Although detection of preinvasive disease has increased, the incidence of invasive cervical cancer has dramatically decreased in the United States due to widespread screening by cervical cytology (Papanicolaou smears). However, cervical cancer remains the leading cause of cancer related deaths among women in developing countries (National Cervical Cancer Coalition Web site, http://www.nccc-online.org/). In the United States, approximately 14,000 new cases and 3,900 deaths occur annually. The goal of evaluating abnormal Papanicolaou smears with colposcopy-guided biopsies for appropriate patients is to diagnose and treat disease of the cervix in the preinvasive state [Stoler MH, Schiffman M; Atypical squamous cells of undetermined significance-low-grade squamous introepithelial lesion triage study (ALTS) group. Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study. JAMA. 2001;285:1500–1505]. Risk factors for cervical cancer include a history of sexually transmitted diseases, HIV infection, multiple sexual partners, early age of first intercourse, lower socioeconomic status, smoking, and human papilloma virus (HPV) infection. Because the majority of squamous cell cancers of the cervix contain high-risk HPV DNA, an HPV vaccine (Gardasil) has been developed and should be administered to females between the ages of 9 and 26 years, although the impact in eradicating cancer will take several decades.
- Presentation and clinical features.Patients may be asymptomatic or present with irregular or postcoital vaginal bleeding or a foul-smelling or watery discharge. Advanced stages may present with leg pain (sciatic nerve involvement), flank pain (ureteral obstruction), renal failure, or rectal bleeding.
- Diagnosis is by biopsyvia speculum examination of a visible or palpable lesion. Staging remains clinical and is based on a thorough bimanual and rectovaginal examination, cystoscopy, and proctoscopy. Appropriate adjuvant radiographs include chest x-ray, intravenous pyelogram, and barium enema. Positron emission tomography (PET) scan is a useful diagnostic modality for assessing distant disease activity. Stage, which is never changed by intraoperative findings, remains the most important prognostic factor, with an 88% 5-year survival for stage I disease and a 38% 5-year survival for stage III disease (Table 36-2).
- Treatment depends on stage and lymph node status.
- Microinvasive disease (stage IA1, depth of invasion <3 mm, diameter <7 mm, negative lymph vascular space invasion) can be treated with cervical conization alone or with extrafascial hysterectomy. Reproductive age patients desiring fertility (preferably with a cervical lesion <2 cm) may be offered a radical vaginal or abdominal trachelectomy with a lymph node dissection and cerclage placement. Lesions with greater depth of invasion, multifocal disease, or upper-vaginal involvement (stages IA2 to IIA) require a radical hysterectomy (removing the parametria and upper vagina) and a complete pelvic and sometimes para-aortic lymphadenectomy. Although radical hysterectomy is only appropriate for a subset of patients, radiotherapy is applicable to any patient with early-stage cervical cancer. The most common complication after radical hysterectomy is bladder dysfunction. Ureteral fistulas, infection, hemorrhage, and lymphocyst formation are less common.TABLE 36-2 Cervical Cancer Staging
TNM FIGO Definition T1 I Cervical Cancer confined to the uterus (extension to the corpus should be disregarded) T1a IA Preclinical invasive carcinoma, diagnosed by microscopy only T1a1 IA1 Microscopic stromal invasion no greater than 3 mm in depth and no wider than 7 mm T1a2 IA2 Tumor with stromal invasion between 3 and 5 mm in depth and no wider than 7 mm T1b IB Tumor confined to the cervix but larger than IA2 T1b1 IB1 Clinical lesions no greater than 4 cm in size T1b2 IB2 Clinical lesions greater than 4 cm in size T2 II Tumor invades beyond the cervix but not to the pelvic side wall or the lower third of the vagina T2a IIA Tumor without parametrial involvement T2b IIB Tumor with parametrial involvement T3 III Tumor extends to the pelvic side wall and/or involves the lower one third of the vagina and/or causes hydronephrosis or nonfunctioning kidney T3a IIIA Tumor invades lower third of the vagina with no extension to the pelvic side wall T3b IIIB Tumor extends to the pelvic side wall and/or causes hydronephrosis or a nonfunctioning kidney T4 IVA Tumor invades mucosa of the bladder or rectum and/or extends beyond the true pelvis M1 IVB Distant metastasis FIGO, International Federation of Gynecology and Obstetrics; TNM, tumor, node, metastasis.
- Radiotherapy is the appropriate treatment for advanced-stage disease. Combined surgery and radiotherapy for advanced-staged disease does not improve survival but dramatically increases the rate of treatment-related complications such as ureteral and bowel obstruction, strictures, and fistula formation. The nature of radiation is based on stage, lesion size, and lymph node status. Both external-beam (teletherapy) and intracavitary (brachytherapy) radiation are used in various combinations. Complications from radiotherapy depend on dose, volume, and tissue tolerance. Acute complications include transient nausea and diarrhea. Early complications including skin ulceration, cystitis, and proctitis occur within the first 6 months after treatment and. Late complications (>6 months after treatment) may include bowel obstruction secondary to strictures, fistulas, hemorrhagic cystitis, and chronic proctosigmoiditis. Recent studies indicate that adding cisplatin to radiation decreases the risk of dying from cervical cancer by 30% to 50% over radiation alone (Lancet 2001;358:781).
- Patients with pelvic recurrence after radical hysterectomy are often treated with radiation. Patients with isolated central recurrence may be candidates for pelvic exenteration. Five-year survival ranges from 20% to 62% after exenteration, with an operative mortality of 10%. Response to chemotherapy alone in recurrent cervical cancer is poor.
- Uncontrolled vaginal bleeding from cervical cancer occasionally is encountered in the emergency department. In most cases, bleeding can be stabilized with tight vaginal packing, after which a transurethral Foley catheter should be placed. Acetone-soaked gauze is the most effective packing for vessel sclerosis and control of hemorrhage from necrotic tumor. Emergent radiotherapy or embolization may be necessary.