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CANCER of the UTERINE CERVIX by A Postgrad Med J: first published as 10.1136/pgmj.28.318.227 on 1 April 1952. Downloaded from 227 CANCER OF THE UTERINE CERVIX By A. H. CHARLES, F.R.C.S., F.R.C.O.G. Gynaecological Surgeon, St. George's Hospital; Surgeon, Samaritan Hospitalfor Women It is impossible within the compass of a short cervical cancers are Grade I (o to 25 per cent. of article to review all aspects of this disease. It is de-differentiated cells). Tumours with a large proposed, therefore, to concentrate mainly on the proportion of undifferentiated cells are the most diagnosis and treatment. malignant; they are also the most radiosensitive Cancer of the cervix occurs frequently in parous but are not equally radiocurable. women between 40 and 70 years of age. Nulli- Spread of cervical cancer takes place by: parous women represent only 7 per cent. of the (i) Direct extension to the adjacent vaginal cases. The disease is relatively uncommon in mucosa, upwards along the surface into the women of the upper classes and in Jewish women corpus, particularly in endocervical growths, or to of all classes. The comparative immunity enjoyed the parametrium. by Jewesses is probably racial and not due to (2) Lymphatic spread, by the lymphatics of the freedom from contact with smegma, as cancer of parametrium outwards to the nodes lying in the cervix is common in certain African tribes relation to the vessels on the pelvic wall. Lymph- where circumcision is ritual. The most important atic glands are situated along the external iliac factor in aetiology is pregnancy, either through 8 to io in in trauma to the cervix or to the cellular vessels, being number, arranged three activity groups, one lateral, one medial and one in front by copyright. which takes place during pregnancy. Trauma alone of the vessels. The latter group is sometimes is not responsible, as shown by the rarity of absent. Another important gland lies in the cancer in cases of procidentia, though the cervix is obturator fossa. Some smaller glands are dis- constantly exposed to friction and may be ulcer- tributed around the internal iliac artery and its ated. It is the cervix that is exposed for a long branches. The so-called ' paracervical gland ' is time to the action of a continuous cervical dis- seldom if ever seen. Efferents from these groups charge that is liable to develop cancer perhaps of to the common iliac and passing through precancerous stages before true glands pass upwards invasive cancer para-aortic nodes. appears. The stage to which a carcinoma has progressed http://pmj.bmj.com/ is more important than histological grading when Symptomatology considering the probable outcome of treatment. The symptom of greatest significance is bleed- Clinical staging is made in accordance with the ing, which may be irregular or a sudden profuse League of Nations' classification. In Harnett's haemorrhage, or menorrhagia. Occasionally, it cases were as follows: follows coitus. In only 2.9 per cent. of the series (1949) series, staged collected by the British Empire Cancer Campaign Per and reported by Harnett was post-coital bleeding Stage I. The carcinoma is strictly confined No. cent. on September 30, 2021 by guest. Protected the first symptom. A vaginal discharge was the to the cervix .. .. .. .. 201 23.4 first in 20. cent. of these cases. Stage II. The carcinoma infiltrates the symptom per Pain parametrium on one or both sides, but is seldom the first symptom and indicates advanced has not invaded the pelvic wall. Upper disease. one-third of vagina infiltrated. Spread to corpus .. .. .. .. 37.0 and Stage III. The carcinomatous infiltration Pathology Diagnosis of the parametrium has invaded the pel- The clinical varieties are: (i) ulcerative, (2) vic wall on one or both sides. Lower proliferative or cauliflower, (3) sclerosing, some- one-third of vagina involved. Isolated times known as the 'worm-eaten ' cervix, and (4) metastases on pelvic wall .. .. 221 23.7 endocervical. Stage IV. Carcinoma involves bladder as determined cystoscopically or a vesico- About 95 per cent. of these tumours are epider- vaginal fistula is present. Rectum in- moid cancers, the other 5 per cent. being adeno- volved. Distant metastases present .. II3 13.2 carcinomas. Histological grading is usually made Not staged for lack of data ... 6 .7 in accordance with Broder's classification based on the degree of cell de-differentiation. Very few Total .. .. .. 