The histology of cervix cancer
The histology of cervix cancer is by and large, about 90% at least, squamous lesions. The other 10% are adenocarcinomas arising in the endocervical canal. Really for purposes of treatment and staging, we treat all the same with one little exception so that the pathologist will subdivide for you the biopsy. Saying this is a squamous cell lesion, it’s a large cell non-keratinizing and that really is going to be treated the same, whether it’s keratinizing or non-keratinizing. The one exception that we find on rare occasion is this small cell carcinoma of the cervix, with neuroendocrine elements. An exceedingly rare lesion. Sort of defies the usual spread patterns and prognosis in that it oftentimes hematogenously spreads and spreads widely despite the fact that it appears to be an early lesion, managed by surgery or radiation therapy. The role of chemotherapy in this group of patients is debated. I think most of us would probably add chemotherapy to that patient, even if she had early stage disease. But it’s such a rare lesion we don’t have clear cut clinical evidence of what’s the right thing to do.
National cancer institute
In staging the patients with cervix cancer, the spread patterns are fairly monotonous and routine. Local spread to the vagina, the perimetria, the tissue next to the cervix and invading the cervical stroma are the initial routes of spread. From there into lymphatics and the lymphatics are again in a step-wise fashion, have to metastasize to pelvic lymph nodes before they will go to periaortic or common ileac lymph nodes. It’s a fairly step-wise progression. Hematogenous metastases can be seen in liver and lung and bone. Usually those patients have very advanced local disease, stage III disease, spreading sidewall to sidewall.
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The staging system that we use and have modified over the years is a clinical staging system, rather than a surgical staging system that we use for endometrial cancer or for ovarian cancer. Cervix cancer is a clinically staged disease because most patients won’t undergo surgery as part of their treatment. They’ll be treated with radiation therapy and chemotherapy now, in most cases. We want to determine the extent of the disease on clinical examination, including a good pelvic examination. Cystoscopy and proctoscopy to evaluate whether there is any invasion anteriorly or posteriorly into the bladder and rectum are reasonable. Surgical staging on the other hand, with second look laparotomy in ovarian cancer, is not considered standard of care. It does fit into some of the clinical protocols that are ongoing or is required that the patient have a lymph node dissection prior to entering a randomized trial but certainly would not be considered standard of care. CT scan, on the other hand, is probably the single most effective test for staging, looking at adenopathy, looking at the liver, looking at the potential for obstructive ureters. So a CAT scan is an important part of that patient’s initial work-up. Stage I disease is disease clinically thought to be confined to the cervix. It’s subdivided by depth of invasion. This requires a conization of the cervix to get a big sample of the cervix to evaluate the depth of invasion. And it’s also related to the size of the primary lesion, if it’s a gross lesion less than or greater than 4 cm in diameter. Stage II is just sort of the next concentric ring of spread locally, into the vagina and the perimetria and the tissue beside the cervix. Stage III, lower vagina or out into the pelvic side-wall. Again, sidewall involvement is determined by a gynecologist on pelvic examination or if the patient has an obstructed ureter. Then stage IVa is rectal or bladder involvement, and IVb would be distant metastases such as lung or liver metastases.