What are the typical signs and symptoms of a patient with stage IIIB cervical adenocarcinoma?

Signs and Symptoms of Stage IIIB Cervical Adenocarcinoma

Stage IIIB cervical adenocarcinoma typically presents with pelvic pain (often radiating to the hips, back, or legs), unilateral or bilateral leg swelling from lymphatic obstruction, abnormal vaginal bleeding or discharge, and urinary symptoms including hematuria or hydronephrosis from ureteral involvement extending to the pelvic sidewall. 1

Primary Clinical Manifestations

Pelvic and Lower Extremity Symptoms

• Pelvic pain that is new, progressive, or radiating to the hips, back, or legs indicates extension to pelvic structures or nerve involvement from parametrial extension to the pelvic sidewall 1
• Leg swelling (lymphedema) - unilateral or bilateral - results from progressive lymph node involvement or vascular compression, which is characteristic of stage IIIB disease with pelvic sidewall extension 1
• Leg pain may accompany the swelling and suggests advanced pelvic sidewall involvement 1

Gynecologic Symptoms

• Vaginal bleeding or discharge that is abnormal, persistent, or worsening indicates active tumor burden 1
• The bleeding pattern may be irregular, postcoital, or intermenstrual 1

Urinary Tract Involvement

• Hematuria (blood in urine) suggests bladder involvement or ureteral obstruction 1
• Urinary frequency or urgency from bladder irritation or compression 1
• Hydronephrosis or non-functioning kidney is the defining feature of stage IIIB disease when tumor extends to the pelvic sidewall causing ureteral obstruction 1
• Declining renal function with elevated creatinine/BUN indicates ureteral obstruction from progressive pelvic sidewall disease 1

Bowel Symptoms

• Rectal bleeding, obstruction, or tenesmus may occur if there is posterior extension toward the rectum 1
• These symptoms are less specific for stage IIIB but can occur with bulky disease 1

Systemic Manifestations

Constitutional Symptoms

• Unexplained weight loss is a concerning systemic sign of progressive disease burden 1
• Anorexia or decreased appetite suggests advanced disease 1
• Anemia (declining hemoglobin) can result from chronic vaginal bleeding or bone marrow involvement 1

Distant Symptoms (Indicating Progression Beyond Stage IIIB)

• Persistent cough or respiratory symptoms may indicate pulmonary metastases, which would represent stage IVB disease 1

Physical Examination Findings

Pelvic Examination

• Speculum examination should reveal the cervical mass and assess vaginal extension 1
• Bimanual pelvic examination is essential to detect parametrial extension to the pelvic sidewall, which defines stage IIIB disease 1
• Rectovaginal examination is critical as it can detect 26-50% of pelvic disease extent and assess posterior parametrial involvement 1
• The examination should detect fixation to the pelvic sidewall, which is the hallmark of stage IIIB 2

Diagnostic Confirmation

Imaging Findings

• Hydronephrosis or non-functioning kidney on imaging (CT, MRI, or ultrasound) confirms stage IIIB disease when caused by tumor extension to the pelvic sidewall 1
• MRI pelvis with IV contrast is superior to CT for assessing tumor extension and parametrial involvement 1
• PET-CT imaging can identify pelvic and para-aortic lymph node involvement, which significantly impacts prognosis in stage IIIB disease 3

Laboratory Abnormalities

• Elevated creatinine/BUN from ureteral obstruction is common in stage IIIB 1
• Anemia from chronic blood loss 1

Critical Clinical Pitfalls

• Do not rely solely on symptoms - 35-68% of disease extent can be detected by thorough pelvic examination including speculum, bimanual, and rectovaginal components 1
• Do not delay imaging when clinical examination or symptoms suggest advanced disease, as 41-83% of disease progression is detected by symptoms 1
• Recognize that stage IIIB adenocarcinoma has particularly poor prognosis - patients with stage IIIB disease have only 3% absolute improvement in 5-year survival with chemoradiotherapy compared to radiotherapy alone, versus 10% improvement for stage IB-IIA 2, 4
• Stage IIIB adenocarcinoma patients have worse outcomes than squamous cell carcinoma - in one series, only 8% of stage IIIA-IVB adenocarcinoma patients were alive at 2 years 4

Prognostic Considerations

The extent of lymph node involvement dramatically affects survival in stage IIIB disease: patients with no lymph node metastasis have 73% 3-year cause-specific survival, those with pelvic nodes only have 58%, those with pelvic and para-aortic nodes have 29%, and those with supraclavicular involvement have 0% 3-year survival 3. This underscores the importance of comprehensive staging with PET-CT imaging 3.