Obgyn · Year 3 · from Obgyn

Case 3: Cervical Cancer - Locally Advanced

Patient Demographics

  • Age: 42 years
  • Sex: Female
  • Occupation: Hotel housekeeper

Chief Complaint

"I've had vaginal bleeding after sex and a foul-smelling discharge for the past 2 months."

History of Present Illness

The patient presents with a 2-month history of postcoital bleeding and intermenstrual spotting. She describes the bleeding as bright red, occurring within hours of intercourse, requiring a panty liner. She also reports a persistent foul-smelling, blood-tinged vaginal discharge. Over the past 3 weeks, she has developed dull lower back pain and left leg swelling. She denies urinary symptoms, constipation, or weight loss. She has not had a Pap smear in over 10 years due to lack of health insurance and access to care. She immigrated from Central America 15 years ago.

Past Medical History

  • G4P4, all vaginal deliveries
  • No prior surgeries
  • No known medical conditions
  • Never received HPV vaccination (not available during her adolescence)
  • Last Pap smear approximately 12 years ago (reportedly normal)
  • Smoker: 1 pack per day for 20 years

Social History

  • First sexual intercourse at age 16
  • Lifetime 4 sexual partners
  • Married for 18 years, monogamous
  • Works as hotel housekeeper
  • 20 pack-year smoking history, current smoker

Physical Examination Findings

  • Vital Signs: BP 118/76 mmHg, HR 82 bpm, BMI 28 kg/m2
  • General: Well-appearing woman in no acute distress
  • Abdomen: Soft, non-tender, no palpable masses
  • Lower Extremities: Left leg edema, 2+ pitting to mid-thigh
  • Pelvic/Rectal Examination:
  • External genitalia normal
  • Speculum examination reveals a large friable, exophytic cervical mass approximately 5 cm in diameter with necrotic areas and contact bleeding
  • Bimanual examination: cervical mass is fixed, extending to the left parametrium; palpable fullness in the left parametrium extending toward but not reaching the pelvic sidewall; uterus not mobile
  • Rectovaginal examination: parametrial involvement confirmed bilaterally, more prominent on left; rectal mucosa intact

Diagnostic Workup

  • Cervical Biopsy: Squamous cell carcinoma, keratinizing type, HPV-related (p16 positive)
  • HPV Testing: High-risk HPV positive (type 16)
  • Complete Blood Count: Hemoglobin 10.8 g/dL, WBC 9,200/microL, Platelets 298,000/microL
  • Comprehensive Metabolic Panel: Creatinine 1.4 mg/dL (elevated), BUN 28 mg/dL
  • MRI Pelvis:
  • Cervical mass measuring 5.2 x 4.8 x 4.5 cm
  • Tumor extends into bilateral parametria (left greater than right)
  • Left parametrial extension approaches but does not reach pelvic sidewall
  • Left external iliac lymph node measuring 2.2 cm (suspicious for metastasis)
  • Left hydroureter and hydronephrosis secondary to ureteral obstruction
  • Bladder and rectal mucosa appear intact
  • CT Chest/Abdomen: No pulmonary metastases, no para-aortic lymphadenopathy, left hydronephrosis confirmed
  • PET-CT: Intense FDG uptake in cervical mass (SUV 18), left external iliac node (SUV 12), and left common iliac node (SUV 8); no distant metastatic disease
  • Cystoscopy: Bladder mucosa intact, no tumor invasion
  • Examination Under Anesthesia: Confirmed bilateral parametrial involvement, tumor does not reach pelvic sidewalls

Diagnosis

Cervical Cancer, Squamous Cell Carcinoma, FIGO Stage IIIC1

  • IIB features: Parametrial invasion bilaterally
  • IIIC1: Pelvic lymph node involvement (elevated to Stage III per 2018 FIGO staging)
  • Associated left ureteral obstruction with hydronephrosis

Staging (2018 FIGO)

  • Stage IIIC1: Pelvic lymph node metastasis only
  • Tumor 5 cm with bilateral parametrial involvement
  • Positive pelvic lymph nodes on imaging
  • No para-aortic nodal involvement
  • No distant metastases

Management Plan

Immediate Interventions:

  1. Left ureteral stent placement by interventional radiology/urology to relieve obstruction and preserve renal function before treatment
  2. Smoking cessation counseling (critical - smoking reduces radiation therapy effectiveness and increases complications)
  3. Nutritional assessment and optimization

