Malignant neoplasm of the cervix ICD 10. Benign diseases of the cervix

Hundreds of thousands of women across the planet are diagnosed with uterine cancer every year. One of the most common symptoms of the disease is bleeding. To heal representatives of the fairer sex, medicine uses surgery, radio and hormonal therapy, chemotherapy individually or in combination.

Pathology of the female reproductive system consistently ranks fourth on the ranks of oncology after breast cancer, skin pathologies and changes in the gastrointestinal tract. The disease most often affects women of Balzac age from 40 to 60 years. Pathology rarely occurs in youth. Up to 35 years of life, malignant formations appear in two cases: when the ovaries produce estrogen, but ovulation does not occur, and with polycystic ovary syndrome. Recently, there has been a steady and constant growth of malignant cells in the uterus. The life expectancy of patients directly depends on the location of the tumor development and the perceptibility of the uterine body. The number of deaths has very disappointing statistics. How long do women live? At early diagnosis Due to improved therapy, uterine cancer can be treated quite successfully. A 10-year life prognosis gives about 95% of patients with stage 1 cancer, 70% with stage 2, 35% with stage 3, and only about 5% with stage 4.

Kinds

Based on the nature of development, oncology of the female organs is divided into:

• Squamous cell neoplasm;
• glandular cancer or adenocarcinoma cervical region and uterine cavity;
• sarcoma - develops quite rarely.

Based on the characteristics of their growth and development, neoplasms are divided into the following forms:

• exophytic – growing inside the uterus – 90% of cases;
• endophytic – growing into the thickness of the walls – 8% of cases;
• mixed – having signs of exophytic and endophytic forms – 2% of cases.

As exophytic uterine cancer grows and progresses, it becomes endophytic and then acquires the characteristics of mixed cancer.

International Classification of Diseases, 10th Revision (ICD-10)

The World Health Organization has summarized diseases, injuries and other health problems into the general ICD-10, assigned them classes, and today on a sick leave certificate we see its code instead of the diagnosis of the disease. How many uterine cancers according to ICD-10 are there? The classification itself consists of 21 classes of pathologies. All of them are divided into blocks. ICD-10 to all malignant changes in female body assigned ІІ class C00-D48 “Neoplasms”. How many types of cancer of the female genital organs are identified by the international statistical classification of diseases?

1. ICD-10 code C51. Tumors of the vulva. They account for 2 to 5% of all cases of malignant changes in the uterus. According to statistics, 950 women lose their lives every year due to this pathology. Such cancer can be detected through examination by a gynecologist and using ultrasound. But despite this simple diagnosis, 70% of women are admitted to clinics already at stages 3 or 4 of the disease. Vulvar cancer develops against the background of previous pathologies, such as lichen sclerosis or atrophic lichen, tissue atrophy. The disease manifests itself through fairly clear symptoms and develops quickly. Therefore, it is very important to treat precancerous conditions in a timely manner in order to prevent severe forms of oncology.
2. ICD-10 code C52. Tumors of the vagina. They account for 1 to 2% of all cases of malignant changes in the uterus. Primary lesions of the vagina are isolated cases. Doctors more often diagnose a secondary lesion - when malignant cells have metastasized from other structural components of the female genital organs. The average age of the disease is 60 years. Vaginal tumors, depending on age, have three peak forms. In childhood, these are botryoid embryonal rhabdomyosarcomas, in adolescence - clear cell adenocarcinoma, and over the age of 40 - squamous cell carcinoma in the form of sarcomas and melanomas. When irradiated in the pelvic area, the risk of vaginal cancer increases hundreds of times. Ultrasound and other diagnostic methods can determine pathology. Often a malignant tumor of the vagina develops from a precancerous disease - dysplasia.
3. ICD-10 code C53. Tumors of the cervix. They account for up to 40% of all cases of malignant changes in the uterus. This type of uterine cancer is considered a widespread disease among women of all ages. age groups. Every year, about 200 thousand women around the world die from this diagnosis. The peak of the disease occurs at 45–50 years of age. It is classified as a “visual” location group, that is, cervical cancer is quite easy to identify during examination by a gynecologist and confirm by ultrasound. But despite the simple diagnosis, the disease is progressive in nature and every year medicine records a significant increase in this form of oncology.
4. ICD-10 code C54. Tumors of the endometrium, or, in other words, the body of the uterus. They account for up to 80% of all cases of malignant changes. According to statistics, up to 500 thousand women around the planet lose their lives every year due to this pathology. The causes are chronic hyperestrogenism, infertility, endometriosis, anovulation. In combination with pathologies of the endocrine system and metabolic disorders, this leads to malignant processes and a significant disruption of the reproductive, metabolic and adaptive purposes of the body. Ultrasound and other diagnostic methods can determine pathology.
5. Separately, in the block of malignant tumors, ICD-10 identifies carcinoma in situ cervix . It occupies 12% of the morbidity structure. It is most common in countries with low socio-economic levels of development. Developed countries diagnose cases of this disease less and less every year.

Stages of development

Although modern diagnostics Uterine cancer makes it possible to identify pathological changes very quickly at the earliest stages of development through an examination by a gynecologist and ultrasound; often women go to medical institutions when the disease is no longer curable. Medicine notes four stages of cancer development:

1. A tumor in the mucous membrane or in the body of the uterus itself, sometimes penetrates its walls. When detected in this phase, 87–90% of women live fully for a long time.
2. The neoplasm affects the cervix female organ, but does not metastasize to neighboring tissues. 76–80% of the female population have a chance of recovery.
3. Malignant cells spread into the parametrial tissue and affect the lymph nodes. In this case, doctors guarantee a favorable prognosis and life expectancy for only 50% of women.
4. The cancer spreads beyond the pelvis and metastasizes to other organs. When detected at stage 4, patients live for a short period of time. Removal of the uterus with this form of development is not always effective.

