In developed countries most cases of cervical carcinoma are diagnosed in asymptomatic patients due to routine screening with a Pap smear. Symptomatic patients present with abnormal vaginal bleeding and occasional vaginal discomfort or malodorous discharge. In patients with advanced disease, symptoms may include flank pain due to hydronephrosis, hematuria due to bladder invasion, rectal bleeding, or other gastrointestinal symptoms.

Cervical cancer arises from the squamocolumnar junction, which migrates over the years from the ectocervix in young women into the endocervical canal in older women. Therefore, exophytic tumors are typical for young women whereas endophytic tumors are more characteristic for older women.

Squamous cell carcinoma is the most common histologic subtype, responsible for 85 % of primary cervical cancers. Adenocarcinomas account for about 10–12 % of cases, but their incidence is on the rise in more developed countries. It is explained by the fact that adenocarcinoma in situ (the precursor lesion) is detected much less efficiently by Pap smear screening than preinvasive squamous lesions (squamous dysplasia and cervical intraepithelial neoplasia [CIN]). Clear cell carcinoma is a rare subtype of adenocarcinoma accounting for about 5 % of adenocarcinomas of the cervix. In the past, many cases were associated with in-utero exposure to diethylstilbestrol [6]. However, since its use in pregnancy was banned in 1971, the number of cases associated with this drug has diminished. Other uncommon histologic subtypes are adenosquamous carcinomas and small-cell carcinomas. Histologic types of carcinoma found in cervix (World Health Organization [WHO] classification) are summarized in Table 3.2.

Once the tissue diagnosis of invasive cervical carcinoma is established, the patient is staged. The International Federation of Gynecology and Obstetrics (FIGO) system, last revised in 2009, is the most widely used staging system for cervical carcinoma (Table 3.3) [7]. The FIGO staging of cervical carcinoma is clinical and does not rely on either surgical or pathologic findings. This allows uniformity of staging for all patients worldwide, which is of particular importance as cervical carcinoma is most prevalent in countries where surgical and diagnostic resources are limited.

For small early-stage tumors (stage IA and IB1), stage is assigned after measurement of the depth and width of tumor invasion on cone biopsy, pelvic examination for clinically assessment of tumor size, or both. For more advanced tumors, pelvic examination under anesthesia is sometimes necessary for the parametrial assessment. Additional tests permitted for FIGO staging are summarized in Table 3.4 and are restricted to imaging modalities available in most countries.

It is well known that clinical staging of cervical carcinoma is associated with significant inaccuracies compared to surgical staging, with an error rate up to 32 % in patients with stage IB disease and up to 65 % in patients with stage III disease [8]. The main difficulty is accurate clinical estimation of the tumor size in craniocaudal plane, assessment of parametrial and pelvic side wall invasion, and evaluation of lymph node metastases.

Although revised FIGO staging system does not allow the results of CT, MRI, or positron-emission tomography (PET or PET CT) to influence the clinical stage, the committee does encourage the use of these imaging techniques, if available, to more accurately assess important prognostic factors as tumor size, parametrial and pelvic side wall invasion, adjacent organ invasion, and lymph node status [7, 9, 10].