Cervical carcinoma

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Cervical carcinoma is the third most common gynecologic malignancy and the eighth most common malignancy among women in the USA. The mean age for developing cervical cancer is about 50 years, though it can affect women as young as 20. The progression of cervical dysplasia to invasive carcinoma is not inevitable. Cervical dysplasia (CIN) is not lethal, and is curable with ablation or local excision, allowing full regeneration of the cervix. This can be done with no detriment to appearance or reproductive health. Untreated, the time of progression to invasive cancer of the cervix is approximately 10 years. Though the quality of data is questionable, it is estimated that about 10% of dysplasia progresses to carcinoma.

If left untreated, cervical dysplasia first invades locally into the parametrium, uterosacral ligament, or upper vagina. Later, local invasion happens in the rectum, bladder, lower vagina, and vulva. Early, dysplasia can metastasize through the lymphatic system to pelvic lymph nodes, while later metasteses take a hematogenous route, affecting the lung, bone, or liver among others.

Cervical cancer is essentially a preventable sexually transmitted disease. Risk factors for cervical dysplasia (and consequently carcinoma) are those factors that also increase risk for HPV, such as a young age at first intercourse, multiple partners, or other STIs as a marker of sexual activity. Anything that creates an immune deficit also increases risk, such as smoking, HIV, transplant patients, or steroid use. The other major risk factor is a lack of pap smear screening, such as in the elderly, new immigrants, and healthy but health-negligent patients.

The most common type of cervical carcinoma is squamous cell carcinoma (75%), which can be either invasive or micrinvasive. Other types of cervical carcinoma include adenocarcinoma (10%), adenosquamous carcinoma (10%), and neuroendocrine carcinoma (5%; aka small cell carcinoma).

Presentation

Cervical carcinoma would present symptoms typical of neoplasms. Primary symptoms include post-coital bleeding and mucousy discharge, though locally advanced disease that has been ignored will invade onto the bladder or the rectum causing difficulty, discomfort or incontinence. Secondary symptoms include leg swelling, hip pain, flank pain, and central back pain. As with typical neoplamsms, tertiary symptoms include appetite loss, energy loss, or weight loss.

Investigation

On physical examination, the appearance of a normal cervix is pale, homogeneous and pink, with a small ring of more fleshy tissue at the os. A dysplastic cervix looks "normal" to the naked eye. Cervical cancer shows a lesion on the cervix that is usually red, white, raised, exudative, or odoriferous.

When there is a weird-looking cervix, a differential diagnosis is:

A pelvic examination would check for the diameter, shape, and consistency of the cervix, which is normally <3.5 cm, symmetrical, consistency of the "tip of the nose"). Also, one checks for nodularity and thickening of the cardinal or uterosacral ligaments (via a pelvic rectal examination).

Management

Radiation treatment can be used alone for treatment when lesions are larger than 4cm, and has a cure rate comparable to surgery. For larger lesions where there are metastases in lymph nodes, surgery alone does not remove all the disease, and so radiation treatment may be desirable. Also, radiation treatment avoids the risks of major surgery.

In contrast, a surgical intervention can be used alone to treat cervical cancer. This is generally desirable for lesions less than 4 cm. Surgical intervention avoids the 10% radiation complication of permanent scarring of the bowel, bladder, and rectum, which could cause chronic diarrhea, abdominal cramping, and fecal incontinence. It also prevents unwanted ovarian ablation in younger patients.

Patients with cervical carcinoma die specifically from renal failure or vaginal hemorrhage, and non-specifically from pulmonary embolism, sepsis, progressive inanition, or organ failure from distant metastases.

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