Dear women! Know! If you have been diagnosed with uterine cancer, your life expectancy and the answer to the question of how many more years you have will directly depend on the degree of development of the tumor process, the correctness of diagnosis and the adequacy of treatment. Your task is to promptly seek medical attention at the first disturbance in the functioning of the genitourinary system. medical care, undergo annual examinations with a gynecologist and ultrasound.

Causes

If you consult a doctor in a timely manner, undergo an ultrasound, know the causes of uterine cancer, avoid them, and treat them on time inflammatory diseases genitourinary system, then the disease can be quickly and easily dealt with. How many factors are there that contribute to the development of cancer? What are the main causes of malignant processes in a woman’s body?

1. Age.
2. Hereditary and genetic predisposition.
3. Early onset of sexual activity.
4. Obesity.
5. Availability bad habits– smoking and alcohol abuse.
6. Chronic inflammatory processes.
7. Multiple artificial abortions.
8. Injuries and ruptures during childbirth, caesarean section.
9. Taking tamoxifen.
10. Atrophy of the epithelial layer of the uterus as a result of hormonal effects.
11. Constant use of contraceptive medications.
12. Late menopause.

Medicine is confident that the causes of the disease also lie in precancerous conditions. Diseases that contribute to the development of cancer processes in the uterus are noted:

• venereal diseases;
• diabetes;
• hypertension;
• papillomavirus;
• ulcers, erosions, postoperative scars;
• condylomoviruses;
• leukoplakia;
• endocervicitis and endometritis;
• polycystic diseases.

A significant risk of the disease is observed in patients with endocrine metabolic pathologies in the body and ovarian dysfunction.

Primary clinical picture

A special place in early diagnosis is occupied by symptoms that women pay attention to in a timely manner, especially after 35–40 years. These include pain, bleeding and specific discharge.

Discharges can be:

• watery;
• mixed with blood;
• mucous membranes;
• smelly.

Purulent discharge is characteristic of infection of the genitourinary system. Bloody discharge occurs at stages 3 and 4 of the development of malignant processes. An unpleasant odor is specific during the period of decomposition of a malignant neoplasm.

Main complaints that need special attention:

• vaginal bleeding after menopause;
• disturbances in the cyclicity of menstruation with random atypical bleeding;
• watery and bloody discharge;
• acute and nagging pain in the pelvis, lower back and perineum, as well as during and after intimacy.
• sudden weight loss and feeling of constant fatigue.

Be carefull! If a woman notices the first symptom - uncharacteristic vaginal discharge, or one of the above signs, she should immediately consult a doctor. Only through this can you have a chance for a full recovery. The quality of life and its duration completely depend on this alone.

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Symptoms in later stages

Late signs include acute pain that cannot be relieved with medications. It is accompanied by purulent discharge with a characteristic putrid odor. The cause is pyometry - the accumulation of pus inside the body of the uterus. Stenosis of the organ neck is observed - its narrowing or complete closure. Late uterine cancer is accompanied by uremia - blood in the urine, constipation and mucus in the stool, and difficulty urinating.

Remember! For any change in the schedule of the menstrual process in women of Balzac age, it is necessary to visit a gynecologist and conduct an ultrasound. Only this will help eliminate all serious causes of physiological changes.

Diagnostics

No medical institution will undertake to treat uterine cancer without a correct diagnosis. Detection in the early stages should not be limited to gynecological examination of the vagina. In case of any violations, the doctor will give a referral for an ultrasound examination. This method will most accurately determine the location of the tumor, its nature and degree of development. To identify pathology, smears are taken for cytological examination or biopsy. For histological analyses, separate curettages of the cervical canals and the inside of the uterus are performed.

It should be noted that not all visits to the doctor can detect the presence of a neoplasm. Women over 40 years of age must undergo an annual ultrasound scan. This is the most effective research method that reveals all benign and malignant changes in the uterus. The doctor may also prescribe an x-ray examination to clarify or refute the diagnosis.

Therapy

The treatment protocol directly depends on the patient’s age, general health condition and clinical form of oncology. Therapy in most cases comes down to surgical intervention - resection of the uterus, appendages, and less often, removal of lymph nodes. Radiation therapy is usually necessary for uterine cancer. This is one of the accompanying methods of therapy. It can be preoperative and postoperative.

At stage 1 of the development of malignant tumor processes, the uterus and appendages are removed with intracavitary and external irradiation. Form 2 involves radiation exposure; in this form, surgery and organ removal are used extremely rarely. Treatment for stage 3 consists of radiation therapy and for stage 4 only chemotherapy is used.

It is important to understand that the main method of treatment is only a complete hysterectomy - surgical removal of the uterus and appendages. Depending on the form of spread of metastases, resection of the ovaries and tubes, the upper part of the vagina and adjacent lymph nodes may be performed. Uterine cancer in the early stages - a non-invasive neoplasm can be cured with only hysterectomy without resection of adjacent organs.

Preoperative radiation is carried out to reduce the size of the tumor and the development of malignant cells. Postoperative – to reduce the risk of metastasis and relapse. Uterine cancer also involves hormonal therapy to reduce the activity and destruction of tumor processes, to inhibit the development of latent forms of metastases.

Recovery after a series of therapeutic measures depends on the extent of the surgical intervention and the general state of the patient’s immune system before surgery. Resumption of functionality usually occurs within 3–4 months.

Women! Remember! If you have been diagnosed with uterine cancer and undergone therapeutic measures, you need regular monitoring by doctors in oncology departments. Do not miss visits to doctors and undergo all examinations prescribed as part of preventive measures.

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RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2012 (Orders No. 883, No. 165)

Cervix of uterus, unspecified part (C53.9)

general information

Short description

Clinical protocol "Cervical cancer"

Currently, significant progress has been made in the developed countries of the world in the prevention, early diagnosis and treatment of cervical cancer (CC). This is mainly due to the fact that, unlike other oncological diseases, the incidence of cervical cancer is well controlled, since the disease has a clear etiology, a clear and often long precancerous stage and a clear tendency to local spread.

