Synonyms: cervical cancer, cancer of the (uterine) cervix, carcinoma of the (uterine) cervix

Worldwide, cervical carcinoma is the second most common female malignancy, causing approximately 500,000 new cases each year. It is responsible for 274,000 deaths and is the third most common cause of female mortality. In Europe the crude mortality rate is 5.9/100,000 women/year but the mortality rate is 10 times higher in developing countries.

It has been proven that the cervical screening programme is associated with improved rate of cure of cervical cancer.

Incidence
The age-standardised (European) annual incidence rate of cervical cancer is 13.2 per 100,000 females. Age-standardised mortality rate for the UK was 2.9 per 100,000 in 2008.

Risk factors
• Heterosexual women.
• Infection with human papilloma virus (HPV), predominantly types 16 and 18 (infection present in around 95% of cases).
• Women with multiple sexual partners, or partners of promiscuous males.
• Smoking.
• Lower social class.
• Immunosuppression ,eg HIV, and post-transplant.
• There is a slight increase in risk with use of a combined oral contraceptive.
• Non-attendance at the cervical screening programme.

Pathogenesis
Three types of primary tumour are generally seen:
• Bulky, ectocervical tumour, which fills the upper vagina.
• Invasive, bulky tumour that can enlarge to a size where it fills the lower pelvis.
• Destructive, invasive tumour that erodes tissue, causing ulceration and excavation with infected, necrotic cavities.

Histopathology
70% are squamous carcinomas, 15% mixed pattern, and 15% adenocarcinoma, all three of which cause both pre-invasive and invasive disease.

Cervical intraepithelial neoplasia (CIN) – disease confined to the epithelium

CIN I : disease confined to the lower third of the epithelium.
CIN II: disease confined to the lower and middle thirds of the epithelium.
CIN III: affecting the full thickness of the epidermis.

Invasive carcinoma
This breaches the epithelial basement membrane at any point.
• If the deepest invasive element is <5 mm from the surface of the epithelium then it is defined as micro-invasive carcinoma.
• If it extends beyond 5 mm or is wider than 7 mm then it is defined as invasive carcinoma and formal staging is required.

Presentation
Many cases are detected by screening. However, symptoms require full pelvic examination including use of a speculum.

The first symptoms of established cervical carcinoma are:
• Vaginal discharge; this varies greatly in amount and can be intermittent or continuous.
• Bleeding; this can be spontaneous but may occur after sex, micturition or defecation, in the early stages. Patients may ignore this if it is scanty and ascribe it to normal menstrual dysfunction. Occasionally, severe vaginal bleeding may necessitate emergency hospital admission.
• Vaginal discomfort/urinary symptoms.

Late symptoms
Painless haematuria.
Chronic urinary frequency.
Painless fresh rectal bleeding.
Altered bowel habit.
Leg oedema, pain and hydronephrosis leading to renal failure are ominous, late signs indicating pelvic wall involvement.

With more advanced disease, patients develop pelvic discomfort or pain that is poorly localised and described as dull or boring in the suprapubic or sacral regions. It is similar to menstrual discomfort, can be persistent or intermittent and may be confused with arthropathy.

NB: symptoms may prompt the patient to seek a cervical smear. A smear test is useful for detecting precancerous lesions, but not carcinoma.
If there is any degree of suspicion of cervical carcinoma then examine carefully and consider urgent referral for further assessment.

Signs
In early-stage cervical cancer, examination can be relatively normal.
• There may be white or red patches on the cervix. As the disease progresses, it can lead to an abnormal appearance of the cervix and vagina, due to erosion, ulcer or tumour.
• Rectal examination may reveal a mass or bleeding due to erosion.
• Bimanual palpation may reveal pelvic bulkiness/masses due to pelvic spread.
• Leg oedema may develop due to lymphatic or vascular obstruction.
• Hepatomegaly may develop in the case of liver metastases.
• Pulmonary metastases are normally only detected if they cause pleural effusion or bronchial obstruction.

Differential diagnosis
Cervicitis.
Dysfunctional uterine bleeding.
Cervical erosion (ectropion).
Pelvic inflammatory disease.
Endometrial carcinoma.
Side-effects of intrauterine contraceptive device (IUCD) use.
Endometrial hyperplasia.
Fibroids.
Atrophic vaginitis.

INVESTIGATIONS,STAGING and MANAGEMENT( SURGICAL,RADIOTHEREPY,PHARMACOTHEREPY,CHEMOTHEREPY),FOLLOWUP,PROGNOSIS,PREVENTION -TO FOLLOW.

G Mohan.