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ESSENTIALS OF DIAGNOSIS

  • Increased risk in women who smoke and those with HIV or high-risk HPV types.

  • Gross lesions should be evaluated by colposcopically directed biopsies and not cytology alone. Cervical lesion may be visible on inspection as a tumor or ulceration but a diagnosis of cervical cancer requires a tissue diagnosis.

GENERAL CONSIDERATIONS

Cervical cancer is the third most common cancer in the world and the leading cause of cancer death among women in developing countries. It is considered a sexually transmitted disease as both squamous cell and adenocarcinoma of the cervix are secondary to infection with HPV, primarily types 16 and 18. Women infected with HIV are at an increased risk for high-risk HPV infection and CIN. Smoking and possibly dietary factors such as decreased circulating vitamin A appear to be cofactors. Squamous cell carcinoma (SCC) accounts for approximately 80% of cervical cancers, while adenocarcinoma accounts for 15% and adenosquamous carcinoma for 3–5%; neuroendocrine or small cell carcinomas are rare.

SCC 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. Two to 10 years are required for carcinoma to penetrate the basement membrane and become invasive. While cervical cancer mortality has declined steadily in the United States due to high rates of screening and improved treatment, the rate of decline has slowed in recent years. In general, black women experienced much higher incidence and mortality than white women. The 5-year survival rate ranges from 63% for stage II cervical cancer to less than 20% for stage IV.

CLINICAL FINDINGS

A. Symptoms and Signs

The most common signs are metrorrhagia, postcoital spotting, and cervical ulceration. 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 with additional surgery or radiation is never justified until definitive diagnosis has been established through biopsy.

C. “Staging” or Estimate of Gross Spread of Cancer of the Cervix

Staging of invasive cervical cancer is achieved by clinical evaluation, usually conducted under anesthesia as shown in eTable 18–2. Further examinations, such as ultrasonography, CT, MRI, lymphangiography, laparoscopy, and fine-needle aspiration, are valuable for treatment planning.

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

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