Primary Treatment - Definitive Chemoradiation:

Radiation therapy is standard of care for stage IIB and above - NOT surgery

External Beam Radiation Therapy (EBRT):

  • 45-50 Gy to the pelvis in 25 fractions over 5 weeks
  • Extended field to include para-aortic region if positive nodes at that level (not needed in this case)
  • Intensity-modulated radiation therapy (IMRT) to minimize bowel and bladder toxicity

Concurrent Chemotherapy:

  • Cisplatin 40 mg/m2 IV weekly during external beam radiation (5-6 weekly doses)
  • Radiosensitizer - improves survival by 30-50% compared to radiation alone

Intracavitary Brachytherapy:

  • Following completion of EBRT
  • Tandem and ovoid or ring applicator placement
  • Total brachytherapy dose to achieve cumulative dose of 80-90 Gy to point A
  • Critical for local control

Treatment Timeline:

  • Total treatment duration should not exceed 8 weeks (delays worsen outcomes)
  • Weekly cisplatin during weeks 1-5 of EBRT
  • Brachytherapy typically during weeks 5-7

Supportive Care During Treatment:

  1. Antiemetics for cisplatin-induced nausea
  2. IV hydration with cisplatin
  3. Monitor renal function (already compromised)
  4. Manage radiation-induced diarrhea, cystitis, fatigue
  5. Nutritional support
  6. Vaginal dilator use to prevent stenosis (starting after treatment)

Monitoring During Treatment:

  • Weekly CBC and metabolic panel
  • Clinical examination to assess tumor response
  • Renal function monitoring (ureteral stent in place)

Post-Treatment Surveillance:

  • Physical examination and Pap smear every 3 months for first 2 years
  • Imaging (PET-CT or MRI) at 3-6 months post-treatment to assess response
  • If complete response: continue surveillance
  • If residual disease: consider salvage options (exenteration if localized)

Why Not Surgery?

  • Stage IIB or higher with parametrial involvement is NOT treated surgically as primary therapy
  • Combining radical hysterectomy with radiation increases morbidity without improving survival
  • Chemoradiation is the standard of care for locally advanced cervical cancer

Counseling Points:

  • Treatment is curative intent with 60-70% 5-year survival for stage IIIC1
  • Radiation will induce permanent menopause
  • Sexual function counseling - vaginal stenosis prevention with dilators
  • Smoking cessation is critical
  • Treatment should not be delayed

Prognosis

  • Stage IIIC1 cervical cancer: approximately 60-70% 5-year survival with optimal chemoradiation
  • Favorable prognostic factors: squamous histology, complete response to treatment
  • Negative factors: large tumor size, nodal involvement, continued smoking

Clinical Image

Image Description: Sagittal T2-weighted MRI image of the pelvis demonstrating a large cervical mass with high signal intensity disrupting the normal cervical stroma. The tumor extends into the parametria bilaterally. Associated left hydroureter is visible secondary to ureteral obstruction by the tumor mass. The bladder and rectum appear intact without evidence of mucosal invasion.

Attribution: MRI findings in cervical cancer staging as described in radiology literature and Radiopaedia cervical cancer staging resources.

Summary of Key Learning Points

  1. Ovarian cancer presents late (70% stage III/IV) with nonspecific symptoms; high-grade serous is most common histology; management involves cytoreductive surgery and platinum-based chemotherapy; BRCA testing should be offered to all patients
  1. Lynch syndrome is the most common hereditary cause of endometrial cancer; universal tumor testing with IHC for MMR proteins is recommended; positive Lynch syndrome has implications for patient surveillance and family testing
  1. Locally advanced cervical cancer (stage IIB and beyond) is treated with definitive chemoradiation, NOT surgery; concurrent cisplatin improves survival; total treatment duration should not exceed 8 weeks
  1. PARP inhibitors represent a major advance in ovarian cancer maintenance therapy for BRCA-mutated and HRD-positive tumors
  1. Sentinel lymph node mapping has become standard for surgical staging of endometrial cancer and reduces lymphadenectomy morbidity
  1. Genetic testing should be considered in gynecologic cancers with family history suggestive of hereditary syndromes or specific histologic/molecular features

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