PART TWO
Diagnostic Cytology
Table 8.3
2 0 0 0 M o d i f i c a t i o n o f F I G O s t a g i n g o f c a r c in o m a o f t h e c e r v ix
u t e r i 197
Stage
Description
0
C a r c i n o m a in s it u ( p r e in v a s iv e c a r c in o m a ) .
I
C a r c i n o m a s t r i c t l y c o n f i n e d t o t h e c e r v i x ( e x t e n s i o n t o t h e
c o r p u s s h o u l d b e d is r e g a r d e d ) .
IA
P r e c lin ic a l c a r c in o m a s o f t h e c e r v ix , i.e ., t h o s e d i a g n o s e d
o n l y b y m ic r o s c o p y .
IA 1
S t r o m a l i n v a s i o n n o g r e a t e r t h a n 3 . 0 m m in d e p t h a n d
7 . 0 m m o r le s s in h o r i z o n t a l s p r e a d .
IA 2
S t r o m a l i n v a s i o n m o r e t h a n 3 . 0 m m a n d n o t m o r e t h a n
5 . 0 m m w i t h a h o r i z o n t a l s p r e a d o f 7 . 0 m m o r le s s .
IB
C li n i c a l l y v is i b l e l e s io n c o n f i n e d t o t h e c e r v ix o r m i c r o -
s c o p ic l e s io n g r e a t e r t h a n IA 2 .
II
I n v a s iv e c a r c in o m a t h a t e x t e n d s b e y o n d t h e c e r v ix b u t
h a s n o t r e a c h e d e i t h e r la t e r a l p e lv ic w a ll; i n v o l v e m e n t o f
t h e v a g i n a is l i m i t e d t o t h e u p p e r t w o - t h i r d s .
III
I n v a s iv e c e r v ic a l c a r c in o m a t h a t e x t e n d s t o e i t h e r la t e r a l
p e lv ic w a ll, o r t h e l o w e r t h i r d o f t h e v a g in a , o r b o t h .
I V A
I n v a s iv e c a r c in o m a t h a t in v o l v e s t h e u r i n a r y b l a d d e r o r
r e c t u m o r b o t h , o r e x t e n d s b e y o n d t h e t r u e p e lv is .
V
D is t a n t m e t a s t a s is .
F IG O : S t a g in g c la s s ific a t io n s a n d c lin ic a l p r a c t ic e g u id e lin e s o f g y n e c o lo g ic
c a n c e rs b y F IG O C o m m i t t e e o n G y n e c o lo g ic O n c o lo g y . 197
Clinical Considerations
In its earliest stages, invasive cancer may not disturb the configu-
ration of the cervix and may remain undetected during palpa-
tion or even at colposcopic inspection. MacLean and co-workers
found in a series of women with invasive cancer that the major-
ity had never had a cytologic smear taken or had not had smears
taken frequently enough.215 Of 122 women found to have
invasive cancer, only 12 women (10%) had ever before been
examined cytologically.
In our experience, in women age 55 years and older, invasive
cervical cancer is almost always diagnosed in a more advanced
clinical stage. Only 2 of 47 women with invasive cancer diag-
nosed in this age group had a cytologic cervical smear taken at
any time in their life. Because 39% of invasive cancers were diag-
nosed in this age group, a considerable reduction in mortality
could be realized if these women were screened periodically.
Macroscopically, malignant cervical tumors can be divided
into two categories. Exophytic growth, consisting of papillary
excrescences or wart-like masses, protrudes above the surface.
This kind of tumor most often originates in the epithelium of
the ectocervix or the portio vaginalis. Endophytic growth is a
growth pattern most commonly found in tumors originating
proximally from the external os.
In squamous cell carcinoma, the most important prognostic
factors are the extent of the tumor, differentiation grade, and
histologic type or subtype. The extent of the neoplasm at the
time of diagnosis is still the most important factor in prognosis.
Women with lymph node involvement have only half the life
expectancy of women without distant spreading of the tumor.216
Accurate determination of the extent of the tumor at the time of
diagnosis is thus of utmost importance. The type of the tumor,
Table 8.4
G r a d in g s y s t e m f o r m a l i g n a n t t u m o r s
Percentage of differentiated
cells
Grade
7 5 - 1 0 0
I
5 0 - 7 5
II
2 5 - 5 0
III
0 - 2 5
IV
A d a p t e d f r o m B ro d e rs .221
the degree of differentiation, and the host's immune response
are of only secondary importance in the final outcome of the
disease. Cervical carcinoma may spread along the mucosal sur-
face and by direct growth into adjacent structures and along tis-
sue spaces. Distant spread occurs via the lymphatic system and
less frequently via blood vessels.
Local growth of the tumor is upward into the body of the
uterus or downward into the vagina. In a horizontal plane, the
tumor may grow into the wall of the bladder and the rectum
as well as laterally, eventually reaching the wall of the pelvis.
The extent (stage) of the disease is determined according to the
FIGO staging system, based on finding from physical examina-
tion (Table 8.3).197
Involvement of vascular structures by the primary tumor is
related to the frequency of lymph node involvement. Van Nag-
ell and co-workers reported lymph node metastases in 6% of
patients without vascular involvement and in 34% of patients
with invasion in lymphatics and small blood vessels.217 Barber
and associates found 5-year survival in patients with stage IB
carcinomas without vascular involvement (90%) to be signifi-
cantly better than in patients who showed vascular involvement
(59.4%).218 In stage IB and IIA carcinomas, lymph nodes were
found in 20 to 45% of patients.216 Most frequently involved are
the external iliac, obturator, and hypogastric nodes, followed in
order of frequency by the common iliac, parametrial, and para-
cervical nodes.
Histology
The classification of types and subtypes of a malignant tumor
should reflect a correlation between the specific morphology
and the biologic behavior of the tumor variant, and it should
enable universal recognition and classification of morphologic
characteristics to ensure uniform reporting and registration.
Tumors composed of poorly differentiated cells in general are
more aggressive than tumors composed of well-differentiated
cells.219,220 The most widely used grading system was proposed
by Broders.221 This grading system was based on the proportion
of well-differentiated cells in the total cell population compos-
ing a tumor (Table 8.4).
Broders later recognized that in tumors of the uterine cer-
vix, there was no counterpart for the grade I epidermoid cancer
of the skin and recommended using three grades with kerati-
nization as the decisive parameter for differentiation. Broders'
grading system has had a very positive influence on the repro-
ducibility of grading of malignant tumors.
However, in squamous cell carcinomas of the cervix, signs of
keratinization were interpreted as a characteristic of differentia-
tion. This may be correct in cases of carcinomas originating in
190
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