Case 27: Cervical cancer

 

Case 27: Cervical cancer

CASE 27: CERVICAL CANCER

History

A 28-year-old woman was referred to the colposcopy clinic because of intermenstrual and

postcoital bleeding. On examination a macroscopically visible lesion was present and on colposcopy features of malignancy were seen. Subsequent biopsy showed invasive squamous

carcinoma of the cervix.

The woman was informed of the diagnosis and as a result went on to undergo an examination

under anaesthetic, cystoscopy and proctoscopy for staging. The mass was found to be 3 cm in

size and there was no palpable extension into the uterus, vagina or parametrial tissues. The

cystoscopy and proctoscopy were both normal.

INVESTIGATIONS

Normal range

Haemoglobin 12 g/dL 11.7–15.7 g/dL

White cell count 8×109/L 3.5–11×109/L

Platelets 344×109/L 150–440×109/L

Sodium 138 mmol/L 135–145 mmol/L

Potassium 3.5 mmol/L 3.5–5 mmol/L

Urea 3.6 mmol/L 2.5–6.7 mmol/L

Creatinine 76 mmol/L 70–120 mmol/L

Chest X-ray report: normal heart and lung fields. No abnormalities detected.

Renal tract ultrasound report: normal sized kidneys. Both ureters are of normal caliber

with no evidence of obstruction.

She has had one child but had been hoping to have at least one more and is devastated

by the diagnosis.

Question

• What are the possible treatment options and their potential complications?100 Cases in Obstetrics and Gynaecology

66

ANSWER 27

Cervical cancer may be treated surgically or by radiotherapy. Staging is performed clinically

at examination under anaesthetic as described.

! Cervical cancer staging

Staging Prognosis

(5-year survival)

I

Confined to cervix

IA1 Microscopic lesion. Invasion <3 mm depth

and lateral spread <7 mm

95%

IA2 Microscopic lesion. Invasion >3 mm and

<5 mm with lateral spread <7 mm

IB1 Clinically visible lesion <4 cm in greatest

dimension

80%

IB2 Clinically visible lesion >4 cm in greatest

dimension

II

Invades beyond

uterus but not to

pelvic wall or lower

1/3 of vagina

IIA1 Involves upper 2/3 of vagina, without

parametrial invasion, <4 cm in greatest

dimension

60%

IIA2 Involves upper 2/3 of vagina, without

parametrial invasion, >4 cm in greatest

dimension

IIB With parametrial involvement

III

Extends to pelvic wall

and/or involves lower

1/3 of vagina and/or

causes

hydronephrosis or

non-functioning

kidney

IIIA Involves lower 1/3 of vagina with no

extension to the pelvic wall

35%

IIIB Extension to pelvic wall and/or

hydronephrosis or non-functioning kidney

IV

Extension beyond

true pelvis or involves

mucosa of bladder or

rectum

IVA Spread of the growth to adjacent organs 15%

IVB Spread to distant organs

Radical hysterectomy

Up to stage IB women may be treated with radical hysterectomy (also known as Wertheim’s

hysterectomy). This involves removal of the uterus, cervix, pelvic lymph nodes and parametrial tissue as well as the upper third of the vagina. Complications involve bleeding and infection. Ureteric damage may occur and blood vessel injury is not uncommon. Postoperative

complications include infections of the chest, wound or urinary tract as well as venous

thromboembolism and later-onset lymphoedema from interruption of lymphatic drainage

from the lower limbs.Case 27: Cervical cancer

67

The advantage of this treatment is that it preserves ovarian function, important for wellbeing

and prevention of osteoporosis. It also avoids the complications of radiotherapy outlined below.

Trachelectomy

This involves removal of the cervix, lymph nodes and parametrial tissue with conservation of the ovaries and uterine body with insertion of a suture (cerclage) at the base of

the uterus. It is used selectively for women with early stage disease who wish to preserve

their fertility.

Radiotherapy

Disease beyond stage IB, and postmenopausal women should be treated with radiotherapy

which is effective but is associated with long-term effects of bowel stenosis, cystitis and vaginal stenosis. It also generally renders women menopausal due to radiation to the ovaries.

KEY POINTS

• Cervical carcinoma should be considered in any woman with intermenstrual or

postcoital bleeding.

• Disease staging is clinical, under anaesthetic.

• Cervical carcinoma may be treated surgically or by radiotherapy, depending on

the stage of disease.