A 55 year old post menopausal woman presents with irregular foul smelling blood stained vaginal discharge, low back ache and left leg oedema for 3 months.a) What is the probable diagnosis?b) Enumerate the causes of post menopausal vaginal bleeding and outline the evaluation.c) Describe the FIGO staging and management of Carcinoma Cervix
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Clinical Case Analysis
55-year-old postmenopausal woman | Irregular foul-smelling blood-stained vaginal discharge + low backache + left leg oedema × 3 months
a) Probable Diagnosis
Carcinoma of the Cervix — Advanced Stage (FIGO Stage IIIB or higher)
The triad of symptoms is highly characteristic:
| Symptom | Explanation |
|---|---|
| Irregular, foul-smelling, blood-stained vaginal discharge | Tumour necrosis and secondary infection of the cervical mass causes offensive purulent/haemorrhagic discharge |
| Low backache | Tumour invasion of the parametrium, uterosacral ligaments, or involvement of lumbosacral nerve plexus / sacral roots |
| Left leg oedema | Lymphatic and venous obstruction from pelvic lymph node metastases or tumour extension to the pelvic side wall — a sign of at least Stage IIIB disease |
The clinical constellation — postmenopausal woman, offensive vaginal discharge, pelvic/back pain, and unilateral leg oedema — is classic for locally advanced cervical cancer until proven otherwise.
— Berek & Novak's Gynecology (Berek & Novak's Gynecology, p. 2223); Grainger & Allison's Diagnostic Radiology, p. 875
b) Causes of Postmenopausal Vaginal Bleeding & Evaluation
Definition
Any vaginal bleeding occurring ≥12 months after the last menstrual period is defined as postmenopausal bleeding (PMB) and is always abnormal — it requires thorough evaluation. PMB is distinct from the PALM-COEIN classification used for reproductive-age women.
Causes (approximate frequency)
| Cause | Notes |
|---|---|
| Atrophic vaginitis / endometrial atrophy | Most common (~60–80%); thinning due to oestrogen deficiency → friable vessels |
| Endometrial carcinoma | ~10% of PMB; 90% of endometrial cancer patients present with PMB — the most important cause to exclude |
| Endometrial polyps | Overgrowth of endometrial glands/stroma; up to 5% can undergo malignant transformation |
| Carcinoma of the cervix | As in this case — especially with foul discharge and pelvic signs |
| Uterine leiomyoma (fibroids) | Less common postmenopausally but can persist or cause bleeding |
| Hormone replacement therapy (HRT) | Exogenous oestrogen/progestogens; most common drug-related cause |
| Anticoagulant therapy | Warfarin, DOACs |
| Vaginal carcinoma / Vulval carcinoma | Less common |
| Ovarian tumours (oestrogen-secreting) | Granulosa cell tumour → endometrial stimulation |
| Cervical polyps | Benign; easily visualised on speculum examination |
| Endometritis / pelvic infection | |
| Bleeding from bladder/rectum mistaken for vaginal | Must be excluded by history |
— Sabiston Textbook of Surgery, p. 2795; Berek & Novak's Gynecology
Evaluation of Postmenopausal Bleeding
Step 1 — History
- Duration, character, and amount of bleeding
- Sexual history, HRT use, anticoagulants, tamoxifen
- Constitutional symptoms (weight loss, anorexia)
- Bladder/bowel symptoms
Step 2 — Physical Examination
- General examination, lymph node survey (inguinal, supraclavicular)
- Abdominal examination: masses, organomegaly, ascites
- Speculum examination: assess cervix (mass, ulcer, discharge), vaginal walls
- Bimanual pelvic examination: uterine size, adnexal masses, parametrial tenderness/nodularity
- Rectal examination: parametrial infiltration, rectal involvement
Step 3 — Investigations
First-line:
- Pelvic ultrasound (TVS): Endometrial thickness (ET)
- ET ≤ 4 mm → low risk for endometrial pathology (biopsy may be avoided, though this cut-off underdiagnoses some cancers, particularly in Black patients)
- ET > 4 mm → endometrial biopsy indicated
- Endometrial biopsy (Pipelle/Vabra aspiration): Indicated when ET >4 mm, focal lesion on imaging, persistent bleeding despite normal ultrasound, or inability to visualise endometrium
- PAP smear / cervical cytology (if not done recently)
- Colposcopy with directed biopsy if cervical lesion suspected
Second-line / as indicated:
- Hysteroscopy + D&C: Gold standard for focal endometrial pathology; allows direct visualisation and targeted biopsy
- MRI pelvis: Best for staging cervical/endometrial cancer, assessing parametrial invasion, and depth of myometrial invasion
- CT chest/abdomen/pelvis: Lymph node metastases, distant spread
- PET-CT: Advanced cervical cancer staging, lymph node detection
- Cervical biopsy (punch/cone biopsy) if cervical lesion present
- Full blood count, coagulation profile, renal/liver function
c) FIGO Staging and Management of Carcinoma Cervix
FIGO Staging System (2018 Revised)
The 2018 FIGO revision incorporated surgical, radiological, and pathological findings — a major change from the earlier purely clinical staging. Key changes: Stage IB divided into 3 substages; Stage IIIC added for lymph node metastasis; horizontal spread no longer considered for Stage IA.
