Introduction

Essentials of Diagnosis

 
• Abnormal uterine bleeding and vaginal discharge.  
• Cervical lesion may be visible on inspection as a tumor or ulceration.  
• Vaginal cytology usually positive; must be confirmed by biopsy.

General Considerations

Cancer appears first in the intraepithelial layers (the preinvasive stage, or carcinoma in situ). Preinvasive cancer (CIN III) is a common diagnosis in women 25-40 years of age and is etiologically related to infection with the human papillomavirus. Two to 10 years are required for carcinoma to penetrate the basement membrane and invade the tissues. After invasion, death usually occurs within 3-5 years in untreated or unresponsive patients.

Clinical Findings

A. Symptoms and Signs
The most common signs are metrorrhagia, postcoital spotting, and cervical ulceration. Bloody or purulent, odorous, nonpruritic discharge may appear after invasion. Bladder and rectal dysfunction or fistulas and pain are late symptoms.

B. Cervical Biopsy and Endocervical Curettage, or Conization
These procedures are necessary steps after a positive Papanicolaou smear to determine the extent and depth of invasion of the cancer. Even if the smear is positive, treatment is never justified until definitive diagnosis has been established through biopsy.

C. “Staging,” or Estimate of Gross Spread of Cancer of the Cervix
The depth of penetration of the malignant cells beyond the basement membrane is a reliable clinical guide to the extent of primary cancer within the cervix and the likelihood of metastases. It is customary to stage cancers of the cervix under anesthesia as shown in Table 17-3. Further assessment may be carried out by abdominal and pelvic CT scanning or MRI.

Complications

Metastases to regional lymph nodes occur with increasing frequency from stage I to stage IV. Paracervical extension occurs in all directions from the cervix. The ureters are often obstructed lateral to the cervix, causing hydroureter and hydronephrosis and consequently impaired kidney function. Almost two-thirds of patients with untreated carcinoma of the cervix die of uremia when ureteral obstruction is bilateral. Pain in the back, in the distribution of the lumbosacral plexus, is often indicative of neurologic involvement. Gross edema of the legs may be indicative of vascular and lymphatic stasis due to tumor.

Vaginal fistulas to the rectum and urinary tract are severe late complications. Hemorrhage is the cause of death in 10-20% of patients with extensive invasive carcinoma.

Treatment

A. Emergency Measures
Vaginal hemorrhage originates from gross ulceration and cavitation in stage II-IV cervical carcinoma. Ligation and suturing of the cervix are usually not feasible, but ligation of the uterine or hypogastric arteries may be lifesaving when other measures fail. Styptics such as Monsel’s solution or acetone are effective, although delayed sloughing may result in further bleeding. Wet vaginal packing is helpful. Emergency irradiation usually controls bleeding.

B. Specific Measures
1. Carcinoma in situ (stage 0)

In women who have completed childbearing, total hysterectomy is the treatment of choice. In women who wish to retain the uterus, acceptable alternatives include cervical conization or ablation of the lesion with cryotherapy or laser. Close follow-up with Papanicolaou smears every 3 months for 1 year and every 6 months for another year is necessary after cryotherapy or laser.

2. Invasive carcinoma
Microinvasive carcinoma (stage IA) is treated with simple, extrafascial hysterectomy. Stage IB and stage IIA cancers may be treated with either radical hysterectomy or radiation therapy. Stage IIB and stage III and IV cancers are treated with radiation therapy plus concurrent cisplatin-based chemotherapy. Because radical surgery results in fewer long-term complications than irradiation and may allow preservation of ovarian function, it may be the preferred mode of therapy in younger women without contraindications to major surgery.

Prognosis

The overall 5-year relative survival rate for carcinoma of the cervix is 68% in white women and 55% in black women in the United States. Survival rates are inversely proportionate to the stage of cancer: stage 0, 99-100%; stage IA, > 95%; stage IB-IIA, 80-90%; stage IIB, 65%; stage III, 40%; and stage IV, < 20%.

Preferences:
ACOG Practice Bulletin. Diagnosis and treatment of cervical carcinomas, number 35, May 2002. Obstet Gynecol 2002;99:855.
Lonky NM: Reducing death from cervical cancer: examining the prevention paradigms. Obstet Gynecol Clin North Am 2002; 29:599.