Obstetrics and Gynecology - A. M. Gromova 2000

Malignant neoplasms of the female reproductive organs
Cervical cancer

In recent years, cervical Cancer has been regarded as a preventable condition; however, it still ranks first in The Structure of gynecological malignancies.

Among primary epithelial tumors of the cervix, Squamous Cell Carcinoma is the most common (in 94-95% of patients), followed by adenocarcinoma (in 4-6% of patients).

Clinical Classification of cervical cancer (1985)

Stage 0 - pre-invasive (intraepithelial) carcinoma.

Stage Ia — microinvasive carcinoma (tumor up to 1 cm in diameter, confined to the cervix with stromal invasion of no more than 3 mm).

Stage Ib — tumor confined to the cervix with stromal invasion greater than 3 mm.

Stage II - tumor extends to the vaginal fornices, upper and middle thirds of the Vagina (vaginal variant) or to the uterine corpus (uterine variant).

Stage IIIa - carcinoma infiltrates the lower third of the vagina and/or there are metastases to the uterine appendages without regional Lymph node involvement.

Stage IIIb - tumor extends to the parametrium, reaching the pelvic wall on one or both sides, and/or regional lymph node metastases are present.

Stage IVa - cancer invades the Urinary Bladder and/or rectum.

Stage IVb - distant metastases are present beyond the lesser pelvis.

International TNM classification of cervical cancer (1985)

T - primary tumor;

Tis - pre-invasive carcinoma (cancer in situ);

T₁ - carcinoma confined to the cervix;

T₁a - microinvasive carcinoma (invasion up to 3 mm);

T₁b - invasive carcinoma;

T₂ - carcinoma extending beyond the cervix but not reaching the pelvic walls;

T₂a - tumor infiltrates only the vagina or the uterine corpus (without parametrial infiltration);

T₂b - carcinoma infiltrates the parametrium;

T₃ - tumor infiltrates the lower third of the vagina and/or the parametrium to the pelvic walls;

T₃a - tumor infiltration reaches the lower third of the vagina;

T₃b - carcinoma extends to the pelvic wall and/or causes Hydronephrosis;

T₄ - tumor extends beyond the lesser pelvis or infiltrates the mucosa of the urinary bladder or rectum.

N - regional pelvic Lymph Nodes;

N₀ - no regional lymph node metastasis;

N₁ - regional lymph node metastasis present;

N₂ - a malignant infiltrate is palpable on the pelvic wall, with a clear space maintained between it and the primary tumor;

N_x - regional lymph nodes cannot be assessed.

M - distant metastasis;

M₀ - no evidence of distant metastasis;

M₁ - distant metastasis present, including involvement of inguinal and lumbar lymph nodes;

M_x - insufficient data to assess distant metastasis.

When determining the extent of cervical cancer, the T, N, and M categories are grouped with the clinical staging data.

Stage 0 - Tis

Stage IA - Tis N₀ M₀

Stage IB - Tib N₀ M₀

Stage II - T₂a N₀ M₀

Stage III — T₃ N₀ M₀; T₁ M₀; T_2-3 N₂ M0

Stage IV - T₄ and/or M₁ regardless of T and N status.

Diagnosis of cervical cancer and staging of the disease are performed using cytological smear examination, colposcopy, and targeted punch biopsy of the affected cervical area. Recently, pelvic ultrasound, computed tomography, Magnetic Resonance imaging, radioisotope studies, and direct radiopaque lymphography combined with excretory echography have been utilized to accurately determine the extent of disease spread.

The Clinical presentation of cervical cancer depends on the tumor growth pattern (endophytic, exophytic, mixed, ulcerative-infiltrative), stage, and pathways of spread (vaginal, uterine, parametrial, metastatic).

Intraepithelial carcinoma initially develops asymptomatically. The first, albeit relatively late, symptom is watery discharge that eventually becomes foul-smelling and resembles "meat washings." Occasionally, the initial signs of pathology are contact bleeding triggered by a pelvic examination or sexual intercourse. Further disease progression leads to a decline in the patient's general condition, accompanied by pain and dysfunction of adjacent Organs.

The choice of Treatment method for cervical cancer depends on the stage of the disease. In young patients with preinvasive cancer, organ-sparing surgeries—such as wide cone diatermoelectroconization of the cervix and Sturmdorf cone amputation of the cervix—are widely accepted.

Historically, patients with microinvasive cervical cancer underwent radical Hysterectomy with adnexectomy. Recent studies have demonstrated the feasibility of performing a cervical amputation in such cases, particularly in young women. If this Procedure is not feasible, a simple hysterectomy without adnexectomy is performed. For T₁B AND T₂a tumors, the Wertheim procedure is indicated (radical hysterectomy with adnexectomy, removal of the upper third of the vagina and pelvic Connective Tissue, along with regional lymphadenectomy).

Favorable treatment outcomes are observed with combined modality therapy. In cases of clinically apparent cervical cancer involving the cervix, adjacent parametrial connective tissue, and vaginal fornices, preoperative Radiation therapy is indicated (intravaginal roentgenotherapy, intracavitary therapy using cobalt). Postoperative external beam radiation therapy is administered in all cases where metastases are detected, as well as when tumor invasion exceeds 1 cm.