| Stage | Description |
|---|---|
| I | Carcinoma strictly confined to the cervix (corpus extension disregarded) |
| IA | Invasive carcinoma diagnosed only by microscopy; max depth of invasion <5 mm |
| IA1 | Stromal invasion <3 mm depth |
| IA2 | Stromal invasion ≥3 mm and <5 mm depth |
| IB | Invasive carcinoma with invasion ≥5 mm, limited to cervix |
| IB1 | Invasion ≥5 mm, lesion <2 cm greatest dimension |
| IB2 | Lesion ≥2 cm and <4 cm |
| IB3 | Lesion ≥4 cm |
| II | Beyond uterus but not to lower third of vagina or pelvic wall |
| IIA | Involvement of upper 2/3 of vagina; no parametrial involvement |
| IIA1 | Tumour <4 cm |
| IIA2 | Tumour ≥4 cm |
| IIB | With parametrial involvement, not to pelvic wall |
| III | Lower 1/3 vagina and/or pelvic wall and/or hydronephrosis/non-functioning kidney and/or pelvic/para-aortic lymph nodes |
| IIIA | Lower 1/3 vagina, no pelvic wall extension |
| IIIB | Pelvic wall extension and/or hydronephrosis or non-functioning kidney |
| IIIC | Pelvic and/or para-aortic lymph node involvement regardless of tumour size |
| IIIC1 | Pelvic lymph node metastasis only |
| IIIC2 | Para-aortic lymph node metastasis |
| IV | Beyond true pelvis or involvement of bladder/rectal mucosa (bullous oedema alone does not qualify) |
| IVA | Adjacent organ invasion (bladder/rectum) |
| IVB | Distant metastases |
Note: 38% Stage I, 32% Stage II, 26% Stage III, 4% Stage IV at diagnosis (Berek & Novak's Gynecology, p. 2223)
Lymph Node Metastasis by Stage (important prognostic data)
| Stage | Positive Pelvic Nodes | Positive Para-Aortic Nodes |
|---|---|---|
| IA1 | 0.5% | 0% |
| IA2 | 4.8% | <1% |
| IB | 15.9% | 2.2% |
| IIA | 24.5% | 11% |
| IIB | 31.4% | 19% |
| III | ~47% | ~30% |
Management by Stage
Stage IA1
- Without LVSI: Cone biopsy (if fertility desired) or simple hysterectomy
- With LVSI: Modified radical hysterectomy (Type II) + pelvic lymphadenectomy; or cone biopsy if margins clear and fertility desired
Stage IA2
- Modified radical hysterectomy (Type II) + pelvic lymphadenectomy, OR
- Radical trachelectomy (fertility-sparing, for selected patients)
- Alternatively: brachytherapy (intracavitary radiation)
Stage IB1 and IB2
- Radical hysterectomy (Type III — Wertheim/Meigs) + bilateral pelvic lymphadenectomy — preferred for younger patients (allows ovarian conservation, avoids vaginal fibrosis from radiotherapy)
- OR definitive chemoradiation (concurrent cisplatin + external beam radiotherapy + brachytherapy) — equivalent survival outcomes
Stage IB3 and IIA (bulky)
- Concurrent chemoradiation (CCRT) is preferred:
- External beam radiotherapy (EBRT) to the pelvis
- Concurrent weekly cisplatin (radiosensitiser)
- Followed by intracavitary brachytherapy
- Neoadjuvant chemotherapy followed by radical surgery — in some centres
Stage IIB, III, IVA
- Definitive concurrent chemoradiation is the standard of care:
- EBRT (45–50 Gy) to whole pelvis (extended field to para-aortics if IIIC2)
- Concurrent weekly cisplatin
- Intracavitary brachytherapy (LDR or HDR) — mandatory to achieve adequate tumour dose
- Pelvic exenteration (anterior/posterior/total) for carefully selected Stage IVA with vesicovaginal or rectovaginal fistula, or for central recurrence after radiotherapy
Stage IVB / Metastatic Disease
- Systemic chemotherapy: platinum-taxane doublet (cisplatin + paclitaxel) + bevacizumab (anti-VEGF) — standard first-line
- Pembrolizumab (anti-PD-1) added for PD-L1-positive tumours
- Palliative radiotherapy for bleeding, pain control
Post-Treatment Surveillance
- Clinical examination every 3 months for 2 years, then every 6 months
- Pap smear from vaginal vault
- Imaging as clinically indicated for recurrence
Prognostic Factors
- Best predictor: Lymph node status — negative nodes: 85–90% 5-year survival; positive nodes: 20–74% depending on extent
- Tumour size: <2 cm → ~90% survival; >4 cm → ~40% survival
- Depth of invasion: <1 cm → ~90% survival; >1 cm → 63–78%
- Parametrial spread: 69% vs 95% survival (positive vs negative)
- Lymphovascular space invasion (LVSI): associated with 50–70% vs 90% survival
— Berek & Novak's Gynecology, pp. 2223–2253; Goldman-Cecil Medicine, p. 184; Grainger & Allison's Diagnostic Radiology, p. 876
Summary of This Case
This patient's symptoms (foul blood-stained discharge, low backache, left leg oedema for 3 months) place her at FIGO Stage IIIB or IIIC (pelvic wall involvement/lymph node metastasis). Management would be:
- Confirm diagnosis with cervical biopsy under direct visualisation
- Staging workup: MRI pelvis, CT/PET-CT, renal function (for hydronephrosis/cisplatin eligibility)
- Definitive concurrent chemoradiation: EBRT + weekly cisplatin + brachytherapy boost
- Consider extended field radiotherapy if para-aortic nodes involved
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