859 0oo.0 Postgrad Med J: first published as 10.1136/pgmj.28.318.227 on 1 April 1952. Downloaded from 228 POSTGRADUATE MEDICAL JOURNAL April 1952 In I950, American gynaecologists put forward or top of the vagina, while others take it direct a revision of the League of Nations' classification from the cervix or cervical canal, while Ayre (I949) which they termed the international classification. and Novak (I947) obtain specimens by scraping The only real change in this is to add Stage o to the cervix with a wooden spatula in the one case include carcinoma in situ and intra-epithelial car- and a scalpel or sharp spoon in the other. By cinoma. It must be emphasized that staging is taking a direct scraping from the cervix, the ex- done from clinical data and cannot take into foliated cells are obtained nearer their source and account lymph node infiltration. Some correction this surface biopsy is more accurate than a vaginal of the staging is possible in cases submitted to smear. operation, but such correction would falsify com- Epidermoid cancer of the cervix arises from the parison of the results of operation with the results squamo-columnar junction and, by scraping all of radiotherapy. round its margin, cancer cells are most likely to be The diagnosis of the established case is generally picked up. Ayre found that when vaginal smears obvious on digital and speculum examination. were taken from cervices which appeared sus- Improvement in the results of treatment must picious of cancer and cancer cells were found to come mainly by earlier recognition of the disease be present, subsequent biopsy confirmed cancer and it is to this end that much recent research has in almost Ioo per cent. of cases. However, when been directed. However, for some time,to come, the scrapings were taken from the squamo- the detection of cervical cancer in a curable stage columnar margin of cervices that appeared normal will depend upon the prompt attention of patients and cancer cells were obtained, the subsequent and their doctors to symptoms. In Harnett's biopsy often gave a negative result. The explanation series 20 per cent. of the patients allowed from lay in the difficulty of deciding from which area three to six months to elapse before consulting to take the biopsy. It is necessary to take a ring their doctors and over 25 per cent. allowed more biopsy, thus obtaining all the tissue round the than six months to go by before seeking advice. circumference of the squamo-columnar junction Some delay must be attributed to the doctor, but and to submit this tissue to serial section. Ifby copyright. a in Harnett's series, 80 per cent. of the patients small area is punched out of the circumference for were examined vaginally at once or within a month biopsy, it may only represent perhaps i/2oth of of the first consultation. Of those who consulted the tissue in which a carcinoma could be growing. a doctor 80 per cent. were referred to a hospital This work has proved that pre-clinical cancer may at once. Howson and Montgomery (1949) in lurk in a normal-looking cervix, and further that Philadelphia found that in the analysis of 1,140 pre-clinical cancer is not necessarily pre-invasive cases, the average duration of delay attributable or intra-epithelial or carcinoma in situ, but may be to the doctor was 7.4 months. In about half of early invasive cancer. Pre-invasive cancer need the cases of delay, no local examination was made. not necessarily proceed ultimately to an invasivehttp://pmj.bmj.com/ Doctors should make it a rule that if the patient stage, but in some of the cases this undoubtedly declines a vaginal examination when symptoms takes place. point to the possibility of cancer being present, the The interpretation of the material obtained by doctor should decline to order any treatment. vaginal smear or cervical scraping is not easy and Palliatives will only prolong examination delay, a long training is required before the cytologist's while refusal to give any medicine may persuade findings become trustworthy. In America, cancer the patient to submit to examination. Unfor- diagnostic clinics have been set up and cytological tunately, the symptoms may be insignificant until examinations are made from the cervices of all on September 30, 2021 by guest. Protected the growth has reached an advanced stage. If those who present themselves for examination. a reliable method can be found for diagnosis of Again in various gynaecological departments, the cervical cancer at its onset or before clinical signs cervices of all patients attending the out-patient are present, then we shall have a real chance of clinic or admitted to the wards, are submitted to reducing the mortality from this disease. a smear examination. This entails a tremendous In I928, Papanicolaou found cancer cells in the amount of laboratory work and it is estimated that vaginal secretions of women with uterine cancer, it costs about I50 dollars to detect a case of pre- but it was not until 194I that he co-operated with invasive cancer. When a vaginal smear has proved Traut to describe the vaginal-smear method of positive, the presence of pre-clinical cancer must diagnosis of uterine carcinoma (Traut and Papa- be confirmed by a ring biopsy before any treatment nicolaou, I941).
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