Thus, in Australia, with the introduction of a screening program in 1994, it was possible to reduce the incidence by almost 2 times - from 13.2 to 6.9 per 100 thousand female population, while according to the Australian Institute of Health, mortality from cervical cancer decreased from 4.0 to 1.9 (1).

Thus, if developed countries have learned to control the morbidity and mortality from CC, then most of the world is still on the way to this. And WHO statistics confirm this: for example, in 2005, more than 500,000 thousand new cases of the disease were registered and 90% of them belonged to countries with developing economies.

Also in 2005, 260,000 women died from the disease, about 95% in developing countries, most with an unconfirmed diagnosis and lack of access to adequate treatment that could prolong their lives.

In the Republic of Kazakhstan, at the end of 2007, 9269 women were under the supervision of oncologists, 1233 new cases were registered and 631 deaths from this disease were registered (Arzykulov Zh.A. et al., 2008).

The modern concept of a program to improve the situation with cervical cancer based on the experience of developed countries is based on three main principles:
1. Primary prevention (healthy lifestyle with the exclusion of possible risk factors, vaccination of certain groups of the population).
2. Secondary prevention (high-quality and well-organized screening of the female population).
3. Introduction of uniform protocols for all modern diagnostics and treatment of invasive cervical cancer.
Only such an integrated approach will allow us to reliably reduce the incidence and mortality from cervical cancer in our country.

Protocol code:РH-O-002 "Cervical cancer"

ICD code: C 53

1. Malignant neoplasms of the cervix (C 53).

2. Internal part (C 53.0).

3. External part (C 53.1).

4. Damage to the cervix extending beyond one or more of the above localizations (C 53.8).

5. Cervix of the uterus, unspecified part (C 53.9).

Abbreviations used in the protocol:

1. FIGO - International Federation of Gynecology and Obstetrics.

2. WHO - World Health Organization.

3. CC - cervical cancer.

4. CIN - cervical intraepithelial neoplasia.

Date of development of the protocol: 2011

Protocol users: doctors involved in the diagnosis, treatment and rehabilitation of patients with cervical cancer.

Disclosure of no conflict of interest: The developers have no financial interest in the subject of this document, and also do not have any relationship with the sale, production or distribution of drugs, equipment, etc. specified in this document.

Classification

Staging of cervical cancer

To determine the stage of cervical cancer, it is used all over the world. clinical classification International Federation of Gynecologists and Obstetricians (Table 1); cases undergoing surgical staging are also classified according to TNM (7th edition, 2009).

Rules for staging cervical cancer

Staging of cervical cancer is based solely on clinical assessment, so a thorough clinical examination is necessary in absolutely all cases, in some cases under anesthesia. It should be remembered that the clinical stage does not change depending on subsequent diagnostic findings. When in doubt about the choice of stage, preference is given to a smaller stage.

The following examination methods are used for staging:

1. FIGO staging is based on the use of exclusively clinical data (examination and colposcopy), chest radiography, intravenous urography, biopsy and curettage of the cervical canal and uterine cavity.

2. Cystoscopy and rectoscopy can be used for clinical staging if germination is suspected: morphological confirmation is required!

3. Lymphography, CT, MRI, PET, laparoscopy cannot be used for clinical staging.

4. If pathological changes are detected on intravenous urography, the case should be classified as stage IIIB.

5. Regional lymph nodes for the cervix are paracervical, parametric, hypogastric, obturator, internal, external and common iliac, presacral, sacral.

6. Findings discovered during additional examination methods, such as laparoscopy, ultrasonography, CT, MRI, PET are valuable for choosing a treatment method, but due to the fact that they are not performed everywhere and their interpretation depends on the qualifications of the doctor, they are not used for clinical staging and their data do not change the stage of the disease.

Table 1. Cervical cancer - FIGO (2009) and TNM staging (7th edition, 2009)

Pathological (surgical) TNM staging (Table 1)

Data obtained from a thorough morphological examination of tissues removed during surgery should be used to most accurately assess the extent of the process. These findings do not allow for changes in clinical staging, but should be used and reflected in the pathological staging protocol. For these purposes, the TNM nomenclature is used.

Sometimes cervical cancer can be an incidental finding after hysterectomy for other indications - in such cases, clinical staging cannot be carried out and these cases are not included in therapeutic statistics, but it is advisable that they be reported separately. The initially established stage does not change when a relapse occurs.

Comparison of treatment results between clinics and various methods treatment is possible only with careful compliance with all staging rules.

Features of staging

The diagnosis of stages IAl and IA2 is based solely on microscopic examination of removed tissue (biopsy material - preferably a cervical cone, which should cover the entire affected area). The depth of invasion should not be > 5 mm from the basement membrane or from the surface of the gland from which the mass originates.

The horizontal spread should not exceed 7 mm. The presence of vascular and/or lymphatic invasion does not increase the stage of the disease, but should be reflected in the diagnosis, as it may influence the choice of treatment in the future.

Larger lesions that are visible to the eye are staged as IB. As a rule, it is impossible to assess by eye whether there is extension to the uterine body. Therefore, clinically suspected extension to the uterine body should not be taken into account.

Patients with tumor extension towards the pelvic wall, which is defined as a short, indurated area, should be staged as IIB. During clinical staging, it is impossible to reliably assess whether the shortening of the vaginal vaults and dense infiltration in the parametrium is truly tumor or inflammatory in nature.

Third stage is set when there is infiltration to the pelvic bones, or direct tumor growth reaches the pelvic bones. The presence of hydronephrosis or a non-functioning kidney is a consequence of ureteral stenosis by the tumor and in such cases stage III is assigned, even if, according to other research methods, the tumor can be classified as stage I or II.

The presence of bullous edema does not give grounds to classify the disease as stage IV. Formations in the form of ridges and grooves protruding into the lumen of the bladder are often a consequence of the involvement of the submucosal layer of the bladder in tumor growth.

The presence of tumor cells in bladder lavages requires additional morphological examination to classify the case as stage IVA.

