Carcinoma of the cervix is among the commonest tumours in the developing world, and causes much suffering. Most tumours are squamous-celled, a few are adenocarcinomas arising from the endocervix. Carcinoma of the cervix is more common in grand multips, in the promiscuous (including those who have a series of husbands), in partners of the uncircumcised, and in women living in very unhygienic conditions. Herpes virus type 2 is associated with carcinoma of the cervix, but its role as a causative agent is still uncertain.
A patient can present with: (1) intermenstrual bleeding, often bright red, (2) postcoital bleeding, (3) postmenopausal bleeding, or (4) a vaginal discharge, which is not always blood- stained, and is usually watery.
The premalignant phases of cervical cancer can be identified in a woman without symptoms by examining a smear of cervical cells on a slide[md]a Papanicolau or ''Pap' smear. At this stage laser treatment, cone biopsy or total hysterectomy will cure her. Unfortunately, a screening program needs good laboratories and a system to recall and monitor patients with abnormal cells. Establishing such a service is beyond the scope of the hospitals for which we write, but if there is such a service, use it. In its absence the best you can do is to make sure that all your staff, who provide primary care, persuade anyone with early symptoms to come for examination and biopsy. Both carcinoma of the cervix and AIDS are less common in patients who use condoms, so encourage promiscuous patients to use them.
Treatment requires either radiotherapy, or radical hysterectomy to remove the upper vagina, the parametrium and the pelvic lymph nodes. This is an an expert's task. Stage 0 can be treated by cone biopsy (see below), and a total hysterectomy is of some value in Stage One, but not later. Your main task is to take cone or wedge biopsies when necessary, and to stage a patient carefully to decide if referral is indicated. If she can be referred, her outlook is good in stages I and IIa, so that the correct staging and prompt referral of these stages is important. Unfortunately, many patients in the developing world present so late, so that even if referral is possible it is of little benefit. There is no useful chemotherapy.
Carcinoma of the endometrium is rare in the developing world. It occurs in older patients, and is the most important cause of bleeding after tne menopause, which is an urgent indication for a ''D and C'.
Fig. 32-21 CARCINOMA OF THE CERVIX. A, a Shapibo Indian from South America with a neglected carcinoma of her cervix showing vulval involvement (Stage IV). B, staging the disease. Stage 0, carcinoma in situ. Stage I, the tumour is confined to the patient's cervix. Stage IIa, it extends into her upper vagina or uterus, but not into her parametrium. Stage IIb, it extends into her parametrium, but not to her pelvic wall. Stage III, it involves the side wall of her pelvis, or the lower third of her vagina. Stage IV, it involves the mucosa of her bladder, or rectum, or she has distant metastases.
C, the sites of carcinoma: (1) Squamous carcinoma of the vaginal cervix. (2) Adenocarcinoma of the endocervix. (3) Adenocarcinoma of the endometrium.
D, carcinoma of the cervix (Stage One or Two). E, pyometra; the body of the uterus is filled with pus above a Stage One carcinoma of the cervix. After Pinter and Roberts, and James Young.
CARCINOMA OF THE CERVIX DIAGNOSIS. Take a careful history and establish the timing and appearance of the bleeding; a patient may confuse vaginal bleeding with haematuria. Examine her abdomen, and her groins. Examine her vagina and cervix with a speculum. Do a rectal examination and a bimanual examination of her pelvic organs. All this can be done as an outpatient procedure. You may see: (1) An ulcer on her cervix, often extending into one or more fornices. (2) A cervical polyp (less common). (3) An enlarged barrel-shaped cervix which may look relatively normal. (4) Erosion into her bladder or cervix causing an RVF or a VVF.
The differential diagnosis includes a simple cervical erosion, a cervical or endometrial polyp, a submucous fibroid, various stages of abortion, irregular bleeding near the menopause, carcinoma of the endometrium, senile vaginitis, urethral caruncle, and a bilharzial granuloma.
Suggesting carcinoma[md]the lesion feels hard, it is friable (bits break off easily), a raised edge, you can feel it extending into her parametrium.
Suggesting an erosion (normal and physiological)[md]an area of glandular epithelium around her external os surrounded by normal squamous epithelium. No raised edge. Does not feel hard and gritty. There is usually no contact bleeding, but a little contact bleeding can occur.
If a Pap smear has shown suspect cells, take a cone biopsy to confirm it. If there is an ulcer, take a wedge biopsy.
A ''D and C' is not necessary for investigating carcinoma of the cervix. This does occasionally reveal carcinoma, but it is usually an adenocarcinoma of the body of the uterus or of the endocervix. Invasion of the body of the uterus by a carcinoma of the cervix is not one of the staging criteria for this tumour.
STAGING AND MANAGEMENT. If you suspect she is in one of the earlier stages, with some hope of cure or palliation, stage her as an inpatient, under anaesthesia, in the lithotomy position. Do a rectal examination to assess spread beyond her uterus. Do a vaginal examination at the same time, and feel her rectovaginal septum between your fingers. If she has an advanced lesion, an examination under anaesthesia is hardly necessary. Examine her gently as an outpatient, and remove a small piece of tissue for histology. You may however need to admit her on social grounds, especially if she is travelling far.
Stage 0, carcinoma in situ. This is a histological diagnosis, made from either a cone (or wedge) biopsy, or a positive Pap smear. The cells look malignant, but have not yet invaded the surrounding tissue, and may not do so for many years, if ever. Cone biopsy is curative at this stage.
If the diagnosis was made from a Pap smear, do a cone biopsy.
If the diagnosis was made by a cone biopsy, follow-up is all that is needed. Or, after a full explanation, refer her for a total (not radical) hysterectomy, if she wants one, or do it yourself (20.12).
