Carcinoma of the Cervix

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.