What are the physical manifestations of cervical cancer on examination?

Physical Manifestations of Cervical Cancer on Examination

Cervical cancer typically presents as a clinically visible lesion that can be either exophytic (growing outward from the surface) or endophytic (with stromal infiltration and minimal surface growth). 1

Common Presentations by Visual Inspection

• Exophytic growth: Appears as a cauliflower-like or papillary mass protruding from the cervix
• Endophytic growth: May show minimal surface changes but with underlying stromal infiltration
• Ulcerative lesion: Can present as an ulcer with or without keratinization
• Nodular appearance: Indurated, firm nodular growth on the cervix

Specific Physical Findings

Early-Stage Disease (FIGO Stage I-IIA)

• May be asymptomatic and not appreciable on gross examination 1
• Small visible lesion confined to the cervix (≤4 cm or >4 cm in greatest dimension) 1
• Subtle color changes or irregular surface
• No parametrial invasion on palpation
• No vaginal extension beyond upper two-thirds

Advanced Disease (FIGO Stage IIB-IV)

• Larger, more obvious lesions that may:
  • Extend to the pelvic wall
  • Involve the lower third of vagina
  • Cause hydronephrosis (detectable on imaging)
  • Invade adjacent organs (bladder, rectum) 1
• Parametrial invasion detected as induration or nodularity on bimanual examination
• Fixation to pelvic sidewall in very advanced cases

Histological Variants and Their Appearance

Squamous Cell Carcinoma (70-80% of cases)

• Keratinizing type: May appear more white/gray with keratin formation
• Non-keratinizing type: Often more reddish/pink and friable
• Papillary variant: Exophytic with finger-like projections 2

Adenocarcinoma (10-15% of cases)

• Often more barrel-shaped or papillary in appearance
• May produce copious vaginal discharge that can obscure visualization 3
• Can develop high in the endocervical canal, making visual detection difficult 3

Examination Pitfalls

1. Hidden lesions: Some cancers develop high in the endocervical canal beyond visual inspection 3
2. Minimal visible changes: Even deeply invasive tumors may be somewhat deceptive on gross examination 1
3. Misinterpretation: Papillary lesions may be mistaken for benign conditions 2
4. Bleeding: Heavy bleeding during examination may obscure proper visualization 2
5. Treatment effect: Prior treatment for presumed cervicitis can mask or alter appearance 3

Examination Approach

• If examination is difficult or there is uncertainty about vaginal/parametrial involvement, examination under anesthesia should be performed together with a radiotherapist 1
• Careful intraoperative palpation of the cervix and uterus can help determine the location and extent of the lesion 3
• For suspected endocervical lesions not visible on routine examination, consider endocervical curettage or advanced imaging

Remember that while visual examination is important, definitive diagnosis requires histological confirmation, and imaging studies like CT, MRI, and PET/CT may be necessary to accurately define the extent of disease 1.