Cervical Cancer

Key Features

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

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 appears to be a cofactor

• 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

• Often asymptomatic in early disease

• Most common signs

  • Irregular or heaving bleeding

  • Postcoital spotting

• 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