Cervical carcinoma

Hopefully, you're coming to this page after reading about CIN. If not, I'd advise reading that first.

Definition

Carcinoma of the cervix. Essentially, the premalignant condition of CIN has now progressed to full-blown malignant disease.

Epidemiology

It has an incidence of around 9.3/100 000 but this is falling due to the screening programme. When it found, it tends to be in the early stages of the disease. The peak incidence is between the ages of 45 and 55 years-old.

Pathophysiology

As I say, if you read the CIN page, you'll get a better idea of the premalignant condition. 90% are squamous cell carcinomas, the remaining 10% are adenocarcinoma which has a worse prognosis.

Risk Factors

Essentially, the risks are the same as for CIN.

Clinical Features

In occult carcinoma, there are no clinical features because this is found on biopsy.

In clinical carcinoma, the main features are postcoital bleeding, intermenstrual/postmenstrual bleeding (depending on whether the patient has gone through the menopause) and offensive discharge. Pain does not occur early in cervical carcinoma. Later stages involve other lower abdominal organs (ureters, bladder, rectum mostly) and have symptoms in each of these areas (uraemia, haematuria, rectal bleeding, pain).

Investigations

Confirmation of the diagnosis is done by biopsy. Staging is done by a variety of methods: vaginal and rectal examination to assess the size and parametrial/rectal invasion (done under anasthetic unless the lesion is small); cystoscopy detects bladder involvement; and an intravenous pyelogram is done if ureteric obstruction is suspected. Fitness for surgery is assessed by doing FBC, U+Es and chest Xray.

Classification

Like many gynae cancers, they use the International Federation of Obstetrics and Gynaecology (FIGO) classification system. It is split into four stages:

• Stage 1 - lesions confined to cervix
  • a(i):<3x7mm (H x W); (ii):3-5x<7mm; b(i):<4cm; (ii):>4cm
• Stage 2 - invasion into vagina
  • a:upper two-thirds of vagina; b: invasion of parametrium
• Stage 3 - invasion of lower vagina/pelvic wall or causes ureteric obstruction
• Stage 4 - invasion of bladder or rectal mucosa or beyond the true pelvis

Management

This is depedent on stage.

Stage 1a(i)

This is microinvasion and can be excised by doing a cone biopsy (cutting out a small cone shape from the cervix). Haemorrhage and cervical incompetence are the main complications and hysterectomy can be a better option in older women.

Stage 1a(ii)-b(ii)

There are three options at this stage:

Radical abdominal hysterectomy which involves a

• hysterectomy (surprisingly)
• clearing pelvic lymph nodes
• removing the parametrium
• upper-third of the vagina
• and ovaries (except in young women with squamous carcinoma)

This can be performed vaginally with laparoscopic lymph node clearance.

Radical trachelectomy is a less invasive procedure and preserves a women's fertility. This removes:

• 80% cervix
• upper vagina
• pelvic lymph nodes (via laparscopy)

This is appropriate so long as the tumour is <20mm in diameter. The cervix is sutured to prevent pre-term delivery.

Radio- and chemotherapy are used on top of surgery in certain circumstances. This is if lymph node involvement is shown on biopsy or the excision margins are incomplete.

Stage 2a (or women medically unfit for surgery)

Radiotherapy and chemotherapy alone is the only option left as the tumour is too big to resect. Palliative radiotherapy can be used for bone pain.

Prognosis

Once again, this is dependent on stage.

• Stage 1a - 95%
• Stage 1b - 80%
• Stage 2 - 60%
• Stage 3-4 - 10-30%
• Lymph node involvement - 40%
• Lymph clear - 80%