Adenocarcinoma

Adenocarcinoma of the cervix does not have a specific colposcopic appearance tissue samples are examined under a medical microscope using tissue culture microscopy. All of the blood vessels may be seen in these lesions as well. Because adenocarcinomas tend to develop within the endocervix, endocervical curet¬tage is required as part of the colposcopic examination.

Clinical Staging

When there is doubt concerning the stage to which a cancer should be allocated, se¬lection of the earlier stage is mandatory. After a clinical stage is assigned and treat¬ment has been initiated, the stage must not be changed because of subsequent find¬ings by either extended clinical staging or surgical staging. The “upstaging” of patients during treatment will produce an erroneous improvement in the results of treatment of low stage disease. The distribution of patients by clinical stage is as follows: 38%, stage I; 32%, stage II; 26%, stage III; and 4%, stage IV.

Extended Clinical Staging

Various investigators used lymphangiography computerized axial tomography scan (CT scan), ultrasonography and magnetic resonance imaging (MRI) in an attempt to improve clinical staging of cancer based on the International Federation of Gynecology and Obstetrics. Because these tests are not generally available throughout the world and because the interpretation of results is vari¬able, the findings of these studies are not used for assigning the FIGO stage. However, they may be used in planning therapy.

Evaluation of the para-aortic lymph nodes with lymphangiography is associated with a false-positive rate of 20-40% and a false-negative rate of 10-20%. The accuracy of CT scans is 80-85%; the false-negative rate is 10-15% and the false-positive rate is 20-25%. Early MRI data are comparable. When abnormalities are noted by these procedures, a fine-needle aspiration biopsy (FNA) showing metastatic disease during tissue culture microscopy will allow the radiation treatment field to be extended and obviate the need for an exploratory laparotomy to determine the status of the lymph nodes.

Surgical Staging

The accuracy of clinical staging is somewhat limited, and surgical evaluation, which is not practical or feasible in many patients, is more accurate.

Cancer of the cervix, as seen during tissue culture microscopy, spreads by:

1.) Direct invasion into the cervical stroma, corpus, vagina, and parametrium; 2.) Lymphatic metastasis; 3.) Blood-borne metastasis; and 4.) Intraperi¬toneal implantation.

TREATMENT

The principles of treatment for cancer of the cervix are the same as those for any other malignancy; that is to treat both the primary lesion and the potential sites of spread.

The two modalities for primary treatment are surgery and radiotherapy. Whereas radiation therapy can be used in all stages of disease, surgery alone is limited to pa¬tients with stage IIa disease and I. The 5-year survival rate for stage I cancer of the cervix is approximately 85% with either radiation therapy or radical hysterectomy.

There are advantages to using surgical therapy instead of radiotherapy, particularly in younger women for whom conservation of the ovaries is important. Chronic bladder and bowel problems that require medical or surgical intervention occur in up to 8 % of patients undergoing radiation therapy. Such problems are difficult to treat because they result from fibrosis and decreased vascularity. This is in contrast to surgical injuries, which in general are easily repairable and without long-term complications. Sexual dysfunction after radiation therapy is more likely to occur because of vaginal shortening, fibrosis and atrophy of the epithelium. The surgical procedure shortens the vagina, but gradual lengthening is brought about by sexual activity. The epithelium, seen after tissue culture microscopy examination, does not become atrophic because it responds either to the patient’s endogenous estrogen or to exogenous estrogens if the patient is postmenopausal.

In general, radical hysterectomy is reserved for women who are in good physical condition. Chronologic age should not be a deterrent. With improvements in anesthesia patients withstand radical surgery almost as well as their younger counterparts.

Generally, it is prudent not to operate on lesions, when examined under medical microscopes using tissue culture microscopy, which are larger than 4 cm in diameter. When selected in this manner, the urinary fistula rate is <2% (25) and the operative mortality rate is less than 1 %. An advantage of radiotherapy is its applicability to all stages to most patients regardless of their age, height and weight, and medical condition.