Cervical stump carcinoma is a condition that is usually attributed to either subtotal hysterectomy or supravaginal hysterectomy. Other research studies have also attributed cervical carcinoma to other forms of disease conditions, most notable of which include uterine fibromyomas.
The risk factor of a woman contracting cervical carcinoma who has previously undergone subtotal hysterectomy is ever significantly high and does not reduce with increased duration of the period from the time that the subject might have undergone a subtotal hysterectomy. Indeed various research studies that had sought to investigate the association between cervical carcinoma and subtotal hysterectomy had concluded that the eventual occurrence of carcinoma in the cervix is independent of the presence of malignant tumors that could have remained behind since subjects took as long as 29 years to develop cervical stump carcinoma in some instances. (1)
Case Report
A woman patient aged 47 years old was referred to our oncology Rapid Access Clinic after a routine cervical smear examination indicated evidence of a possible case of invasive adenocarcinoma. On further examination of the patient, no other symptoms were observed that were linked to gynecological conditions such as bladder or bowel problems. However, the patient had previously undergone subtotal abdominal hysterectomy with bilateral oophorectomy as a result of a benign gynecological condition in 2001. On the further assessment of the medical history of the patient, it was also determined that the patient had undergone a cholecystectomy surgery 26 years ago.
The medical file of the patient indicated that the patient has a history of suffering from an array of disease conditions that included hypertension and diabetes and was currently under medication that required daily insulin injections and another daily dosage of 0.625 mg of Premarin that the patient was using to control the symptoms of menopause.
The primary purpose of cervical smear test is to screen patients for malignant and premalignant cancerous tumors that are located in the octocervix region which are usually attributed to the cause of cervical cancer. (1) Because older women are increasingly susceptible to the risk of cervical cancer, the NHS Cancer Screening Programme recommends that women who are in the age bracket of 25-49 to undergo a cervical screening test three times a year and thereafter 5 times in a year until they are above age 64. (2) The patient in this case fitted the profile of persons that are at high risk of contracting cervical cancer and therefore the routine smear examination was justified.
In medical context a diagnosis of invasive adenocarcinoma is the first indication of evidence that physicians rely on to determine whether any form of cancerous process is underway during diagnosis of a patient. More often a diagnosis of invasive adenocarcinoma in a patient would imply the presence of an actively progressing cancer that is most likely to be breast cancer, stomach cancer, bowel cancer or cervical cancer among others. (2)
Because diagnosis of invasive adenocarcinoma is usually relied as a preliminary assessment in diagnosis of cancers further specific tests are often necessary to narrow down the list of possible conditions that a patient could be suffering from. It is on this basis that further diagnostic tests of the patient was justified as well as assessment of primary symptoms that are associated with the mentioned cancers which were found to be absent at the time. Previous medical condition of the patient also indicated the woman had undergone a subtotal abdominal hysterectomy in 2001 because of a benign gynaecological problem.
Hysterectomy is a procedure that involves surgical operation of the uterine as a treatment option of a dysfunctional uterine bleeding; subtotal abdominal hysterectomy is the partial removal of the uterine that conserves the cervix. (3,4) This method is regarded to be generally more effective than total removal of the uterine despite the fact that there is a minimal chance of cases developing cervical and invasive cancer.
At this point it was necessary to perform more specific and detailed medical tests to arrive at a conclusive diagnosis of the patient’s condition. Colposcopic examination of the cervical region of the patient indicated white and irregular vascularisation of mosaic aceto in a 2 cm area of the 4th quadrant of the cervix which was indicative of carcinoma or cervical intraepithelial neoplasia. Further laboratory tests were done on two samples of the biopsies that were obtained from the infected region for specific identification and categorization of the cancerous cells.
The laboratory findings on both of the specimens submitted were returned inconclusive because of the inability to orientate the fragments of the first specimen and lack of identification of any form of invasive cells in the samples. In addition, a significant proportion of specimen A that was under investigation indicated prescence of glands which showed architectural atypia, crowding and significant nuclear pleomorphism. Other glands contained normal endocervical epithelium merging with the neoplastic epithelium which would indicate an endocervical origin.
Because not all the slices of the specimen indicated the same results this assessment could not be completely relied. In addition the accuracy of the laboratory examination of the specimen was complicated by the nature of excision of the CIN which appeared incomplete as well as excision of the CGIN which was also determined incomplete at both ecto and endorcervical regions.
These characteristics could be attributed to the subtotal abdominal hysterectomy that the patient had previously undergone which must have interfered with the morphology of the cervical epithelial lining. This could be the reason why the lab report was inconclusive in arriving at a diagnosis, a difficulty which is attributed to the diathermy artifact with denudation of the surface epithilim. The lab report of specimen A finally reported there was no definite invasive neoplasia in all the particular specimen blocks that were examined because of the orientation and fragmentation of the of the specimen which made it difficult to ascertain the specific margin involved, nevertheless a high likelihood of ectocervical margin was suggested.
Specimen B was a stromal tissue that had small focus of endocervical epithelium; the microscopic examination of the specimen described it to contain fragments of blood clots and benign endocervical epithelium without any presence of endometrium. The summary of these observations from the laboratory examination of the specimen provided possible presence of atypical glandular proliferation and ESI which would mean presence of certain type of tumor.
