Carcinoma of the Cervix

Incidence:

Despite a screening program aimed at the prevention of cervical cancer, the incidence is continuing to rise.

Aetiology:

Carcinoma of the cervix is more frequently seen in developing countries and its incidence is higher in lower socioeconomic groups. Cancer of the cervix is essentially a sexually transmitted disease. A number of factor may predispose to cervical cancer. Presently the wart virus has the strongest association. Smoking may also have a role.

Staging:

Cancer of the cervix is staged clinically. An examination under anesthesia is performed, combined with cervical biopsy, hysteroscopy and sampling, and cystoscopy.

Stage I: Microinvasive disease. Lesions with a depth of invasion through the basement membrane of less than 5mm and with a horizontal spread of less than 7mm. All other cases confined to the cervix.

Stage II: The carcinoma extends beyond the cervix but has not extended onto the pelvic sidewall. The carcinoma involves the vagina but not as far as the lower one-third.

Stage III: Carcinoma extends to the pelvic side wall. The lower one-third of the vagina may be involved. All cases with a hydronephyrosis or a non-functioning kidney, unless they are known to be due to another cause.

Stage IV: Carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Up to 90% cervical cancers are squamous cell.

Pathology:

Up to 90% of cervical cancers are squamous cell tumours originating in the transformation zone. Adenocarcinomas account for the remainder of cases. Cervical cancer spreads by direct extension or via the lymphatics.

Clinical Features:

Patients may present with vaginal bleeding, particularly after intercourse. There may be vaginal discharge. Early lesions may be symptomless and are detected by screening.

Investigations:

Once the diagnosis is confirmed histologically and examination under anaesthesia is necessary for staging . Chest X-ray, IVP and routine biochemical and haematological investigations are usually required. CT scan is helpful in advanced and recurrent disease.

Management:

Hysterectomy is usually advised for early disease. Cone biopsy may be considered in a young woman desiring children. Stage I or II Cervical cancer can be treated by either radiotherapy or radical Wertheim’s hysterectomy (removal of the uterus, fallopian tubes, upper one- third of the vagina, parametrium and pelvic lymph nodes). Wertheim’ hysterectomy is the treatment of choice in younger women who wish to retain ovarian function and avoid vaginal stenois and gastrointestinal side effects which may be caused by radiotherapy. The results of radiotherapy and radical surgery in early stage disease are similar, both having 5 year survival rates in excess of 80%. The finding of tumour in lymph nodes will halve this survival rate. Radiotherapy is commonly used method of treatment.

Carcinoma of the Vagina:

Is rare and tends to occur mainly in the 6th and 7th decades. Presenting symptoms are vaginal bleeding or a purulent discharge. Treatment of the condition is determined by histology, staging and the health of the patient. Surgery, radiotherapy and a combination of both have been used.