What is the best course of action for a patient with cervical adenocarcinoma (cervical cancer) presenting with abdominal pressure and pain, post-coital spotting, dyspareunia (painful intercourse), hematuria (red blood cells in urine), back pain, and urinary urgency?

Management of Cervical Adenocarcinoma with Locally Advanced Symptoms

This patient requires urgent comprehensive staging with CT/MRI and PET/CT imaging followed by concurrent chemoradiation with cisplatin, as the constellation of symptoms—hematuria, back pain, urinary pressure, abdominal pain, and post-coital bleeding—strongly suggests locally advanced disease (stage IIB or higher) with likely bladder and/or parametrial involvement.

Immediate Diagnostic Workup

The symptom complex indicates disease extension beyond the cervix:

• Hematuria (RBC in urine) necessitates cystoscopy to evaluate for bladder invasion, which would upstage the disease to stage IVA 1
• Back pain suggests possible parametrial involvement or lymph node metastases, particularly para-aortic nodes 1
• Urinary pressure and abdominal pain indicate pelvic sidewall extension or hydronephrosis from ureteral obstruction 2
• Post-coital spotting and dyspareunia are classic presenting symptoms but in combination with systemic symptoms suggest advanced rather than early-stage disease 2

Required Imaging Studies

Order the following imaging immediately 1:

• MRI of the pelvis to determine tumor size, degree of stromal penetration, vaginal extension, parametrial involvement, and corpus extension with high accuracy 1
• PET/CT scan for detection of lymph node involvement (sensitivity 75% for para-aortic nodes with 95% specificity in advanced stages) and distant metastases 1
• CT of chest/abdomen/pelvis if PET/CT unavailable, to detect pathologic lymph nodes and distant disease 1

Essential Laboratory and Procedural Workup

• CBC with platelets, comprehensive metabolic panel including liver and renal function tests 1
• Cystoscopy is mandatory given hematuria to rule out bladder mucosal involvement 1
• Proctoscopy only if rectal symptoms present (not indicated based on current symptoms) 1

Treatment Algorithm Based on Staging

If Locally Advanced Disease (Stage IIB-IVA) - Most Likely Scenario

Concurrent chemoradiation is the definitive treatment 1:

• External beam pelvic radiation with high-energy photons plus intracavitary brachytherapy at high doses (>80-90 Gy) delivered in short time (<55 days) 1
• Concurrent weekly cisplatin chemotherapy during radiation 1
• This applies regardless of adenocarcinoma histology, though adenocarcinomas historically show worse outcomes than squamous cell carcinomas with chemoradiation 3, 4

If Early-Stage Disease (IB1-IIA1) - Less Likely Given Symptoms

Radical hysterectomy with pelvic lymphadenectomy or primary radiotherapy are equally effective options 1:

• For stage IB-IIA disease, 5-year overall survival is 83% with surgery and 74% with radiotherapy 1
• Surgery may be preferred for adenocarcinoma specifically, as retrospective data suggests better outcomes with surgery versus radiotherapy for early-stage adenocarcinoma 5, 6
• However, severe morbidity is higher with surgery (28%) versus radiotherapy (12%) 1

If Stage IB2-IIB Disease

Recent evidence favors surgery for adenocarcinoma in younger patients 6:

• In propensity-matched analysis of 614 patients with stage IB2-IIB adenocarcinoma, 5-year overall survival was 73.0% with surgery versus 65.5% with radiotherapy (HR=1.394, p=0.023) 6
• Age >65 years, radiotherapy treatment, and stage IIB are independent poor prognostic factors 6
• Surgery should be considered for patients <65 years old even with stage IIB adenocarcinoma 6

Critical Clinical Pitfalls

Adenocarcinoma-specific considerations that differ from squamous cell carcinoma 3, 4, 7:

• Greater propensity for lymph node, ovarian, and distant metastases compared to squamous cell carcinoma 3
• Worse prognosis with chemoradiation compared to squamous cell carcinoma, both before and after concurrent chemoradiation era 3
• HPV-18 is more common in adenocarcinomas (nearly 100% of usual-type endocervical adenocarcinomas) 1
• Rare subtypes (clear-cell, mesonephric) are HPV-independent and may have different biology 1, 7

Do not delay treatment beyond 55 days if radiotherapy is chosen, as prolonged treatment time worsens outcomes 1

Avoid empiric antibiotics in the absence of fever, erythema, or warmth, as adult pelvic masses with these symptoms are neoplastic until proven otherwise 8

Symptom Management Priorities

Address urinary obstruction urgently if present:

• Hydronephrosis from ureteral compression can lead to renal failure 1
• May require ureteral stent placement or nephrostomy tubes before definitive treatment

Pain control is essential as pelvic pain indicates locally advanced disease with parametrial or pelvic sidewall involvement 2