Clinical Examination and Anesthesia Examination: In cases of suspected cervical carcinoma, a gynecological examination with a speculum and palpation is initially performed. An examination under anesthesia can be useful to more accurately assess tumor size, parametrial involvement, and vaginal extension with relaxed muscles. It is mainly used for advanced findings or for preoperative staging. Nowadays, anesthesia examinations are applied selectively; modern imaging (e.g., MRI) has replaced many older staging examinations.
Cytological Smear (Pap Test): The Pap smear is a central component of early detection. If an abnormal finding is present (e.g., Pap IIID, IVa, or higher), further diagnostics are initiated for clarification. However, a Pap smear alone does not provide a definitive diagnosis – abnormal cytology must be confirmed by histological examination. Nevertheless, the Pap test provides initial indications of dysplasia or carcinoma of the cervix.
Colposcopy and Biopsy: Following an abnormal Pap finding, a colposcopy is performed. Under magnification and application of acetic acid, suspicious areas on the cervix can be identified. A biopsy is taken from abnormal areas to obtain a histological diagnosis. If a high-grade intraepithelial lesion or suspicion of invasion is confirmed, a conization is indicated.
Diagnostic Conization (LEEP Conization): Conization – usually performed as Loop Excision (LEEP/LLETZ) or cold knife surgery – serves to completely remove the transformation zone of the cervix. It is diagnostic and, in very early carcinomas, simultaneously therapeutic. Indication: in cases of suspected microcarcinoma (e.g., HISTO PAP V/a, carcinoma in situ with suspicion of invasion) or non-definitive biopsy. Conization provides the definitive histological assessment: If invasive carcinoma is present, the specimen can be used to evaluate tumor size, depth of stromal invasion, and resection margin status (R0 vs. R1). A tumor removed with clear margins (R0 conization) can already be curative in microinvasive carcinomas (FIGO IA1). Otherwise, conization allows for precise staging and planning of definitive therapy.
Fractional Curettage and Hysteroscopy: In cases of unclear genesis of a cervical adenocarcinoma or suspicion of a descending endometrial carcinoma with cervical involvement, fractional curettage is indicated. The mucosa of the cervical canal and uterine corpus is scraped separately and examined histologically. This allows differentiation of whether the tumor originates primarily from the cervix or if an endometrial carcinoma is present that has grown into the cervix. If necessary, a hysteroscopy with targeted biopsy is performed additionally. These measures are particularly important in postmenopausal bleeding to rule out endometrial carcinoma. Fractional curettage provides the basis for further therapy planning: An endometrial carcinoma with cervical involvement is treated according to stage like a corpus carcinoma (FIGO stage II) (usually primarily surgically with hysterectomy and adnexectomy), while a primary cervical carcinoma requires different therapeutic approaches.
Imaging Procedures: Imaging examinations are used for pretherapeutic staging diagnostics. A transvaginal ultrasound can estimate tumor extension in the cervical area and, for example, detect hydronephrosis (indicating ureteral compression in advanced tumors). For tumors from approximately FIGO IB2 (≥4 cm), a pelvic MRI is generally recommended to assess local tumor extension (parametrial, vaginal involvement). For metastatic spread diagnostics, CT thorax/abdomen or PET-CT is used, especially in clinically advanced disease. Since the FIGO classification 2018, imaging is also included in staging, but it does not replace classical clinical findings.
Cystoscopy and Rectoscopy: A bladder endoscopy (cystoscopy) or endoscopy of the rectum/sigmoid (recto- or rectosigmoidoscopy) is only indicated if there is a concrete suspicion of involvement of these organs. In extensive cervical carcinoma with possible infiltration of the bladder (e.g., in hematuria or anterior parametrial involvement), a cystoscopy can be performed to detect tumor infiltration of the bladder mucosa, which corresponds to FIGO stage IVA if detected. Similarly, rectoscopy is performed if bowel involvement is suspected (bleeding per rectum, extensive dorsal tumor). These examinations are not routinely performed for every tumor today, as the hit rate is low in the absence of suspicion and imaging usually provides sufficient information.
Reference:
- Oncology Guidelines Program (German Cancer Society, German Cancer Aid, AWMF): S3 Guideline Diagnosis, Therapy, and Follow-up of Patients with Cervical Carcinoma, Long Version, 2.2, 2022, AWMF Registry Number: 032/033OL
- Fehm T, Beckmann MW, Mahner S, Denschlag D, Brucker S, Hillemanns P, Tempfer C; Uterus Commission of the AGO and the AGO Working Group. Statement of the Uterus Commission of the Gynecological Oncology Working Group (AGO) on Surgical Therapy for Patients with Stage IA2-IIB1 Cervical Cancer. Geburtshilfe Frauenheilkd. 2023 Oct 5;83(10):1199-1204. doi: 10.1055/a-2160-3279. PMID: 37808259; PMCID: PMC10556864.
- Bipat, S., et al., Computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol, 2003. 91(1): p. 59-66.
- Horn, L.C., et al., The 2019 FIGO classification for cervical carcinoma-what's new? Pathologe, 2019. 40(6): p. 629-635.
- Dappa, E., et al., The value of advanced MRI techniques in the assessment of cervical cancer: a review. Insights Imaging, 2017
- Woo, S., et al., Magnetic resonance imaging for detection of parametrial invasion in cervical cancer: An updated systematic review and meta-analysis of the literature between 2012 and 2016. Eur Radiol, 2017.