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Treatment

Cervical cancer treatment

Microinvasive cancer

The diagnosis of stage IA1 or IA2 cervical cancer is made solely on the basis of a morphological examination of the cervical cone with negative resection margins or on the basis of a removed specimen after trachelectomy or hysterectomy. If CIN III or invasive cancer is detected at the resection margins after cervical conization, repeat conization or treatment of the patient as for stage IB1 disease is necessary (2). Vaginoscopy (colposcope!) is performed to exclude concomitant vaginal intraepithelial neoplasia (VAIN) before choosing a treatment method.

Stage IA1

The main treatment method for cervical cancer at this stage is total abdominal or vaginal hysterectomy. In the presence of vaginal intraepithelial neoplasia, removal of the corresponding part of the vaginal tube is necessary (3). If it is necessary to preserve fertility, observation after wide conization of the cervix with negative resection margins is possible, subject to a Pap test. A Pap test is performed at 6, 12 months and annually thereafter if the previous two tests were negative. Level of evidence B.

Stage IA2

There is a certain potential for lymphatic metastasis in patients with stage IA2 disease, and therefore it is necessary to perform pelvic lymphadenectomy during surgical treatment (4,5). An adequate operation for these clinical cases is a modified radical hysterectomy (type 2 operation) supplemented by bilateral pelvic lymphadenectomy. In the absence of lymphovascular invasion according to preliminary biopsy, it is possible to perform extrafascial extirpation (type 1 surgery) with pelvic lymphadenectomy. Level of evidence C.

If you want to preserve fertility possible options treatments are:

Wide conization of the cervix, supplemented by extraperitoneal or laparoscopic removal of pelvic lymph nodes;

Radical trachelectomy, supplemented by extraperitoneal, transperitoneal or laparoscopic removal of pelvic lymph nodes (6).

Monitoring of this group of patients is mainly based on an annual Pap test after two negative tests at 6 and 12 months.

Invasive cervical cancer

In patients with visible to the eye lesions on the cervix, a biopsy is required to confirm the diagnosis morphologically (under anesthesia if necessary); vaginoscopy is performed to exclude vaginal intraepithelial neoplasia (VAIN). Concomitant symptoms (from the bladder and rectum) should be examined: cystoscopy and rectoscopy are necessary. A chest x-ray and kidney examination (ultrasound, excretory urography, CT and MRI) are also required. CT and MRI are also performed to assess the condition of regional lymph nodes and local spread of the tumor. If PET is available, it can be used.

Disease stages IB1, IIA1 (tumor< 4 см)

Early stages of cervical cancer (IB1, IIA< 4см) имеют хороший прогноз и могут одинаково успешно лечиться как хирургическим, так и лучевым методом (7,8). Level of evidence A.

The choice of treatment method depends on the availability of appropriate resources: a trained gynecologic oncologist, the age and general condition of the patient. It is preferable to use the capabilities of a multidisciplinary team (gynecologic oncologist, radiologist, chemotherapy) in developing a treatment plan and informing the patient about various therapeutic alternatives, their side effects and expected treatment results.

Typically, the combination of surgical and radiation treatment methods increases the number of complications, therefore, when initially planning therapy, simultaneous administration of surgery and postoperative radiation should be avoided. Level of evidence A.

Surgery: standard for surgical treatment of stage IB1/IIA1 cervical cancer (< 4 см в диаметре) является модифицированная или радикальная абдоминальная гистерэктомия (класс II или III согласно классификации Piver, Rutledge, Smith, 1974 г.) в сочетании с тазовой лимфаденэктомией. У молодых пациенток яичники сохраняются и выводятся из полости малого таза в брюшную полость (транспозиция) для сохранения их функции на случай проведения послеоперационной лучевой терапии. В отдельных случаях возможно выполнение радикальной трахелэктомии с лапароскопической тазовой лимфаденэктомией (9,10). Level of evidence C.

Radiation therapy: standard radiotherapy for stage IB1/IIA1 cervical cancer (< 4 см в диаметре) является сочетанная лучевая терапия. Рекомендуемые дозы для дистанционного компонента и брахитерапии источником низкой мощности - 80-85 Грей на точку A и 50-55 Грей на точку B. Суммарная доза дистанционной лучевой терапии (EBRT) должна составлять 45-50 Грей при 1,8-2,0 Грей за фракцию. При использовании источников высокой мощности для брахитерапии (ВТ), дозы определяются согласно биологической эквивалентности.

Adjuvant treatment after surgery: the risk of relapses after radical surgical treatment is high in the presence of metastases in the lymph nodes, positive resection margins and the presence of tumor elements in the parametria (paracervical tissues). Adjuvant competitive chemoradiotherapy (using 5FU + Cisplatin or Cisplatin) improves treatment outcomes compared with concomitant radiation therapy in this category of patients (11). Level of evidence A.

The risk of relapse increases in patients with uninvolved lymph nodes, large tumor sizes, involvement of the lymphovascular space, and invasion of more than 1/3 of the cervical stroma. In this group of patients, pelvic irradiation reduces the risk of recurrence and increases disease-free survival compared with patients who did not receive adjuvant treatment after surgery. In addition, postoperative radiation therapy is preferred in patients with cervical adenocarcinoma and cervical glandular squamous cell carcinoma (12). Level of evidence A.

Two collaborative groups of investigators reported acceptable results from postoperative small-field radiotherapy targeting the vaginal stump and parametrial tissues (13,14). The upper limit of irradiation in this case is the level S1-2, and not L5-S1 as with conventional fields. Level of evidence C.

Fundamentally, the issue of prescribing adjuvant radiation/chemoradiotherapy for stage 1 CC is decided on the basis of the GOG scoring scale, developed on the basis of a large pathological and surgical study (Table 2).

Table 2. Relative risk of relapse in stage 1 cervical cancer after radical hysterectomy

Stage IB2, IIA2 (tumor > 4 cm)

The selection methods are:

1. Primary competitive chemoradiotherapy (15).

2. Radical hysterectomy with pelvic lymphadenectomy (type III surgery), which is usually supplemented with adjuvant radiation therapy.

