Skip to content

Cervical Malignancy

Basics

  • Malignant neoplasm from uterine cervix cells.
  • ~90% squamous cell carcinoma at squamocolumnar junction (transformation zone).
  • Adenocarcinomas arise from glandular endocervical cells.

Epidemiology

  • US incidence (2015-2019): 7.7 per 100,000 person-years.
  • WHO: 4th most common female cancer worldwide; 604,000 new cases and 342,000 deaths in 2020.
  • Most diagnoses at ages 35-44; average age 50.
  • 20%+ cases occur in women >65 years.
  • 2023 US estimates: 13,960 new cases, 4,310 deaths.

Etiology & Pathophysiology

  • High-risk HPV (especially types 16, 18) infection is primary cause (99% cases).
  • Other high-risk types: 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68.
  • HPV infection common in sexually active adults.

Risk Factors

  • Persistent HPV infection.
  • Early coitarche (<18 years), multiple partners, unprotected sex.
  • History of STIs, low socioeconomic status.
  • First birth <20 years, high parity (≥3).
  • Smoking (doubles risk).
  • Immunosuppression (HIV/AIDS, chemotherapy).
  • In utero DES exposure.
  • Oral contraceptives ≥5 years.
  • Family history of cervical cancer.
  • Limited healthcare access/screening.

Prevention

  • Routine Pap and/or HPV screening.
  • HPV vaccination (Gardasil 9 is current standard).
  • Recommended through age 26.
  • 2-dose series starting age 9-12 years; 3-dose if started ≥15 years.
  • Immunocompromised and certain populations through 26 years.

Associated Conditions

  • Condyloma acuminata.
  • Preinvasive/invasive lesions in vulva, vagina, oral, anal, oropharyngeal sites.

Diagnosis

History

  • Often asymptomatic initially.
  • Symptoms: irregular/heavy bleeding, postcoital bleeding, unusual discharge, dyspareunia, pelvic pain.

Physical Exam

  • Pelvic exam essential.
  • Early/microinvasive disease may have normal exam.
  • Lesions: exophytic, endophytic, polypoid, papillary, ulcerative, necrotic.
  • Evaluate for uterine, vaginal, rectovaginal, parametrial, pelvic sidewall involvement.
  • Assess for lymphadenopathy, edema, ascites, respiratory signs (metastases).

Differential Diagnosis

  • Cervical condyloma, leiomyoma, cervical polyp.
  • Metastatic endometrial carcinoma, gestational trophoblastic neoplasia.

Diagnostic Tests

  • Pap test screening.
  • Colposcopy with directed biopsy or biopsy of gross lesions is diagnostic.
  • Advanced disease labs: CBC, UA, BUN, creatinine, LFTs.
  • Imaging: CT chest/abdomen/pelvis or PET scan for metastasis.
  • MRI pelvis for staging and treatment planning.
  • Exam under anesthesia, endocervical curettage, conization as indicated.
  • Cystoscopy/proctoscopy if bladder/rectal invasion suspected.

Treatment

General Measures

  • Nutritional support, anemia correction (Hb <12 g/dL).
  • Treat infections; evaluate lymph nodes carefully.
  • Manage urinary obstruction before chemoradiation.

Medication

  • Chemoradiation (cisplatin-based) for stages IB3-IVA.
  • Neoadjuvant chemotherapy for early/locally advanced tumors.
  • Adjuvant chemotherapy may improve progression-free survival.
  • Bevacizumab addition improves survival in recurrent/metastatic disease.
  • First-line recurrent/metastatic: cisplatin/carboplatin/paclitaxel/bevacizumab/topotecan.
  • Second line: docetaxel, ifosfamide, 5-FU, irinotecan, gemcitabine, mitomycin; bevacizumab adjunct.

Surgery

  • Removal of precursor lesions (CIN) via LEEP, cold knife conization, laser, cryotherapy.
  • Open hysterectomy preferred for stages IA1 and IB1.
  • Radical hysterectomy or chemoradiation for stages IA2 to IIA.
  • Fertility-sparing trachelectomy considered in selected IA2-IB1.
  • Pelvic exenteration for stage IVA.
  • Palliation for stage IVB.

Pregnancy Considerations

  • Treatment guided by lesion stage, gestational age, maternal risk-benefit.
  • Early stage diagnosed before 3 months: treatment may delay until fetal maturity.
  • Later pregnancy: possible cold knife conization or trachelectomy with planned early C-section.
  • Advanced disease: chemotherapy usually safe in 2nd/3rd trimester; risks include early labor, low birth weight.

Admission & Nursing

  • For active bleeding, dehydration, treatment complications, ureteral obstruction.
  • Vaginal packing and radiation for bleeding control.

Ongoing Care

Follow-Up

  • Physical/pelvic exams every 3-6 months for 2 years, then every 6-12 months until 5 years, then yearly.
  • Pap smears yearly; limited for recurrence detection.
  • CT and PET imaging if recurrence suspected (3-4 months post treatment).
  • Watch for vaginal bleeding, weight loss, edema, pelvic/thigh pain.

Patient Education

  • Refer to Society of Gynecologic Oncology and Foundation for Women’s Cancer.

Prognosis

  • 5-year survival:
  • Localized: 92%
  • Regional: 59%
  • Distant: 17%
  • Overall: 67%
  • Serum SCC-Ag useful for monitoring treatment response, recurrence, prognosis.

Complications

  • Ovarian failure (radiation or surgery).
  • Hemorrhage, pelvic infection, genitourinary fistula, bladder/sexual dysfunction.
  • Ureteral obstruction with renal failure.
  • Bowel obstruction, pulmonary embolism, lymphedema.

Clinical Pearls

  • Second most common malignancy in women worldwide.
  • HPV immunization and screening can nearly eliminate cervical cancer.
  • Early detection and access to care are critical to reducing disease burden.