16. Cervix cancer - The GEC-ESTRO Handbook of Brachytherapy

Cervix cancer

5

THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 01/09/2023

4. PATHOLOGY

including anaemia and renal dysfunction also have a negative impact on prognosis. Gynecological examination is an essential part of tumour assessment and is ideally carried out jointly by the gynecological surgeon and the radiation oncologist, preferably under general anesthesia. Pelvic examination begins with inspection of the external genitalia and insertion of a speculum to visualise the ectocervix. Next, the extent of disease on the cervix and vagina are digitally assessed per vagina; bimanual abdomino-vaginal examination is useful to assess the size and mobility of the uterus. Pelvic examination is completed by bi-digital rectovaginal examination to assess for parametrial involvement (right hand right pelvis, left hand left pelvis). Cystoscopy and/or proctoscopy are indicated if there is suspicion of organ infiltration on imaging. In all cases, a biopsy should be obtained for histology. Cross sectional imaging often provides additional information on local tumour extent that is not available from clinical examination. MRI is the imaging modality of choice because of its superior soft tissue delineation. MRI is superior to clinical examination for detecting early proximal parametrial and uterine involvement (Figure 2a). However, distal parametrial and vaginal involvement

The most common histological type is squamous cell carcinoma accounting for 80-85% of cases, followed by adenocarcinoma which is more common in young women. Non-squamous tumours are generally considered to have a worse prognosis but at present, are treated in the same way as squamous cancers. Different macroscopic forms are described (Figure 1) which may have an impact on prognosis.

5. WORK UP

Optimal management is critically dependent on thorough assessment of patient and tumour factors. Patient comorbidity and performance status will influence tolerance of treatment and risk of side-effects. Smoking has been shown to adversely affect response to treatment and increase risk of acute and late toxicity. Laboratory findings

Figure 1. Examples of macroscopic types a. Sagittal MRI showing an exophytic tumour arising from the cervix – at examination under anaesthetic, there was no evidence of vaginal involvement. b. Axial MRI showing an expansive Stage IIIB tumour. Note that the lateral edge of the parametrium is ~15 mm from the bony pelvis c. Axial MRI showing an infiltrative Stage IVA tumour invading into bladder (confirmed on cystoscopy and biopsy)

Figure 2. Primary tumour on MRI a. Stage IIB disease. There is breach of the dark stromal ring on the right indicating proximal parametrial involvement. b. Stage IIIB disease. Extensive left parametrial involvement with hydronephrosis. Distal parametrial involvement may be less obvious on MRI compared to clinical examination.