Competitive chemoradiotherapy: The most widely used treatment is concurrent radiotherapy combined with weekly platinum-drug chemotherapy.

Recommended doses of radiation therapy for point A are 85-90 Gray, for point B 55-60 Gray. Cisplatin is prescribed at a dose of 40 mg/m2 weekly along with the external beam component of radiation therapy. In patients with metastases to the para-aortic and common iliac lymph nodes, it is necessary to expand the irradiation field to the para-aortic zones (17,18). Currently, data on the toxicity of competitive chemoradiation therapy associated with expanded irradiation fields are scarce. Level of evidence A.

Primary surgical treatment with possible adjuvant radiation

Radical hysterectomy performed at the first stage has certain advantages, which include the possibility of thorough surgical staging with simultaneous removal of the primary tumor and thereby eliminating the need for subsequent brachytherapy (19).

In addition, the surgery removes all regional and any diseased or enlarged lymph nodes, which are much less likely to respond adequately to radiation (20). Because these tumors are inherently large, they are likely to require adjuvant radiation postoperatively.

The risk of recurrence increases with involvement of the lymphovascular space and with tumor invasion of more than 1/3 of the cervical stroma (21). Patients with no metastases in regional lymph nodes and a high risk of relapse are subject to external irradiation of the entire pelvis (12) or small-field irradiation (13,14).

Patients with regional lymph node metastases and common iliac and para-aortic lymph node metastases should receive extended-field external beam irradiation with or without chemotherapy (17,18). Level of evidence C.

Neoadjuvant chemotherapy followed by radical hysterectomy and lymphadenectomy: Randomized trial data suggest better treatment outcomes with preoperative chemotherapy compared with primary radiation (16,22). There are currently no data comparing the results of neoadjuvant chemotherapy followed by radical hysterectomy and concurrent chemoradiotherapy. Level of evidence B.

Neoadjuvant chemotherapy used in the Argentine protocol was carried out according to the following scheme (16):

1. Cisplatin 50 mg/m2 IV - 15 minute infusion on the 1st day.

2. Vincristine 1 mg/m2 IV infusion immediately after cisplatin, on the 1st day.

3. Bleomycin 25 mg/m2 subsequent 6-hour infusions, from days 1 to 3.

This regime is repeated every 10 days, three times.

Locally advanced cervical cancer (includes stages IIB, III and IVA disease)

The standard treatment is combined radiotherapy with competitive chemotherapy (15,23). Level of evidence A.

In stage IV A, it is possible to perform pelvic exenteration at the first stage, especially in the presence of a cystic or rectal fistula, which, however, is not a contraindication to chemoradiotherapy according to a radical program. Level of evidence C.

Table 3. Treatment of locally advanced cervical cancer

Radiation technique and doses: doses and irradiation fields are presented in Table 3. Irradiation should be carried out with appropriate energy with a uniform dose distribution (± 5%) between the primary tumor and regional areas of metastasis. The volume of the tumor to be irradiated should be determined using clinical studies and CT, where possible. The irradiation technique consists of using at least 4 fields. Brachytherapy can be performed with both low and high power sources.

The standard treatment is combined radiation therapy with competitive chemotherapy based on platinum-based drugs. Cisplatin is prescribed at a dose of 40 mg/m2 once a week during external beam radiation therapy. Recommended doses range from 85 to 90 Gray at point A and from 55 to 60 Gray at point B. In patients with metastases in the common iliac and/or para-aortic lymph nodes, it is necessary to consider expanding the radiation fields to the para-aortic region (17,18,24 ). Level of evidence C.

Stage IVB and relapses

Relapse can be in the pelvis (local relapses) or outside the pelvic organs (distant metastases). With large sizes of the primary tumor, the number of patients with relapses in the pelvis and distant metastases increases. Most relapses occur in the first two years and the prognosis for this category of patients is unfavorable, most of them die from disease progression (25). Median survival is seven months.

The main symptoms of cervical cancer as it progresses are pain, swelling in the legs, anorexia, bloody issues from the genital tract, cachexia, psychological and other problems. When choosing a method of treatment and management of this group of patients, it is optimal to combine the efforts of a whole group of specialists: gynecological oncologists, radiologists, chemotherapists, psychologists, nutritionists, and specially trained nurses. Relief from pain and other symptoms, along with comprehensive support, is the main goal of the medical staff.

Management of patients with primary relapses: the choice of treatment method is based on the general condition of the patient, the location of relapse/metastasis, their prevalence and the method of primary treatment.

Possible methods treatment of relapses after primary radical hysterectomy (Table 4): Recurrences in the pelvis after radical hysterectomy can be treated with both radiation therapy and surgery (pelvic exenteration). Radical irradiation (± competitive chemotherapy) for localized pelvic relapses after primary surgical treatment is effective in a significant number of patients (26). The dose and volume of radiation therapy should be determined by the extent of the disease.

Thus, for microscopic tumor sizes, the usual dose is 50 Gray with a ROD of 1.8-2.0 Gray with reduced irradiation field sizes, and for large tumors the dose is 64-66 Gray.

In disseminated forms of the disease or local relapses after unsuccessful primary treatment, when it is not possible to carry out conventional treatment, palliative chemotherapy or symptomatic treatment is prescribed. Cisplatin is one of the most effective drugs for CC (27,28). Median average duration life in such cases ranges from 3 to 7 months.

Table 4. Local relapses after surgical treatment of cervical cancer

Radical hysterectomy is performed in patients with minor recurrences (< 2 см в диаметре), ограниченными шейкой матки. Несмотря на увеличение количества осложнений при операциях после первичной лучевой терапии, в большинстве случаев нет необходимости накладывать колостомы (29, 30).

Patients with centrally localized recurrence, involvement of the bladder and rectum in the absence of intraperitoneal dissemination and distant metastases, and the presence of free space between the cervix and the pelvic wall are potential candidates for pelvic exenteration.