But because no endometrial tissue was present for assessment the microscopic examination was also not conclusive in specimen B. The imaging results indicated the patient had no evidence of parametrial extension and pelvic lymph node enlargement which would indicate advanced stage of the invasive. At this point the doctor in charge recommended surgery through radical trachelectomy as it was the most effective form of management of the condition. (5)
Discussion
Subtotal hysterectomy provides unique advantages to the patient but which are also overshadowed by the health implications that the procedure presents to the patient even after immediate proliferation of the tumor has been averted. As a matter of fact, the cervix since it is never removed during subtotal hysterectomy becomes one of the site that malignant tumors are most likely to proliferate from. It is for this reason that it is always recommended to have the cervix “cupped” to the vagina in a technique that would lessen the chances of cervical carcinoma in the stump. (6) The proliferation of cancerous cells in the cervix is dependent on the duration from when the infection the Human Papilloma Virus (HPV) occurred, which will then determine the stage of the cancer in the body.
There are five stages that adenocarnicoma can be categorized according to the International federation of genecologists and obsestricians; in stage I, the cancer is still in its early stages and is confirmed in the area of origin which in this case is within the cervix. Stage II involves the cancer cells invading other regions but not yet affecting the pelvic sidewall, but when it does invade the pelvic, lower part of the vagina and the uterus, it becomes stage III. Stage IV is when it has invaded and affected other body organs that are located far beyond the cervical area of origin. (8)
The pre-invasive stage of adenocarcinoma is what is referred as the cervical glandular intraepithelial neoplasia (CGIN) which is either categorize as high CGIN or low CGIN depending on the stage of the cancer.
Most often invasive adenorcarcinoma cancer of the cervix usually invade the vagina area, pelvic, bladder and in the rectum region. (1,6) The cancerous cells also at times invade the lymphatic system of the body by infecting the pelvic lymph nodes, iliac lymph nodes, aortic lymph nodes and groin lymph nodes depending on the extent of the cancer in the body. The diagnosis of CGIN in a patient indicates a highly probability of adenocarcinoma since CGIN is thought to be a causal factor of most forms of cervical adenocarcinoma. The similarity between the two conditions is also very striking because both CGIN and adenocarcinoma have similar distribution in major areas of invasion including morphometric and morphological appearances that are very much alike.
But because invasive adenocarcinoma is asymptomatic during the early stages, as is the case for all other cancerous diseases, the lack of these symptoms indicated that it was still in stage I. The profile of the patient indicated a high susceptibility to suffering from invasive adenocarcinoma primarily because of the subtotal hysterectomy that she had previously undergone and also based on her age, gender and medical history. The major risk factors that are associated with these conditions include prolonged use of contraception’s, smoking, multiple sexual partners, repeated births, genetic factors and lifestyle factors among others. (6)
The patient profile included a history of using premarin medication normally used for easing symptoms that are associated with menopause; premarin main content is a form of synthetically manufactured estrogen that contain both estrone and equilenin. Estrogen is one of the key components used to manufacture many forms of oral contraceptives which are known risk factors of cervical carcinoma. By extension we can determine that use of premarin medication by the patient is one of the risk factors that contributed to the disease condition.
Because the cervix is not removed during subtotal hysterectomy as opposed to total hysterectomy, there is usually a probability that malignant tumors can proliferate from this region. (3) Nevertheless, subtotal hysterectomy has far much more advantages than total hysterectomy and a cost-benefit analysis will support the choice of subtotal hysterectomy. Foremost subtotal hysterectomy leads to rapid recovery of the patient as opposed to total hysterectomy; perhaps, one of the most compelling factors of choosing between the two procedures has to do with the mortality rate.
Generally, total hysterectomy is regarded to be a more dangerous procedure than subtotal hysterectomy because of the high incidence of mortality that is associated with it. But on the other hand, total hysterectomy is considered safer since there is zero probability of occurrence of cervical carcinoma given that the cervix is completely removed. Finally two other factors increased the patient susceptibility to cervical cancer which include her age (42 years) and number of births which are 2; this is because both of these factors are considered causal factors of cervical cancer.
References
- Cancer.org. Cervical cancer. 2010. Web.
- Nhs. uk. NHS Cervical Screening Programme. 2010. Web.
- McKinnon, D. & Virgil, S. Total Versus Subtotal Hysterectomy for Benign Conditions. 2010. Web.
- Thakar, R., Ayers, S., Clarkson, P. & Stanton, S. Outcomes after Total versus Subtotal Abdominal Hysterectomy. 2004. Web.
- Saiseni, A. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner’s Manual. Br J Cancer; 2003: 89 (1): 88–93.
- Walboomers JM, Jacobs MV, Manos MM, et al (1999). Human papillomavirus is a necessary cause of invasive cervical cancer worldwide”. J. Pathol. 2005; 189 (1): 12–19.
- Parys BT, Haylen BT, Hutton JL, Parsons KF. The effects of simple hysterectomy on vesicourethral function. Br J Urol. 1989; 64(1): 594-609.
- Green, J. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Intr J Cancer. 2007: 120(4): 885-891. 2007.