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.
In very early phases of stromal invasion, cervical cancer may not generate any obvious symptoms or clinical features, and, therefore, is known as preclinical invasive disease. The earliest form of invasive cancer is histologically recognized as microinvasive carcinoma: cancers that have invaded no more than 5 mm deep and 7 mm wide into the underlying cervical stroma. Early invasive cancers appear as a tiny bud of invasive cells that have penetrated through the basement membrane and pushed into the underlying stroma (Figures 3.1 and 3.2
). Evidence of stromal reaction to invasion in the form of localized lymphocytic collection or loosening of the stroma surrounding the invasion may also be evident.
As the stromal invasion progresses, the disease becomes clinically obvious, with several growth patterns, which are often visible on speculum examination. Very early lesions may present as a rough, reddish, granular area that bleeds on touch (Figure 3.3
). More advanced cancers can be exophytic, endophytic or a combination of both (Figures 3.4
, Figures 3.5
). Exophytic carcinomas are usually superficially invasive and their bulk grows into the vaginal lumen as a mushroom or proliferating, bulging cauliflower-like growth with polypoid or papillary excrescences. Endophytic cancers may extensively infiltrate the stroma, distorting the cervix, without much visible surface growth. These lesions may expand into the endocervix leaving the squamous epithelium of the cervix intact until the lesions exceed 5-6 cm in a diameter. They result in a grossly enlarged, irregular barrel-shaped cervix with a rough, papillary or granular surface. Such cancers may remain silent for a long time. Partly exophytic and endophytic tumours are usually ulcerated with deep infiltration of the underlying stroma. In all types, bleeding on touch and necrosis are predominant clinical features. Foul-smelling discharge is also common due to superadded anaerobic infection of the necrotic tissue.
As the invasion continues further, it may directly involve the vagina, parametrium, pelvic sidewall, bladder and rectum. Compression of the ureter due to advanced local disease causes ureteral obstruction with resulting hydronephrosis (enlargement of kidneys) and, ultimately, renal failure. Regional lymph node metastasis occurs along with local invasion. Metastatic cancer in para-aortic nodes may extend through the node capsule and directly invade the vertebrae and nerve roots. Direct invasion of the branches of the sciatic nerve roots causes back pain, and encroachment of the pelvic wall veins and lymphatics causes oedema of the lower limbs. Haematogenous spread to lumbar vertebrae and psoas muscle may occur without nodal disease. Distant metastases occur late in the disease, usually involving para-aortic nodes, lungs, liver, bone and other structures.