Triad of symptoms - bilateral lymphedema lower limbs, sciatica, urinary tract obstruction indicate an inoperable process. Palliative and symptomatic treatment is indicated for this group of patients.

The most favorable prognosis is with a relapse-free period of more than 6 months, a tumor size of less than 3 cm and the absence of infiltrates in the parameters (31-34). 5-year survival rates in this group of patients range from 30 to 60%, and perioperative mortality does not exceed 10%.

Table 5. Local relapses after radiotherapy for cervical cancer

The role of systemic chemotherapy in stage IVB and metastatic CC is presented in Table 6.

Table 6. Systemic chemotherapy for metastatic CC

Distant metastases: Radiation therapy is indicated for symptomatic tumor metastases as palliative treatment, for example, for bone metastases (34), enlarged para-aortic, subclavian lymph nodes for pain relief, or for brain metastases (35).

Random finds of cervical cancer

These findings mainly relate to cases of invasive cervical cancer diagnosed after simple hysterectomy performed for other indications. Before starting treatment in such situations, additional examination is necessary: ​​CT or MRI of the pelvic and abdominal organs, chest x-ray to clarify the extent of the process. The treatment method should be determined on the basis of morphological examination and radiological findings.

In the absence of pathological findings:

1. For stage IA1, no additional treatment is performed.

2. For stage IA2 and above, the following treatment is necessary:

In cases of positive resection margins, deep stromal invasion, and involvement of the lymphovascular space, competitive chemoradiation therapy is prescribed (38);

In patients without deep stromal invasion, negative resection margins, and no lymphovascular involvement, radical parametrectomy with the upper third of the vagina and lymphadenectomy is performed as an alternative to competitive chemoradiation therapy (39). Level of evidence C.

CC during pregnancy

In general, treatment of cervical cancer during pregnancy is based on the same principles as in non-pregnant women. There are only a few specific recommendations. Conization of the cervix is ​​performed only if invasive growth is suspected based on cytological examination and colposcopy due to the high risk of bleeding, miscarriage or premature birth.

The most important condition in determining the management tactics for pregnant women with cervical cancer is a multidisciplinary approach involving a neonatologist and obstetrician-gynecologist in addition to a radiologist and chemotherapist. The participation of the woman herself and her partner in decision-making is necessary, and their desire to continue the pregnancy should be taken into account.

In patients with suspected microinvasive cervical cancer, a delay in treatment does not harm the mother and is manifested by a significant increase in fetal viability.

Women with stage IA1 disease confirmed by conization and negative resection margins can carry their pregnancy to term and give birth vaginally. The method of delivery for microinvasive cervical carcinoma does not affect the outcome of the disease.

For disease stage IA2 and higher, treatment must be selected individually, mainly the decision on the method of treatment and its timing is based on the stage of the disease and the stage of pregnancy. MRI is performed to assess the extent of the process. If diagnosis is made before 20 weeks of gestation, treatment should begin immediately. The treatment of choice is radical hysterectomy with the fetus in situ. When carrying out chemoradiotherapy, as a rule, termination of pregnancy is not performed, since spontaneous miscarriage occurs after the start of treatment.

If cervical cancer is detected after 28 weeks of pregnancy, it is recommended to delay treatment until a viable fetus is obtained. Treatment of cervical cancer between 20 and 28 weeks of gestation in stage IA2 and IBI can be delayed until a viable fetus is obtained without significantly affecting the maternal prognosis (40, 41). When the disease stage is higher than IBI, delay in treatment significantly worsens the prognosis and affects survival.

It should be noted that there are no standards for determining how long the start of treatment can be delayed. In practice, the delay period depends on the stage of the disease, morphological findings, gestational age and the wishes of the parents. When planning the timing of delivery for locally advanced CC, it is possible to make a decision on prescribing neoadjuvant chemotherapy in order to prevent further progression of the disease (42) - dynamic monitoring is required! Delivery takes place no later than 34 weeks of gestation.

If the cervical mass is not removed at the time of diagnostic conization, the preferred method of delivery is classical cesarean section, although several retrospective studies have demonstrated that the method of delivery has no effect on the prognosis of cervical cancer (43).

Observation

The largest number of relapses after treatment for cervical cancer occur in the first 3 years, which determines the need for frequent monitoring of patients after treatment.

The minimum amount of research during a woman’s visit consists of:

1. Inspection in mirrors.

2. Gynecological examination.

3. Pap test.

These studies are carried out at least once every 3 months, during the first 2 years, at least once every 4 months, during the 3rd year, once every six months, during the 4th and 5th year of observation, then annually.

Pathological examination

Table 7. Pathomorphological examination of the drug for cervical cancer

Cervical cancer is a malignant tumor that affects the cervical mucosa at stage 1 and spreads to the vagina and vulva at stages 2-4. According to medical data, women aged 45-50 years are at risk.

Risk group

The causes of uterine cancer are:

• Early sexual life.
• Frequent change of partners.
• Unprotected sexual intercourse.
• Abortions, natural terminations of pregnancy.
• Human papillomavirus infection types 16 and 18.
• Other diseases: herpes, chlamydia.
• Smoking.

Clinical picture

It is almost impossible to diagnose cervical cancer even at the initial stage: the disease is not accompanied by any special symptoms.

• Bleeding, contact and non-contact, occurring involuntarily or from minor mechanical damage.
• Pain localized in the lower abdomen, intestines, lower back, as well as in the left side and thigh, lower extremities.
• Vaginal discharge - leucorrhoea. Watery in nature with admixtures of blood. At later stages with tissue impurities (the result of tumor decomposition).

Additional symptoms include urinary problems, headaches, weakness, decreased appetite, weight loss, pallor and flaking of the skin.

