Cervical Cancer Clinical Presentation

  • Author: Cecelia H Boardman, MD; Chief Editor: Warner K Huh, MD   more...
 
Updated: Mar 28, 2012
 

History

Because many women are screened routinely, the most common finding is an abnormal Pap smear. Typically, these patients are asymptomatic.

Clinically, the first symptom is abnormal vaginal bleeding, usually postcoital. Vaginal discomfort, malodorous discharge, and dysuria are not uncommon.

The tumor grows by extending upward to the endometrial cavity, downward to the vagina, and laterally to the pelvic wall. It can invade the bladder and rectum directly. Symptoms that can evolve, such as constipation, hematuria, fistula, and ureteral obstruction with or without hydroureter or hydronephrosis, reflect local organ involvement. The triad of leg edema, pain, and hydronephrosis suggests pelvic wall involvement.

The common sites for distant metastasis include extrapelvic lymph nodes, liver, lung, and bone.

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Physical Examination

In patients with early-stage cervical cancer, physical examination findings can be relatively normal. As the disease progresses, the cervix may become abnormal in appearance, with gross erosion, ulcer, or mass. These abnormalities can extend to the vagina. Rectal examination may reveal an external mass or gross blood from tumor erosion.

Bimanual examination findings often reveal pelvic and/or parametrial metastasis. If the disease involves the liver, hepatomegaly may develop. Pulmonary metastasis usually is difficult to detect upon physical examination unless pleural effusion or bronchial obstruction becomes apparent. Leg edema suggests lymphatic/vascular obstruction from tumor.

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Contributor Information and Disclosures
Author

Cecelia H Boardman, MD  The Dianne Harris Wright Professorship for Obstetrics and Gynecology Oncology Research, Virginia Commonwealth University Medical Center; Associate Professor (Collateral), Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Virginia Commonwealth University School of Medicine

Cecelia H Boardman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, Minnesota Medical Association, and Society of Gynecologist Oncologists

Disclosure: Merck Salary Speaking and teaching; Glaxo Salary Speaking and teaching; Depuy Salary Speaking and teaching

Coauthor(s)

Kirk J Matthews Jr, MD  Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Warner K Huh, MD  Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; INTUITIVE SURGICAL Proctor Fee Consulting; Qiagen Consulting fee Consulting

Additional Contributors

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Anthony El-Khoueiry, MD Assistant Professor of Medicine, Clinical Instructor, Division of Medical Oncology, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

Agustin A Garcia, MD Associate Professor of Medicine, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

Omid Hamid, MD Associate Director of Melanoma Center, Medical Director of Neuro-oncology Clinic, USC/Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

John J Kavanagh Jr MD, Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas Medical School at Houston

John J Kavanagh Jr is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, Society of Gynecologist Oncologists, Southern Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Cervical carcinoma with adnexa.
Squamous cell cervical carcinoma.
Table. Summary of 2012 Screening Guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology
ParametersACS Recommendations
Age to start screeningBegin screening with cytology at 21 years old, regardless of sexual history
Screening interval age 21–29Screen with cytology alone every 3 years.* HPV testing should not be used in this age group.
Screening interval age 30-65Screen with a combination of cytology and HPV testing every 5 years (preferred) or cytology alone every 3 years. Screening by HPV testing alone is generally not recommended.*
Age to stop screeningAge 65, if the woman has adequate negative prior screening and is not otherwise at high risk for cervical cancer
Screening after hysterectomyNot indicated for women without a cervix and without a history of a high-grade precancerous lesion (eg, CIN2 or CIN3) in the past 20 years or cervical cancer ever
HPV-vaccinated womenScreen according to the same recommendations as for unvaccinated women
These guidelines do not address special populations (eg, women with a history of cervical cancer, women who were exposed in utero to diethylstilbestrol, women who are immunocompromised) who may require more intensive or alternative screening.



*If abnormal test results are present, further testing and management should be performed according to the ASCCP Guidelines as noted below under Management of Abnormal Cytology.



Table 1. Cervical Cancer Staging (primary tumor [T])
TNM Stage FIGO Stage
Tx-Primary tumor cannot be assessed
T0-No evidence of primary tumor
Tis0Carcinoma in situ
T1ICervical carcinoma confined to uterus (extension to corpus should be disregarded)
T1aIAInvasive carcinoma diagnosed only by microscopy. All macroscopically visible lesions--even with superficial invasion--are T1b/1B. Stromal invasion with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less. Vascular space involvement, venous or lymphatic, does not affect classification.
T1a1IA1Measured stromal invasion 3 mm or less in depth and 7 mm or less in lateral spread
T1a2IA2Measured stromal invasion more than 3 mm but not more than 5 mm with a horizontal spread 7 mm or less
T1bIBClinically visible lesion confined to the cervix or microscopic lesion greater than IA2
T1b1IB1Clinically visible lesion 4 cm or less in greatest dimension
IB2Clinically visible lesion more than 4 cm
T2IICervical carcinoma invades beyond uterus but not to pelvic wall or to the lower third of vagina
T2aIIATumor without parametrial invasion
T2bIIBTumor with parametrial invasion
T3IIITumor extends to the pelvic wall and/or involves the lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney
T3aIIIATumor involves lower third of vagina; no extension to pelvic wall
T3bIIIBTumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney
-IVCervical carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the bladder mucosa or rectal mucosa. Bullous edema does not qualify as a criteria for stage IV disease.
T4IVASpread to adjacent organs (bladder, rectum, or both)
M1IVBDistant metastasis
Table 2. AJCC Stage Grouping
Stage Tumor Node Metastasis
0TisN0M0
IA1T1a1N0M0
IA2T1a2N0M0
IB1T1b1N0M0
IIAT2aN0M0
IIBT2bN0M0
IIIAT3aN0M0
IIIBT1N1M0
-T2N1M0
-T3aN1M0
-T3bAny NM0
IVAT4Any NM0
IVBAny TAny NM1
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