bOn rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to another cause.
equivalent specificity. Additionally, MRI has excellent sensitivity on T2-weighted images for the detection of parametrial disease (23). As a result, MRI is the preferred study to evaluate tumor size, lymph node metastasis, and local tumor extension.
PET scans are increasingly being utilized either alone or in conjunction with CT or MRI to detect metastatic disease; however, large prospective data series are limited. Early studies suggest that PET may be more useful than other techniques for the detection of abdominal and extrapelvic disease, with comparable or better sensitivity (76% to 100%) and specificity (94%) (24,25). In addition, PET scans may be better predictors of treatment outcome. Although early studies show promise for the use of PET scans in evaluating cervical cancer, the sensitivity for detecting metastatic disease less than 1 cm in size appears to be limited (26).
When abnormalities are noted on CT, MRI, or PET, radiographic-guided fine-needle aspirations (FNA) can be performed to confirm metastatic disease and individualize treatment planning. Because these tests are not available equally throughout the world and the interpretation of results can be variable, these studies are not used for staging. They may be useful in individual treatment planning.
The clinical staging system developed by FIGO is based on the belief that cervical cancer is a local disease until rather late in its course. The accuracy of clinical staging is limited, and surgical evaluation, although not practical or feasible in all patients, can more accurately identify metastatic disease. Surgical staging is advocated by providers who believe that surgical information details the extent of disease, allowing the treatment to be tailored to the individual (27). However, other providers believe that surgical staging should be limited to patients who are enrolled in clinical trials. These beliefs are based on the lack of randomized controlled studies demonstrating a survival benefit in patients who had surgical staging.
Figure 36.3 Carcinoma of the cervix uteri: staging cervical cancer (primary tumor and metastases). (From Benedet JL, Odicino F, Maisonneuve P, et al. Carcinoma of the cervix. J Epidemiol Biostat 2001;6:5–44, with permission.)
Squamous Cell Carcinoma Invasive squamous cell carcinoma is the most common variety of invasive cancer in the cervix. Histologically, variants of squamous cell carcinoma include large cell keratinizing, large cell nonkeratinizing, and small cell types (28). Large cell keratinizing tumors consist of tumor cells forming irregular infiltrative nests with laminated keratin pearls in the center. Large cell nonkeratinizing carcinomas reveal individual cell keratinization but do not form keratin pearls (Fig. 36.4). The category of small cell carcinoma includes poorly differentiated squamous cell carcinoma and small cell anaplastic carcinoma. If possible, these two tumors should be differentiated. The former contains cells that have small-to medium-sized nuclei and more abundant cytoplasm than those of the latter. The designation of small cell anaplastic
Table 36.2 Staging Procedures a Allowed by the International Federation of Gynecology and Obstetrics (FIGO). bInformation that is not allowed by FIGO to change the clinical stage.