Jori S. Carter
History of present illness
A 45-year-old gravida 3, para 3 woman presents to the emer- gency room with heavy post-coital vaginal bleeding. This is the first time she has been sexually active in six months. She usually has regular monthly menses and has not had irregular bleeding before. She has vague lower abdominal pain that has been present for the last several months. She has not received gyne- cologic care since the birth of her youngest child 20 years ago.
Her medical history is unremarkable, but she does not receive regular checkups. She is a 30 pack-year cigarette smoker, and occasionally drinks alcohol. Upon further questioning, she states that she has some occasional foul-smelling vaginal dis- charge. Aside from intermittent cramping lower abdominal pain, the remainder of her review of systems is negative.
Physical examination
General appearance:Well-nourished woman who is alert and oriented and in no apparent distress
Vital signs:
Temperature: 37.0°C Pulse: 100 beats/min
Blood pressure: 110/60 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 97% on room air BMI: 25 kg/m2
HEENT:Normal
Neck:Supple, no lymphadenopathy
Chest:Clear to auscultation in all four quadrants Cardiac:Regular rate and rhythm
Abdomen:Soft, nondistended, minimal tenderness across the lower abdomen, greater on the left than right, without rebound or guarding
External genitalia:Unremarkable
Speculum examination:Vagina with a large amount of blood in the vaginal vault. The cervix is replaced by a 7 cm friable, fungating cervical mass deviated to the left (Fig. 90.1) Bimanual examination:A 7-cmfixed mass deviating to the left that obliterates the left vaginal fornix, but otherwise no extension to the vagina
Rectovaginal examination:A 7-cm cervical mass that is fixed to the left pelvic sidewall and with right parametrial involvement not extending to the pelvic sidewall. No invasion of the rectal mucosa
How would you manage this patient?
This patient has a large, friable, bleeding cervical mass. She is presumed to have cervical cancer until proven otherwise. Her history of heavy smoking and a lack of gynecologic care are risk factors for this diagnosis. She will need a biopsy for a tissue diagnosis; however, she is currently having heavy vaginal bleeding, which should be managed acutely with the placement of vaginal packing. Referral to a gynecologic oncologist is recommended for the staging and workup.
Cervical cancer
Cervical cancer is the most common gynecologic cancer in women worldwide and it is overall the third most common cancer and the fourth leading cause of death in women. An
Fig. 90.1 Fungating cervical mass.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
estimated 12 340 new cases of cervical cancer will be diagnosed in the United States in 2013, accounting for 4030 deaths [1].
Most cases of cervical cancer occur in women who were inadequately or never screened. The most important risk factor is human papilloma virus (HPV) infection (especially the high- risk types 16, 18, 31, 33, and 45). Risk factors also include cigarette smoking, immunosuppression, high parity, increased number of sexual partners, young age atfirst intercourse, low socioeconomic status, and (while the mechanism is unclear) combination oral contraceptive pill use [2]. HPV infection is essential for malignant transformation leading to the develop- ment of cervical cancer, and can be identified in 99% of cervical cancer cases. The high-risk subtypes of HPV are more strongly linked to cervical cancer, with HPV 16 and 18 accounting for 70% of cervical cancer cases in the United States [3]. While most HPV infections are transient, when they are persistent, it takes over 15 years from initial infection to the development of cervical intraepithelial neoplasia (CIN) and then to invasive cervical cancer. The implementation of the HPV vaccine promises to reduce the incidence of cervical cancer when widely administered, and is most effective when given in sexually nạve people. The vaccine is approved for administration between the ages of 9 and 26 years of age [4].
Cervical cancer is staged clinically after tissue diagnosis is obtained. A thorough gynecologic examination, including external genitalia and vagina, should be performed. Visible cancer may appear ulcerated, papillary, exophytic, polypoid,
or barrel-shaped. If the lesion is large, such as in this case, it can become friable or necrotic and give off a foul odor with discharge that is bloody, watery, or purulent. A rectovaginal examination is performed to evaluate for spread into the parametria that may feel firm and irregular resulting in less mobility of the uterus. Vaginal involvement is present when there is obliteration of the vaginal fornices or a thick rectova- ginal septum. Often exams are performed under anesthesia to achieve a thorough evaluation along with cystoscopy and proctoscopy to evaluate for regional spread to the rectum or bladder.
Renal function is taken into consideration in the staging of cervical cancer and can be evaluated with serum creatinine and/or intravenous pyelogram to assess for the presence of hydronephrosis. Generally in developed countries a CT scan is performed, which can add information about the tumor size, extent of disease spread, lymph node involvement, and hydro- nephrosis. Information gathered from CT is not included in the International Federation of Gynecology and Obstetrics (FIGO) staging parameters however, because the purpose is to have a unified international staging system that is feasible in resource-rich and resource-poor countries, which allows for consistent data for research and comparability.
Stage I cervical cancer is diagnosed after screening (by cytology and/or positive high-risk HPV testing) leads to col- poscopy and cervical biopsy. Screening guidelines can detect preinvasive dysplasia, but also can detects early stage,
Table 90.1 International Federation of Obstetricians and Gynaecologists (FIGO) staging for cervical cancer
Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded).