Stage 1 The tumour is confined to her cervix and can be cured, either by radical hysterectomy, or by radiotherapy. Refer her for them. She has an 85% to 90% chance of surviving 5 years. If she cannot have a radical hysterectomy, a total one is of some benefit.
Stage 2A The tumour extends out from her cervix into her upper vagina or uterus, but not into her parametrium. Stage 2A is uncommon because progress to stage 2b is so rapid. Manage her as for Stage I. She has a 75% to 80% chance of 5 year survival. A total hysterectomy is useless, but a radical one is of some value
Stage 2B The tumour extends into her parametrium but not as far as her pelvic wall. Radical surgery is impossible, but radiotherapy is not, and can achieve 5 year survival rates of 45% to 55%. Even if it fails, it is good palliation.
Stage 3 The tumour involves the lower third of her vagina and/or the side wall of her pelvis. Manage her as for Stage IIB. Radiotherapy can achieve 5 year survival rates of 30% to 40%.
Stage 4 The tumour involves the mucosa of her bladder or her rectum, or has metastasized beyond her pelvis. Palliate her with chlorpromazine and analgesics, as her pain increases (33.1).
CAUTION ! (1) A negative Pap smear does not exclude invasive carcinoma, nor does a positive smear prove it (she may have carcinoma in situ). (2) Carcinoma in situ does not cause abnormal bleeding or other symptoms. (3) Abnormal lesions need to be confirmed by wedge or cone biopsy.
CONE BIOPSY [s7]FOR CARCINOMA OF THE CERVIX INDICATONS. (1) To confirm a positive or suspicious Pap smear. If her cervix is clinically normal, repeat the Pap smear before you take the biopsy. (2) As treatment for carcinoma in situ, as shown by a positive Pap smear. (3) As primary treatment for a lesion considered to be carcinoma in situ or possibly stage I, in order to obtain reliable distinction between these two.
ANAESTHESIA. (1) General anaesthesia. (2) Low subarachnoid anaesthesia (A 7.7). (3) Caudal epidural anaesthesia (A 7.3).
CAUTION ! (1) Don't do a preliminary dilatation. If she needs one, do it after you have taken the biopsy. (2) Don't use diathermy[md]it spoils the specimen.
METHOD. Put her into the lithotomy position. A cone biopsy is notorious for postoperative bleeding, both reactionary and secondary. Minimize this by taking it in the postmenstrual period, and inserting a preliminary catgut suture to prevent bleeding, exactly as with McDonald's cervical suture (16.5), or by injecting dilute adrenalin and tying the descending cervical arteries.
Either, start by inserting a McDonald's suture, as in Figs. 16-2 and 32-22, and tie it. You only want it to act for a day or two, so use catgut, not monfilament. Put it all round her cervix, as high up as you can, and loop it into her cervix to hold it. Pull it tight to occlude her descending cervical vessels.
Or, use vulsellum forceps to grasp the anterior aspect of her cervix away from the lesion. Then, infiltrate her cervix with 20 or 30 ml of 1:100 000 adrenalin solution (1 ml of 1:1000 adrenalin with 100 ml of saline). Transfix her descending cervical vessels on each side with No. 0 chromic catgut, leaving the ligatures long to act as stays.
Schiller's test (optional) helps to define the extend of the atypical epithelium, but is not absolutely reliable. Apply 1% iodine to the lesion and the surrounding epithelium. Normal epithelium stains, atypical epthelium may not.
Incise the normal epithelium about 5 mm from its junction with the abnormal epithelium, and extend your incision all round her cervix. Apply vulsellum forceps to the lips of her cervix at 12 o'clock and 6 o'clock. Deepen the incision to remove a cone, with its apex at her cervical canal, keeping its edge 3 to 5 mm away from the abnormal tissue. Leave the raw surface open. Cut the cone open in the 12 o'clock position, and send it intact for histology.
CAUTION ! If a pathologist is going to examine a cone biopsy adequately: (1) it must be big enough, (2) its orientation in the patient must be identifiable (hence the 12 o'clock cut). (3) It must be in one piece, and (4) it must be injured as little as possible. He should be able to report that the edges of the cone are normal, and if not, where the suspicious tissue is.
WEDGE BIOPSY [s7]FOR CARCINOMA OF THE CERVIX INDICATIONS. To confirm or exclude malignancy in an ulcer of the cervix.
METHOD. At 3 sites or more on the ulcerated area, excise ellipses at least 3 mm deep, crossing the margin between the ulcerated and the normal area.
CARCINOMA OF THE ENDOMETRIUM STAGING AND SURVIVAL. The 5 year survival after surgery and radiotherapy is given for each stage.
Stage 1 The carcinoma is confined to the corpus (80% 5 year survival).
Stage 1a The length of her uterine cavity is 8 cm or less.
Stage 1b The length of her uterine cavity is [mt]8cm.
Stage 2 Her corpus and cervix are involved (58%).
Stage 3 The carcinoma extends outside her corpus, but not outside her true pelvis. It may involve her vagina or her parametrium, but not her bladder or her rectum (33%).
Stage 4 It involves her bladder or her rectum, or extends outside her pelvis (7%).
MANAGEMENT. Confirm the diagnosis by doing a ''D and C', and sending scrapings for histology. If she is Stage Two or more, she needs radiotherapy. A total abdominal hysterectomy with the removal of a cuff of vagina is the next best.
Fig. 32-22 BIOPSY OF THE CERVIX. A, a wedge biopsy. B, inserting McDonald's suture before doing a cone biopsy. C, cutting the cone. D, removing the cone. E, the cone opened out with an incision in the 12 o'clock position.