Patients w/ abnormal Pap smear are referred for colonoscopy to screen for presence of cervical cancer.
Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion & biopsy of the most abnormal area for tissue diagnosis.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge & postcoital bleeding or intermittent spotting may be present & are usually unrecognized by the patient.


Stage IA1

  • Postoperative pelvic radiotherapy with or without Cisplatin-containing chemotherapy should be considered in patients with at least 2 high-risk factors (ie lymphovascular invasion, deep stromal invasion, large primary tumor)
  • Patients with positive surgical margins, parametrial involvement or pelvic node involvement should be treated with post-op pelvic external beam radiation with concurrent Cisplatin-containing chemotherapy with or without vaginal brachytherapy
    • Concomitant chemoradiation may utilize Cisplatin as single agent or Cisplatin with 5-Fluorouracil

Stage IA2

  • Brachytherapy + pelvic external beam radiotherapy (point A dose: 70-80 Gy)
    • Dose is based on summation of conventional external-beam fractionation and low-dose rate (40-70 cGy/hour) brachytherapy equivalents
    • Dose should be modified based on normal tissue tolerance
  • Brachytherapy is an important part of radiotherapy for cervical carcinomas
    • It treats mainly the primary tumor
    • The surrounding tissue can be relatively spared while high doses of radiation are delivered to the tumor
    • Delivery is through manual or remote after-loading techniques
    • If brachytherapy is not available in limited-resource settings, extrafascial hysterectomy or its modification may be performed in patients with residual tumor found 2-3 months after concurrent chemoradiotherapy and additional boost

Stage IB1 or Stage IIA1 

  • Patients with stage IB1 or stage IIA1 may be treated with pelvic EBRT plus brachytherapy (point A dose: 80-85 Gy)
    • Should be modified based on normal tissue tolerance
    • When using high dose-rate brachytherapy, define the doses according to biological equivalence
  • Combined radio-surgery, which represents a therapeutic option, consists of pre-op brachytherapy followed by surgery

Advanced Tumors

  • Concurrent chemoradiation represents the standard treatment  
    • Has been shown 30-50% decrease in the mortality risk compared to radiotherapy
  • In patients undergoing primary chemoradiation, the volume of radiotherapy is critical and is guided by assessment of nodal involvement in the pelvic and para-aortic nodes
  • Patients with advanced stage IB2-IIA/B may benefit more from chemoradiotherapy than patients with stage III and IVA
    • Based on trials done, it translated to a 5-year survival benefit of 10% for patients with stage IB-IIA, 7% for patients with stage IIB and 3% for patients with stage IIIB-IVA
  • Patients with locally advanced cancer may benefit from initial pelvic EBRT of 40-45 Gy to obtain tumor shrinkage for optimal intracavitary placements
    • With low-dose rate intracavitary systems, total doses from brachytherapy and external-beam radiation to point A of at least 80 Gy are recommended particularly for small tumors; whereas for larger tumors, doses of 85 Gy or higher is recommended
  • Inguinal lymph nodes should be treated in patients with lesions in the lower 1/3 of the vagina
    • Treatment of occult or macroscopic para-aortic lymph node disease using extended-field EBRT should be carefully planned so that adequate dose (45 Gy for microscopic disease) is given without exceeding bowel, spinal cord, or renal tolerances
  • Patients with positive para-aortic lymph nodes after surgical staging should undergo further screening with CT or PET scan
    • Once indicated, biopsy of suspected areas should be considered
    • If positive for distant metastases, they should be treated with chemotherapy and individualized radiotherapy  
  • In basic-resource settings, neoadjuvant chemotherapy may be given to patients with larger tumors or advanced cancer to shrink the tumor prior to hysterectomy

Relapse and Metastases

  • After radical surgery, factors that increase risk of early cervical cancer recurrence include high grade tumor, >4-cm tumor, non-squamous histology, lymphovascular space or deep stromal invasion, and involvement of lymph nodes, lower uterine segment, or parametrial or vaginal margin

Local or Regional Therapy

  • Determine whether radiotherapy or surgery may be utilized for patients with local recurrence after initial treatment
    • Survival rates of approximately 40% have been reported
    • Salvage pelvic radiotherapy may be offered to radiotherapy-naive patients with local recurrence
  • Individualized EBRT and chemotherapy with platinum-based agent(s), with or without brachytherapy, may be recommended in the following patients: With local or regional recurrence but without previous radiotherapy, and with recurrences outside of the previously treated radiotherapy field
    • Surgical resection may be considered

Central Recurrence

  • Patients with central recurrence after radiotherapy may benefit from pelvic exenteration, with or without intra-operative radiotherapy (IORT)
  • Patients will benefit from pelvic exenteration if rehabilitation programs dealing with psychosocial and psychosexual issues are available
    • Reconstructive procedures should also be available
  • Radical hysterectomy or brachytherapy may be an option in very few selected patients with small central lesions of <2 cm

Noncentral Recurrence

  • The following options may be utilized:
    • Resection with or without IORT for close or positive margins
    • Individualized EBRT with or without chemotherapy
    • Chemotherapy
    • Best supportive care
    • Participation in clinical trials
  • Patients who recur after 2nd-line therapy, such as radiotherapy or surgery, have a poor prognosis
    • Chemotherapy, supportive care, or participation in clinical trials are the treatment options for these patients
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Human papillomavirus (HPV) infection is a prevalent disease worldwide. Consequences of HPV infection vary, depending on the infected individuals and the HPV genotype involved. Life-threatening consequences are not uncommon, and cervical cancer is a clear demonstration of the virus’s potency. While the incidence of cervical cancer is heavily concentrated on developing countries,1 the impact of HPV-related diseases on developed countries has not ceased. In the United States alone, HPV infections are the most common sexually transmitted disease with an estimated 5 million new cases being diagnosed in 2000 among young adults, incurring nearly US$3 billion in terms of direct medical costs.2 A multinational study involving 18,498 women showed that cervical HPV prevalence varied greatly geographically, ranging from the low of 1.6% in North Vietnam to the high of 27% in Nigeria. In general, HPV prevalence peaked among young, sexually active women and declined with age. In selected countries, however, a second peak was noted in women older than 55 years.3 The high prevalence of HPV-related diseases incurs a heavy burden on the healthcare systems of developed and developing countries alike, which renders HPV research and prevention a global public health imperative. On an individual level, the afflictions caused by HPV-related diseases go beyond that of physical suffering to affecting the psychological well-being of the infected. This is the focus of our paper.

27 Nov 2017
Chronic hepatitis B virus (HBV) infection is a global problem. Chronic HBV infection is probably the most common maternal infection encountered in Hong Kong, China, and Southeast Asia. In Hong Kong, which is one of the endemic areas, immunisation against HBV was first provided in 1983 to infants born to mothers who were screened positive for hepatitis B surface antigen (HBsAg). Immunisation became widespread since November 1988, but HBsAg-positive mothers are still encountered frequently.1