Cervical Cancer

The cervix is the bottom part of the uterus and is contiguous with the body of the uterus.  It is a roughly cylindrical, fibro-muscular organ about 3 – 4 cm in length. 

Part of the cervix called the portio is visible on vaginal inspection.  There is a narrow canal extending from the vaginal aspect of the cervix to the endometrial cavity called the endocervical canal.  The vaginal opening to the endocervical canal is called the external os, and the opening to the endometrial cavity is called the internal os.  See Figure 1.

The cervix is lined by two types of cells: squamous cells on the outer aspect, and columnar, glandular cells along the inner canal. The transition between squamous cells and columnar cells is an area termed the squamo-columnar junction. Most of precancerous and cancerous changes arise in this zone.  Cervical cancer can arise from either of these cell types.  Squamous cell cancer is the commonest type of cervical cancer (75%) and arises from the squamous cells of the outer part of the cervix.  Cancer that arises from the endocervical or glandular cells is called adenocarcinoma (25%).

Symptoms

  • Abnormal bleeding, particularly bleeding after intercourse, but also bleeding between periods or post menopausal bleeding
  • Vaginal discharge
  • Pain with intercourse
  • Pelvic pain

Spread

  • Local invasion to surrounding structures, including the cervix and the parametrium – the tissue adjacent to the cervix.
  • Lymph nodes, particularly the lymph nodes of the pelvis
  • Adenocarcinomas have a slight propensity to spread to the ovaries
  • To distant sites, via the bloodstream, eg lung.
  • In the peritoneal cavity

Risk Factors

  • HPV infection
  • No history of HPV vaccination
  • Deficient cervical cancer screening
  • Cigarette smoking
  • Immunosuppression
  • Multiple sexual partners and early age of first intercourse
  • Intra uterine exposure to diethylstilbestrol (DES)

Diagnosis

  • Clinical history and physical exam
  • Cervical screening for HPV and abnormal cells
  • Colposcopy (light, magnification and some special dyes to highlight abnormal areas
  • The diagnosis must always be confirmed with histological confirmation of a biopsy.  For early cervical cancer, sometimes a cone biopsy of the cervix will be required.

Investigations

  • Routine pre-operative blood tests including FBC and ELFT
  • PET – CT scan
  • MRI

Treatment – Early cervical cancer

Options for surgery will depend on the reproductive requirements and age of the patient and the extent, type and profile of the tumour.  Options include:

  • Cone biopsy alone may be adequate treatment for early cervical cancer
  • Simple hysterectomy
  • Simple or radical trachelectomy (removal of the cervix) + removal of pelvic lymph nodes, may be feasible for some women who wish to retain reproductive capacity.
  • Radical hysterectomy and removal of pelvic lymph nodes. This can usually be done laparoscopically or robotically, but is often done as an open operation
  • Occasionally chemo-radiation will be required in addition to surgery

Treatment – Advanced cervical cancer

  • Chemo-radiation
  • +/- completion hysterectomy

Follow up

Follow up will consist of history and physical examination.  For patients who have not had radiation, cytology screening + HPV may be undertaken annually.  Cytology screening is not performed after radiation.  The interval of follow up is as follows

  • 3 monthly for 2 years
  • Then 6 monthly for 3 years
  • Annually thereafter.

Figure 1.  Female Reproductive Organs (Diagram courtesy of NCI)