposcopy should be performed depending on the symptoms, examination findings and general condition of the patient.