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Key Features

Essentials of Diagnosis

  • Early on, cervical cancer usually does not cause symptoms or signs

  • Increased risk in women with infections with HIV and high-risk HPV types as well as in smokers

  • Watery vaginal discharge, intermittent spotting, or postcoital bleeding may be signs of a lesion

  • Cervical lesion may be visible on inspection as a tumor or ulceration

General Considerations

  • Can be considered a sexually transmitted disease

  • Both squamous cell and adenocarcinoma of cervix are secondary to infection with the human papillomavirus (HPV), especially types 16 and 18

  • Women infected with HIV are at an increased risk for high-risk HPV infection and cervical intraepithelial neoplasia (CIN)

  • Smoking and possible dietary factors, such as decreased circulating vitamin A, appear to be cofactors

  • Squamous cell carcinoma (SCC) appears first in the intraepithelial layers (the preinvasive stage, or carcinoma in situ)

Demographics

  • Preinvasive cancer (CIN III) is a common diagnosis in women 25–40 years of age

  • Incidence of cervical cancers

    • SCC accounts for approximately 80% of cervical cancers

    • Adenocarcinoma accounts for 15%

    • Adenosquamous carcinoma, for 3–5%

    • Neuroendocrine or small cell carcinomas are rare

Clinical Findings

Symptoms and Signs

  • Most common signs

    • Metrorrhagia

    • Postcoital spotting

    • Cervical ulceration

  • Bladder and rectal dysfunction or fistulas and pain are late symptoms

Differential Diagnosis

  • Cervical intraepithelial neoplasia

  • Cervical ectropion

  • Cervical ectopy (columnar epithelium on face of os, common in adolescence)

  • Genital warts (condyloma acuminata)

  • Cervical polyp

  • Cervicitis

  • Nabothian cyst

  • Granuloma inguinale

Diagnosis

Laboratory Tests

  • Positive Papanicolaou smear

Imaging Studies

  • Further examinations, such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and lymphangiography are valuable for treatment planning

Diagnostic Procedures

  • Laparoscopy and fine-needle aspiration are also valuable for treatment planning

  • 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

  • "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 eTable 18–2

eTable 18–2.FIGO1 staging of cancer of the cervix.

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