Cervical carcinoma - stage IV with nephrostomy insertion

Q: What is the main abnormality ? show answer

A: There is a mass involving the cervix

Q: What additional abnormality is present within the uterus ? show answer

A: There is an exophytic fundal leiomyoma

Q: What extra uterine abnormality is seen ? show answer

A: There is complicating bilateral obstructive hydronephrosis

Q: How is cervical carcinoma staged? show answer

A: The FIGO staging system is historically based on clinical and surgical staging using examination under anaesthesia, cystoscopy and proctoscopy. The 2009 revised FIGO staging now encourages imaging as an adjunct to clinical staging. MRI is the imaging modality of choice for local disease extent and CT or PET has a role for detecting distant disease.

Q: What are the pitfalls in reporting MRI in cases of cervical carcinoma? show answer

A: The accuracy of MRI in staging cervical carcinoma is variable in the literature. It has a high negative predictive value in excluding parametrial, bladder and rectal invasion. However inflammatory tumours may cause changes within the parametrium which is misinterpreted as parametrial invasion with a consequent upstaging of disease. The FIGO staging and definition of bladder and rectal involvement is biopsy-proven involvement of the mucosa. MRI may be oversensitive in staging advanced disease if there there is no full-thickness involvement of the adjacent organs.

Q: How is the management of the patient determined by the stage of the tumour? show answer

A: Conventionally tumours greater than 4cm in maximum dimension or stage IIB and above are non amenable to primary surgical management. First line treatment in these cases in combined chemotherapy and radiotherapy.

Q: What is worse in terms of staging ? - causing obstructive uropathy or rectal invasion ? show answer

A: Rectal invasion

Q: What is the significance of obstructive uropathy alone on staging of the disease ? show answer

A: It places the disease at stage IIIb

Q: What is the significance of rectal invasion alone on staging of the disease ? show answer

A: It places the disease at stage IVa

Q: What is the commonest histological sub type of carcinoma of the cervix ? show answer

A: Squamous cell carcinoma of the cervix : accounts of 80 - 90 % of cases

Q: Given the current stage of the disease, will surgery be reasonable option once the hydronephrosis is relieved by nephrostomies ? show answer

A: No. At the time of writing (2011-2012) stage IIa is considered the crucial separator between deciding whether a case is suitable for surgery (below stage IIa) or chemo-radiation (IIa or above). This patient has stage IV disease!