gynecology and obstetrics
Cervical Cancer
Diagnosis of Cervical Cancer
Papanicolaou (Pap) test (cervical cytology) Biopsy Cervical cancer may be suspected during a routine gynecologic examination. Further evaluation is required for patients with A visible cervical lesion Abnormal vaginal bleeding Cervical cancer is usually diagnosed when cervical cytology and/or HPV testing detects abnormalities. Findings are usually microscopic, but in some cases there is a cervical lesion. A large tumor may be exophytic and necrotic, but a lesion may also be smaller and less distinctive. Biopsy should be performed for any cervical lesion for which there is a suspicion of malignancy. [ Diagnosis references ]). Further evaluation with cytology, HPV testing, or colposcopy is indicated if atypical or cancerous cells are found and/or HPV testing is positive. Colposcopy (examination of the vagina and cervix with a magnifying lens) is used to identify areas that require biopsy; endocervical curettage is also often performed. Cone biopsy (conization) is required if the diagnosis is uncertain and high-grade CIN or invasive cancer is suspected; a cone of tissue is removed using a loop electrical excision procedure (LEEP), laser, or scalpel (cold knife). Cervical cancer staging underwent a major revision in 2018. The previous International Federation of Obstetrics and Gynecology (Federation Internationale de Gynecologie et d'Obstetrique, or FIGO) 2009 staging system allowed only clinical examination, cervical biopsy, and a few additional tests to assign the stage. The FIGO 2018 staging system allows, when available, cross-sectional imaging (eg, ultrasonography, CT, MRI, positron emission tomography [PET], PET-CT, MRI-PET), and surgical pathology results to supplement clinical findings in all stages. Imaging and pathology results are optional because they may be not available in low- and middle-resource countries, where cervical cancer is more common ( Diagnosis references , Other changes in the 2018 staging system include the following: Horizontal spread of the tumor is no longer considered part of stage IA1 and IA2. Stage I is subdivided into 3 subgroups according to tumor size (IB1 ≤ 2 cm, IB2> 2 to ≤ 4 cm, and IB3 > 4 cm) instead of 2 subgroups (stages IB1 and IB2, which used only 4 cm as a cutoff value). Lymph node status is now part of the staging system. Positive pelvic nodes are now stage IIIC1 and positive paraortic nodes are stage IIIC2. Micrometastases in the lymph nodes are considered positive; however, these isolated tumor cells do not change the stage to III, but they should be recorded. If lymph nodes are classified as positive by imaging studies, an "r" is added to the stage (eg, IIIC1r, IIIC2r); if they are classified as positive by pathology results, a "p" is added(IIIC1p, IIIC2p [ Diagnosis references , If the stage is higher than A2, CT or MRI of the abdomen and pelvis is typically done to better determine tumor size, parametrial involvement, vaginal compromise, and nodal metastases. PET with CT (PET/CT) is often used to check for spread beyond the cervix. If PET/CT, MRI, or CT is not available, cystoscopy, sigmoidoscopy, chest x-ray, and IV urography, when clinically indicated, may be used for staging. When imaging tests suggest that pelvic or para-aortic lymph nodes are grossly enlarged (>2 cm), surgical exploration, typically with a retroperitoneal approach, may be indicated. Its sole purpose is to remove enlarged lymph nodes so that radiation therapy can be more precisely targeted and more effective. 1.Nayar R, Wilbur DC: The Pap test and Bethesda 2014.Cancer Cytopathology, 123: 271–281, 2015. doi:10.1002/cncy.21521 2.Bhatla N, Berek JS, Cuello Fredes M, et al: Revised FIGO Staging for Carcinoma of the Cervix Uteri.Int J Gynaecol Obstet145 (1):129–135, 2019. doi: 10.1002/ijgo.12749 3.Bhatla N, Berek JS, Cuello Fredes M, et al: Corrigendum to “Revised FIGO staging for carcinoma of the cervix uteri” [Int J Gynecol Obstet145(2019) 129–135].Int J Gynaecol Obstet147(2):279-280, 2019. doi: 10.1002/ijgo.12969 4.Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R: Cancer of the cervix uteri: 2021 update.Int J Gynaecol Obstet155 Suppl 1(Suppl 1):28-44, 2021. doi:10.1002/ijgo.13865 