Cancer of the cervix uteri. Cervical cancer is second only to breast cancer as the most common female malignancy in both incidence and mortality, and results in approximately 275 000 deaths annually. More than 85% of new cases are diagnosed in economically disadvantaged people.
The cervix is the lower aspect of the uterus. It is roughly cylindrical in shape, projects through the superior-anterior vaginal wall, and communicates with the vagina through the endocervical canal,
which terminates in the external os located at the top of the vagina.
Cancer of the cervix may originate from the mucosa of the surface of the cervix or from within the canal. Carcinoma of the uterine cervix grows locally and may extend in continuity to the uterus
and paracervical tissues, and pelvic organs.
Cervical cancer may spread to regional lymph nodes, and only later metastasize hematogenously to distant structures. The cervix is drained into the following first echelon nodal stations: parametrial, internal iliac (obturator–hypogastric), external iliac, and presacral, followed by drainage to the common iliac nodes.
From the common iliac nodes, lymph drainage goes to the paraaortic nodes. The most common sites of distant spread include the para-aortic, mediastinal and supraclavicular nodes, the lungs, liver,
FIGO staging is based on clinical examination. The FIGO staging guidelines were most recently updated in 2009 (Table 1) . Stage 0 is no longer included in the FIGO 2009 staging.
A thorough pelvic examination is mandatory to provide information for FIGO staging, and this rarely requires anesthesia. When there is doubt as to which stage a particular cancer should be allocated, the earlier stage is mandatory.
The following examinations are permitted for the determination of FIGO staging, as indicated by presenting characteristics (see sections below): palpation, inspection, colposcopy, endocervical
curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous pyelography, and X-ray examination of the lungs and skeleton. Blood tests should include full blood count, renal and liver functions.
Syphilis and HIV serology need to be considered, based on discussion with the patient about risk factors.
The diagnosis of both Stage IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone biopsy, which must include the entire lesion. The depth of invasion should not be >5mm taken from the base of the epithelium, either surface or glandular, from which it originates. The second dimension, the horizontal spread, must not exceed 7mm. Vascular space involvement, either venous or lymphatic, should not alter the staging, but should be specifically recorded because it may affect treatment decisions. Macroscopically obvious lesions, and those with larger dimensions, should be staged as IB. It is impossible to clinically determine if a cancer of the cervix has extended to the corpus. Extension to the corpus should therefore be disregarded for staging purposes.
The diagnosis of Stage IA1 or IA2 disease can only be made on the basis of a cone biopsy with negative margins, or on a trachelectomy or hysterectomy specimen. If the margins of the cone biopsy are positive for cervical intraepithelial neoplasia (CIN) III or invasive cancer, a second cone biopsy should be performed or the patient treated as for Stage IB1 disease .
Visible lesions require a biopsy to confirm a diagnosis of cervical carcinoma. A patient with a growth apparently fixed to the pelvic wall by a short and indurated, but not nodular, parametrium should be allotted to Stage IIB. Stage III should be defined for cases where the parametrium is nodular to the pelvic wall or if the growth itself extends to the pelvic wall. The presence of hydronephrosis or nonfunctioning kidney(s) resulting from obstruction of the ureter(s) by cancer also permits a case to be allotted to Stage III. In cases of grossly invasive disease, a chest X-ray, and evaluation of hydronephrosis (with renal ultrasound, intravenous pyelography, CT, or MRI) are mandatory. The bladder and rectum are evaluated by cystoscopy and sigmoidoscopy only if the patient is clinically symptomatic. Suspected bladder or rectal involvement should be confirmed by biopsy and histologic evidence.
The presence of bullous edema, as such, should not permit a case to be allotted to Stage IV. Imaging evaluation may be of additional benefit to clinical examination in practice areas where resources allow. Imaging may allow for identification of additional prognostic factors and help direct selection of therapy. MRI provides the best radiologic assessment of primary tumors greater than 10mm, but is not mandatory. Level of Evidence B
I The carcinoma is strictly confined to the cervix (extension to the uterine corpus should be
IA Invasive cancer identified only microscopically. (All gross lesions even with superficial
invasion are Stage IB cancers.)
Invasion is limited to measured stromal invasion with a maximum depth of 5mmb and no
wider than 7mm.
IA1 Measured invasion of stroma ≤3mm in depth and ≤7mm width.
IA2 Measured invasion of stroma >3mm and <5mm in depth and ≤7mm width.
IB Clinical lesions confined to the cervix, or preclinical lesions greater than stage IA.
IB1: Clinical lesions no greater than 4 cm in size.
IB2: Clinical lesions >4 cm in size.
II The carcinoma extends beyond the uterus, but has not extended onto the pelvic wall or to the
lower third of vagina.
IIA Involvement of up to the upper 2/3 of the vagina. No obvious parametrial involvement.
IIA1: Clinically visible lesion ≤4cm
IIA2: Clinically visible lesion >4cm
IIB Obvious parametrial involvement but not onto the pelvic sidewall.
III The carcinoma has extended onto the pelvic sidewall. On rectal examination, there is no
cancer-free space between the tumor and pelvic sidewall. The tumor involves the lower third
of the vagina. All cases of hydronephrosis or non-functioning kidney should be included
unless they are known to be due to other causes.
IIIA Involvement of the lower vagina but no extension onto pelvic sidewall.
IIIB Extension onto the pelvic sidewall, or hydronephrosis/non-functioning kidney.
IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of
the bladder and/or rectum.
IVA Spread to adjacent pelvic organs.
IVB Spread to distant organs.
a Adapted from FIGO Committee on Gynecologic Oncology .
b The depth of invasion should not be more than 5mm taken from the base of the epithelium, either
surface of glandular, from which it originates. Vascular space invasion should not alter the staging.
CT and/or MRI and/or positron emission tomography (PET) may provide information on nodal status or systemic spread, but are not mandatory. Compared with CT and MRI, PET-CT is a more accurate imaging method for detecting nodal metastases that are greater than 10mm [5,9–12]. Isolated and unexpected areas of PET enhancement should be further investigated with tissue diagnosis, if possible, to confirm or exclude the presence of distant metastatic disease .
Compared with radiologic evaluation, surgical node dissection is more accurate for assessment of para-aortic nodal disease. In patients with advanced disease, laparoscopic staging of paraaortic lymph nodes may be considered to allow treatment according to extent of disease. No impact on survival has been demonstrated; however, surgical exclusion of para-aortic lymph node involvement portends a better prognosis than radiographic exclusion alone. Level of Evidence B In a surgicopathologic staging study, positive para-aortic nodes were identified in 21% of Stage IIB and 31% of Stage III tumors.