A 28-year-old woman was referred to the colposcopy clinic because of intermenstrual and postcoital bleeding. On examination a macroscopically visible lesion was present and on colposcopy features of malignancy were seen. Subsequent biopsy showed invasive squa- mous carcinoma of the cervix.
The woman was informed of the diagnosis and as a result went on to undergo an examin- ation under anaesthetic, cystoscopy and proctoscopy for staging. The mass was found to be 3 cm in size and there was no palpable extension into the uterus, vagina or parametrial tissues. The cystoscopy and proctoscopy were both normal.
She has had one child but had been hoping to have at least one more and is devastated by the diagnosis.
What are the possible treatment options and their potential complications?
Cervical cancer may be treated surgically or by radiotherapy. Staging is performed clin- ically at examination under anaesthetic as described.
Up to stage 1b women may be treated with radical hysterectomy (also known as Wertheim’s hysterectomy). This involves removal of the uterus, cervix, pelvic lymph nodes and parametrial tissue as well as the upper third of the vagina. Complications involve bleeding and infection. Ureteric damage may occur and blood vessel injury is not uncom- mon. Postoperative complications include infections of the chest, wound or urinary tract as well as venous thromboembolism and later-onset lymphoedema from interruption of lymphatic drainage from the lower limbs.
The advantage of this treatment is that it preserves ovarian function, important for well- being and prevention of osteoporosis. It also avoids the complications of radiotherapy outlined below.
This involves removal of the cervix, lymph nodes and parametrial tissue with conserva- tion of the ovaries and uterine body with insertion of a suture (cerclage) at the base of the uterus. It is used selectively for women with early stage disease who wish to preserve their fertility.
Disease beyond stage 1b, and postmenopausal women should be treated with radiotherapy which is effective but is associated with long-term effects of bowel stenosis, cystitis and vaginal stenosis. It also generally renders women menopausal due to radiation to the ovaries.