In very early phases of invasion, cervical cancer may not be associated with obvious symptoms and signs, and, therefore, is known as preclinical invasive cancer. Women with moderately advanced or advanced invasive cervical cancer often present with one or more of the following symptoms: intermenstrual bleeding, postcoital bleeding, excessive seropurulent discharge, recurrent cystitis, backache, lower abdominal pain, oedema of the lower extremities, obstructive uropathy, bowel obstruction, breathlessness due to severe anaemia and cachexia.
As the stromal invasion progresses, the disease becomes clinically obvious, showing several growth patterns, which are visible on speculum examination. Early lesions may present as a rough, reddish, granular area that bleeds on touch (figure 1.11
) More advanced cancers may present as a proliferating, bulging, mushroom- or cauliflower-like growth with bleeding and foul-smelling discharge (figure 1.12
). Occasionally they may present without much surface growth, resulting in a grossly enlarged, irregular cervix with a rough, granular surface.
As the invasion continues further, it may involve the vagina, parametrium, pelvic sidewall, bladder and rectum. Compression of the ureter, due to advanced local disease, causes ureteral obstruction which results in hydronephrosis 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 causing back pain. Direct invasion of the branches of the sciatic nerve roots causes low back pain and leg aches, and encroachment of the pelvic wall veins and lymphatics causes oedema of the lower limbs. Distant metastases occur late in the disease, usually involving para-aortic nodes, lungs, liver, bone and other structures.
Histologically, approximately 90-95% of invasive cervical cancers in developing countries are squamous cell cancers (figure 1.13
) and 2 - 8% are adenocarcinomas (figure 1.14
). It is obligatory that all invasive cancers be clinically staged. The most widely used staging system for cervical cancer was developed by the International Federation of Gynecology and Obstetrics (FIGO) (see Appendix 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. Stage I represents growth localized on the cervix, while stage IV represents the growth phase in which the cancer has spread to distant organs by metastasis.
Women with early invasive cancers (stages I, II A) may be treated with radical surgery and/or radiotherapy. Those with stage IIB and III cancers should be treated with radiotherapy with or without cisplatinum-based chemotherapy. Women with stage IV cancers are usually treated with palliative radiotherapy and/or chemotherapy and with symptomatic measures.