Classification of cervical cancer

In medicine, the international classification of pathology is used:

• “T” - initial stage (primary tumor).
• “T0” carcinoma of a pre-invasive nature.
• “T1” tumor limited to the body of the uterus, without spreading to other organs or lymph nodes.
• “T1a1” tumor, not exceeding a diameter of 7 mm and a depth of 3 mm.
• "T1a2" tumor not exceeding a diameter of 7 mm and a depth of 5 mm.
• "T1b" tumor is visible to the naked eye, limited to the cervix.
• “T1b1” tumor, up to 4 cm in diameter.
• "T1b2" tumor, more than 4 cm in diameter.
• “T2” tumor, the area of ​​​​distribution of which is outside the body of the uterus, but the lower third of the vagina or pelvic wall is not affected.
• "T2a" parametrium is not invasive.
• “T3” pathology is extended to the lower part of the vagina, the pelvic wall, there is hydronephrosis or a non-functioning kidney.
• “T3a” the area of ​​tumor spread is the lower part (third) of the vagina.
• “T3b” the tumor has affected the pelvic wall, hydronephrosis is observed or kidney function is impaired.
• “T4” the lining of the bladder and intestines enters the affected area and extends beyond the pelvis.

Lymph node information:

• “N0” - there are no signs of metastases.
• "N1" - metastasis of regional lymph nodes.

Classification of uterine cancer MBK 10:

1.1.1. C00 – D48: neoplasms;
1.1.2. C00 – C97: malignant neoplasms;
1.1.3. C51 – C58: malignant neoplasms affecting the female genital organs;
1.1.4. C53 uterine cancer;
1.1.5. C 53.0 tumor affecting the internal part;
1.1.6. C 53.1 tumor affecting the outer part;
1.1.7. With 53.8, a tumor is localized in the outer and inner parts or extends beyond the limits.
1.1.8. Since 53.9, the location of the cancer has not been determined.

Classification of cervical cancer MBC 10:

1.1.1. C00-D48 – signs of neoplasm;
1.1.2. D 00-D09 – “in situ”;
1.1.3. D 06 - carcinoma;
1.1.4. D 06.0 - tumor affecting the inside of the cervix;
1.1.5. D 06.1 - tumor affecting the outer part of the cervix;
1.1.6. D 06.7 – localization of the tumor in other parts of the cervix;
1.1.7. D 06.9 – cancer location is not determined.

The onset of the development of a cancerous tumor is often accompanied by the appearance of profuse, liquid, watery leucorrhoea, colorless or slightly yellowish, odorless and non-irritating. Subsequently, the nature of the leucorrhoea changes: it becomes purulent-serous with an unpleasant odor and causes irritation of the skin. Another symptom characteristic of cervical cancer is acyclically recurring bleeding from the vagina. They may be scanty or become bleeding. Sometimes this is the first and only symptom of the disease. Most often, bleeding at the onset of the disease is of a contact nature and appears after sexual intercourse, during straining or digital examination of the cervix. Cervical cancer in some women can also manifest itself in the form of menstrual irregularities, expressed in lengthening, intensification and frequency of menstruation. The appearance of blood from the genital organs of a woman during menopause is especially suspicious for cancer. Pain in cervical cancer generally indicates an advanced process. However, even with limited involvement of cervical cancer, pain may appear in the lower abdomen and groin areas due to the penetration of infection, which contributes to the development or exacerbation of inflammatory diseases in the pelvic tissue or appendages. In addition, cramping pain in the lower abdomen may indicate developing cancer of the cervical canal, when the tumor closes its lumen and the secretions accumulating in the uterine cavity do not have a free outflow, which leads to dull, cramping pain in the lower abdomen. With further growth of the cancerous tumor, its germination into neighboring tissues and organs and metastasis to the lymph nodes, pain appears due to compression of the nerve trunks and plexuses by tumor infiltrates or enlarged lymph nodes near the pelvic walls. Patients in such cases complain of severe pain in the lower back, lower abdomen, groin areas and lower extremities. When the tumor spreads into the prevesical tissue, frequent urination occurs with incomplete emptying of the bladder, which in turn leads to congestive cystitis. Collapse of the rectum by a tumor leads to difficulty in defecation.
The clinical picture of early cervical cancer often does not manifest itself specifically, but still existing individual signs of malignancy can be taken into account when examining the cervix in speculum and palpation examination. Cervical cancer can be characterized by small ulcerations or papillary growths that have sharp boundaries and spread to the outer surface of the cervix. Cervical cancer may appear as a nodular formation. This form of lesion, as well as lesions of cervical canal cancer, is usually accompanied by thickening and deformation of the cervix. The type of diffuse infiltration of cancer (usually adenogenic), in which the cervix retains its configuration for a long time, is especially difficult to recognize. All forms of cancer in the initial stage are characterized by the presence of focal compactions, loss of tissue elasticity and easy bleeding during injury.
In simple forms of cervical cancer, it is customary to distinguish between exophytic, endophytic and mixed forms of tumor growth. Exophytic cervical cancer is characterized by excess tissue and the presence of an easily bleeding and crumbling small-tuberous papillary tumor located on a broad base. This form of tumor growth is called a “cauliflower” tumor. With endophytic cancer, the cervix becomes dense, lumpy, intractable and can reach a large size. In this case, its cover is often ulcerated. Sometimes the ulceration takes on the character of a crater-shaped retraction with a dense bottom and raised ridge-like edges.

In ICD-10 it is classified as a malignant neoplasm. If the tumor is localized internally, its ICD code is C53.0, and externally - C53.1. For lesions of the cervix that extend beyond one or more of these locations, it is assigned code C53.8. This classification is not considered clinical and does not influence the choice of treatment method.

Statistics

Among all types of oncological pathologies of the female genital area, cervical cancer accounts for approximately 15% and ranks 3rd after malignant neoplasms of the endometrium and breast. This diagnosis annually claims the lives of more than 200 thousand women around the world. In Russia, this type of oncology ranks 5th among the causes of death in women from malignant tumors. In recent years, this oncological pathology has become most often identified in women under the age of 40 years.