IA Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion≤5 mm and largest extension≤7 mm
IA1 Measured stromal invasion of≤3 mm in depth and extension of≤7 mm
IA2 Measured stromal invasion of>3 mm and not>5 mm with an extension of not>7 mm IB Clinically visible lesions limited to the cervix uteri or preclinical cancers greater than stage IA
IB1 Clinically visible lesion≤4 cm in greatest dimension IB2 Clinically visible lesion>4 cm in greatest dimension
Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina IIA Without parametrial invasion
IIA1 Clinically visible lesion≤4 cm in greatest dimension IIA2 Clinically visible lesion>4 cm in greatest dimension IIB With obvious parametrial invasion
Stage III The tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney
IIIA Tumor involves lower third of the vagina, with no extension to the pelvic wall IIIB Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney
Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV
IVA Spread of the growth to adjacent organs IVB Spread to distant organs
asymptomatic disease. The implementation of cervical screening has decreased the incidence of cervical cancer by 75% over the last three decades in the United States [5]. Advanced stage cervical cancer (as in the case of this patient) often presents with physicalfindings of irregular bleeding, malodorous vaginal discharge, vaginal or abdominal pain, and dysuria. Stage II cancer can involve the upper vagina or extend into the para- metria (but not to the pelvic sidewall). Patients with stage III (or greater) disease may present with acute renal failure or with hydronephrosis. Patients with stage IVA disease may have hematuria, hematochezia, or changes in bowel movements as the tumor burden extends to the bladder or rectum. Palpable inguinal or supraclavicular lymphadenopathy can be indicative of widespread metastases present in stage IVB disease.
Cervical cancer is clinically staged as opposed to surgically staged (Table 90.1). FIGO clinical staging allows inclusion of physical examination, colposcopy, cervical biopsy, endocervical curettage, conization, hysteroscopy, cystoscopy, proctoscopy, x-ray of the chest, skeleton, and intravenous pyelogram to determine the proper stage [6]. The earliest stages IA1 and IA2 are distinguished using an excisional cervical biopsy to evaluate the depth and width of invasion. Any stage higher usually has a visible lesion, and requires only a direct biopsy.
The patient in this scenario has a large 7-cm visible lesion, which makes her at least a stage IB. Because the tumor extends to the left pelvic sidewall, she becomes a stage IIIB.
The treatment of stage IA1 cervical cancer is with either a simple hysterectomy or cone biopsy (loop electrosurgical exci- sional procedure [LEEP] or cold knife) and is associated with a 99% 5-year overall survival rate [7]. Stage IA2 lesions have a 7% risk of lymph node metastases and are treated with radical hysterectomy (or radical trachelectomy for fertility-sparing in young women [8]) and pelvic lymphadenectomy. Stage IB–IIA1 tumors can be treated by radical hysterectomy (or radical tra- chelectomy for stage IB) or receive primary radiation therapy with similar 5-year overall survival rates of 83% and 74%,
respectively [9]. Stages IIA2–IVA generally have a 5-year sur- vival rate of less than 50% and are treated with a combination of primary radiation therapy (external beam and brachytherapy) and cisplatin-based chemotherapy, based on five randomized phase III trials showing that the use of concurrent chemoradia- tion decreased the risk of death by 30–50% [10]. Treatment for stage IVB cervical cancer is individualized, and can include multiagent systemic chemotherapy for disseminated disease, radiation therapy for pain or bleeding, and an emphasis on clinical trials and palliative care [11], with consideration that the 5-year overall survival is 15%.
The patient in this case presented with common symptoms of locally advanced cervical cancer. When women present with symptoms of pain and bleeding it is essential that they undergo a thorough pelvic examination with visualization of the cervix.
If a cervical mass is identified in the acute care setting, biopsies should be obtained and if a cervical cancer is confirmed, follow-up with gynecologic oncology is recommended to per- form accurate staging and for coordination of future care.
Key teaching points
A thorough pelvic examination should be performed in any women presenting with abnormal bleeding, vaginal/
abdominal pain, or malodorous discharge.
Risk factors for cervical cancer include: women without regular cervical cancer screening, human papilloma virus (HPV) infection, cigarette smoking, immunosuppression, high parity, increased number of sexual partners, young age atfirst intercourse, low socioeconomic status, and oral contraceptive pill use.
Cervical cancer is staged clinically and treatment is dependent on the stage at diagnosis.
Cervical cancer can be prevented or detected at an early stage with regular cervical cancer screening with cytology and HPV testing.
References
1. American Cancer Society.Cervical Cancer. Last revised 1/31/2014.
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Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: The IARC multicentric case-control study.Lancet 2002;359:1085–92.
3. de Sanjose S, Quint WG, Alemany L, et al. Human papillomavirus genotype attribution in invasive cervical cancer:
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5. American College of Obstetricians and Gynecologists. Screening for cervical cancer. Practice Bulletin No. 131.Obstet Gynecol2012;120:1222–38.
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101 patients and 28 pregnancies.Int J Gynecol Cancer2012;22:1251–7.
9. Landoni F, Maneo A, Colombo A, et al.
Randomised study of radical surgery versus radiotherapy for stage IB-IIA cervical cancer.Lancet1997;350:
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10. National Institutes of Health.NCI issues Clinical Announcement on Cervical Cancer: Chemotherapy Plus Radiation Improves Survival. Released Feb 22, 1999. Available athttp://
www.nih.gov/news/pr/feb99/nci-22.
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11. Scatchard K, Forrest JL, Flubacher M, Cornes P, Williams C. Chemotherapy for metastatic and recurrent cervical cancer.Cochrane Database Syst Rev 2012, Issue 1. Art. No.: CD006469.
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pub2.
Case 90: A 45-year-old woman with a fungating cervical mass