Cervical Cancer

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 human papillomavirus (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 infection

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

• Women infected with HIV and with other forms of immunosuppression 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 25–35 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 sequelae

Differential Diagnosis

• Cervical intraepithelial neoplasia

• Cervical ectropion

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

• Genital warts (condylomata 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, definitive diagnosis must be established through biopsy before additional treatment is given

• "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