Individual approach to treatment

Doctors adhere to the standards of treatment for cervical cancer (according to ICD-10 - C53), using innovative techniques of surgical interventions, radiation treatment and the most effective antitumor medications. At the same time, an individual approach to the choice of treatment method for each patient is extremely important. The use of modern diagnostic techniques, therapy, including surgical methods, immunotherapy, chemotherapy, and radiation allows oncologists to increase the survival rate of sick women.

Reasons for development

At the present time, scientists have not established the factors that provoke the development of cervical cancer (according to ICD-10 - C53). It is believed that oncological processes develop under the influence of various causes. Viral infections, chemical effects on the female body, and mechanical damage to cervical tissue are considered exogenous.

The following endogenous factors in the development of such a pathological process are identified:

• hormonal imbalance;
• genetic predisposition;
• metabolic disorders;
• decreased immunoresistance of the female body.

HPV

In 90% of cases, the trigger for this disease is HPV. The most common malignant tumors are types 16, 31, 18, 33. Typically, type 16 virus is detected in cervical cancer. Its oncogenicity increases significantly with a decrease in the body's immune response. The virus, which is involved in the mechanism of the pathology, is transmitted through sexual contact. In most cases, spontaneous recovery occurs. But if pathogenic microorganisms constantly remain in the cervix, a cancerous tumor develops.

Chronic inflammation

Significant factors provoking the development of pathology include the chronic inflammatory process. It leads to the formation of dystrophic changes in the structures of the cervical epithelium, which ultimately causes the development of severe complications. An equally important factor in the development of this type of oncology is considered to be traumatic injury during abortion, during childbirth, as well as by certain means of contraception.

Exogenous and endogenous factors

Experts include early sexual activity with different sexual partners, as well as smoking, as exogenous causes of cervical cancer (according to ICD-10 - C53). The following endogenous factors are identified:

• increased estrogen levels in the blood;
• immunodeficiency conditions in women, including the presence of HIV infection;
• long-term use of oral hormonal contraceptives.

We should also not forget about various occupational hazards, quality and lifestyle.

Symptoms of the disease

At the beginning of the process of its formation, cervical cancer (according to ICD-10 - C53) does not manifest itself with any pathological signs that can greatly disturb a woman. Only when the malignant formation begins to disintegrate do the following pronounced signs appear:

• leucorrhoea of ​​various types;
• pain, most often localized in the lower abdomen, back, and rectum;
• bleeding that occurs during local, even fairly mild trauma as a result of ruptures of small, fragile vessels of tumor formation located superficially.

An oncological tumor can metastasize through the lymphatic vessels into the walls of the vagina by germination in places where it comes into contact with the oncological tumor. The ureter is most resistant to tumor growth. Much more often, specialists detect compression of the ureters by oncological infiltrates; as a result, the normal outflow of urine is disrupted.

The growth of a tumor in the rectum indicates the neglect of the oncological process. The mucous membrane of the rectum, as a rule, does not remain mobile over the tumor for a long time. Very rarely, cervical cancer can spread to the ovaries and fallopian tubes. Metastases to distant tissues and organs in unadvanced cases are a rare occurrence.

Gynecologists are of the opinion that cervical cancer most often remains a “local process” for a long time. Metastasis, which gives clinical symptoms of a general infection, is extremely rare. The temperature in sick women remains at high levels, sometimes giving periods of remission. Cancer cachexia is observed at a late stage of cancer tumor formation and is caused by various pathological complications.

Symptoms of cervical cancer (ICD-10 - C53) should not go unnoticed.

With the development of a malignant tumor, the entire cervix or its individual sections appear dense to the touch, enlarged, and the mucous membrane is thickened. Abnormalities of the surface epithelium are often visualized in places. You can often see excess tissue in the form of whitish areas of various shapes and sizes.

What to do if you suspect cervical cancer (ICD-10 code C53)?

Diagnosis of pathology

Currently, there is a variety of diagnostic methods. The basis for diagnosing cervical oncology is considered to be a complete examination of the woman, correct collection of anamnesis of life and illness and complaints, an adequate assessment of the severity of the patient’s condition, and a gynecological examination using mirrors. The following instrumental methods for diagnosing this disease are used:

• colposcopy;
• laboratory tests for STIs;
• taking material for biopsy;
• cytological screening.

Colposcopy is considered one of the most effective methods for diagnosing both directly malignant cervical cancer (ICD-10 - C53) and precancerous conditions. The effectiveness of this method reaches 80%. Oncologists combine it with other modern technologies. Colposcopy allows you to determine the depth and nature of damage to the cervix as a whole, the boundaries and dimensions of the affected area, in order to subsequently conduct some morphological studies.

Cervicoscopy is important in diagnosing pathology. This study is performed using a hysteroscope. This technique has some contraindications:

• pregnancy;
• inflammation processes;
• bleeding.

Cervicoscopy allows you to assess the clinical condition of the cervical canal and shows an increase of up to 150 times, due to which a targeted biopsy is performed. One of the effective methods for determining the location of a tumor is a cytological examination, which is recognized throughout the world and recommended by WHO. In combination with colposcopy, the effectiveness of this study reaches 90-95%. The essence of cytology is to collect cells from the cervix and study them microscopically in order to detect pathological elements. The decisive role in diagnosis is given to histological examination of the biomaterial obtained through biopsy.

Treatment

The choice of treatment method for cervical cancer (ICD-10 code - C53) is determined individually. Therapy depends on the extent of the cancer process and the severity of concomitant pathologies. The woman's age matters the least. Traditional methods of treating the disease include:

• surgical;
• combined;
• ray.

Currently, scientists are actively studying the possibilities of chemoradiation treatment of cervical cancer (according to ICD-10, code C53) and drug therapy.

In case of severe intraepithelial cancer, diagnostic separate curettage of the uterus and conization of the cervix are performed using an electric knife, scalpel or laser beam.

Currently, in the treatment of stage 1 and 2 invasive cancer, extended extirpation of the uterus and appendages (Wertheim operation) is used. Combined treatment involves radiation therapy and surgery in different sequences.