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Preclinical invasive cancer refers to early cervical cancer, with minimal stromal invasion, often
without any symptoms or clinical features.
As the stromal invasion progresses, the disease becomes clinically obvious, revealing several growth
patterns visible on speculum examination.
Histologically 90-95% of invasive cervical cancers are squamous cell cancers; adenocarcinoma
constitutes less than 5% of cervical cancers in most developing countries.
The most widely used staging system for invasive cervical cancer is based on tumour size and the
spread of disease into the vagina, parametrium, urinary bladder, rectum and distant organs.
Clinical stage of disease at presentation is the single most important predictor of survival from
invasive cervical cancer.
Clinical features
Women with invasive cervical cancer often present with
one or more of the following symptoms: intermenstrual
bleeding, postcoital bleeding, heavier menstrual flows,
excessive seropurulent discharge, foul smelling
discharge, recurrent cystitis, urinary frequency and
urgency, backache, and lower abdominal pain. In
advanced stages, patients may present with
breathlessness due to severe anaemia, obstructive
uropathy, oedema of the lower limbs, haematuria, bowel
obstruction and cachexia. Vaginal speculum examination
reveals an ulceroproliferative growth in most women.
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Chapter 3
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ulceroproliferative growth
Microscopic pathology
Histologically, approximately 90-95% of invasive cervical
cancers arising from the uterine cervix in developing
countries are squamous cell cancers (Figures 3.7 and
3.8) and 2 to 8% are adenocarcinomas (Figure 3.9).
Microscopically, most squamous cell carcinomas
appear as infiltrating networks of bands of neoplastic
cells with intervening stroma, with a great deal of
variation in growth pattern, cell type and degree of
differentiation. The cervical stroma separating the
bands of malignant cells is infiltrated by lymphocytes
and plasma cells. These malignant cells may be
subdivided into keratinizing and non-keratinizing
types. The tumours may be well, moderately or poorly
differentiated carcinomas. Approximately 50-60% are
moderately differentiated cancers and the remainder
are evenly distributed between the well and poorly
differentiated categories.
FIGURE 3.7:
FIGURE 3.9:
adenocarcinoma (x 20)
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Chapter 3
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Staging
Treatment planning and assessment of prognosis
requires detailed evaluation of the patients general
health and the determination of the clinical stage of
invasive cancer. The widely used staging system for
cervical cancer was developed by the International
Federation of Gynecology and Obstetrics (FIGO), and is
given in Table 3.1. This is primarily a clinical staging
system based on tumour size and extension of the
disease in the pelvis. The extent of growth of cancer is
assessed clinically, as well as by various investigations
to categorize the disease stages I through IV (Table 3.1
and Figure 3.10). Stage I represents growth localized
to the cervix, while stage IV represents the growth
phase in which the cancer has spread to distant organs
by metastases.
The FIGO staging is assessed using methods
including inspection and palpation by vaginal and
rectal
examination,
colposcopy,
cystoscopy,
endocervical curettage, hysteroscopy, intravenous
urogram, and chest and skeletal X-rays.
Lymphangiography, ultrasonography, computerized
tomography (CT) and magnetic resonance imaging
(MRI) and laparoscopy may provide additional
information, but this information should not be used
to assess the FIGO clinical stages, despite the fact
that these investigations may provide valuable
information for planning treatment. In many lowresource settings, however, speculum examination,
per vaginal and per rectal examination are the only
feasible approaches to staging.
Cystoscopy and
radiological assessment with chest and skeletal X-rays
and intravenous urograms may additionally be carried
out if possible. Staging should routinely be carried out
Stage II
Stage II is carcinoma that extends beyond the cervix, but does not extend to the pelvic wall.
The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA:
Stage IIB:
Stage III
Stage III is carcinoma that has extended to the pelvic sidewall. On rectal examination, there is no
cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third
of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
Stage IIIA:
Stage IIIB:
No extension to the pelvic sidewall but involvement of the lower third of the vagina.
Extension to the pelvic sidewall or hydronephrosis or non-functioning kidney.
Stage IV
Stage IV is carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa
of the bladder and/or rectum.
Stage IVA:
Stage IVB:
It is impossible to estimate clinically whether a cancer of the cervix has extended to the corpus.
The determination of the extension to the corpus should therefore be disregarded.
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Chapter 3
Bladder
Rec
tum
Parametrium
Upper 2/3 vagina
Lower 1/3 vagina
Invasive cancer
STAGE I
STAGE II A
STAGE II B
STAGE III A
STAGE III B
STAGE IV A
FIGURE 3.10: A schematic diagram of clinical stages of invasive cancer of the cervix
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