Cancerul de col uterin: o serie de cazuri clinice dintr-un centru terțiar din România

Introduction

Cervical cancer ranks top 4 in women’s malignancies worldwide, with higher incidence in regions and countries with low socioeconomic status. Romania has the highest cervical cancer incidence and mortality rates in the European Union, with approximately 3380 to 4343 new cases diagnosed annually, with an age-standardized incidence rate of 22.6-28.6 per 100,000 women. Cervical cancer is the second most common cancer among women aged 15-44 years old in the country, with mortality rates four times higher than the European average⁽¹⁾. The main histology is represented by squamous (80-90%) and endocervical adenocarcinoma (10-20%). Recently, carcinomas and their precursor lesions are classified by their association with HPV infection for prognostic purposes. Rare histology types include neuroendocrine carcinoma, glassy-cell and gastric-type adenocarcinomas, which are all independent to HPV, and have poorer prognosis^(2-4).

In 2020, World Health Organization (WHO) updated the classification of tumors of the cervix with an emphasis on the association with HPV infection. Invasive squamous lesions are now classified in HPV-associated and HPV-independent. Preinvasive and invasive glandular lesions are also classified in HPV-associated and HPV-independent⁽⁵⁾.

Our case series comprises cases of advanced cervical carcinoma diagnosed and managed in the departments of pathology and gynecology of the University Emergency Hospital Bucharest, Romania, between 2021 and 2026.

Materials and method

This is a case series of cervical carcinoma conducted in the Department of Gynecology at the University Emergency Hospital Bucharest, a major tertiary care hospital in Romania, between January 2021 and February 2026, after obtaining the informed consent from the patients.

Cervical biopsy and hysterectomy specimens of patients who presented with postmenopausal bleeding, postcoital bleeding and vaginal bleeding were considered for histopathological diagnosis.

Hematoxylin and eosin (H&E) staining and relevant immunohistochemistry (IHC) were performed to establish a definitive diagnosis. Medical record details and radiological findings for the selected cases were collected from the hospital information system. Microscopic analysis of the histopathology slides and relevant ancillary studies were documented using a light microscope. In correlation with the histopathological diagnosis and clinical and radiological findings, the selected cases were compiled for the current article.

Results

In the studied period, we found 916 cases of cervical cancer diagnosed in the Obstetrics and Gynecology Department of the University Emergency Hospital Bucharest, Romania, and more than 4900 admissions with the diagnosis of cervical cancer, cervical dysplasia and HPV infection per total, in different hospital departments. The youngest patient diagnosed with cervical cancer was 25 years old, and the oldest one was 95. The number of young women who presented to the hospital for gynecological investigations (especially for Babeş-Papanicolau cytology and HPV screening) increased, but also did the number of patients with advanced stages of cervical cancer. The patients with advanced stages need a multidisciplinary approach which is offered only by tertiary unit hospitals. Many of these women arrive with cervical bleeding of various intensity, moderate to severe anemia, pelvic pain and extensive pelvic tumor with urological implication (urinary bladder invasion, fistulae, ureterohydronephrosis, renal disease) and no previous biopsy for histologic diagnosis. Most of them never had a cervical Pap smear, or their last visit to the gynecologist was decades ago. We selected a few cases who stood out from the rest because of their clinical appearance, patient’s age and management.

Case 1

A 38-year-old primiparous woman presented with severe cervical bleeding and anemia. At 34 years old, she was diagnosed with FIGO IIIC cervical squamous invasive keratinized moderately differentiated NOS carcinoma. The patient received brachytherapy and three sessions of chemotherapy, which she discontinued. In 2024, PET-CT examination revealed pulmonary metastases and progression of the cervical tumor. Left nephrostomy was placed. The patient had previously refused pelvic exenteration, and she returned in 2025 with paresis of her right limb. MRI revealed accentuated post-radiotherapy fibrosis of the pelvic periuterine area, parametria, peritoneum, right rectal fascia, engulfing the ureters and causing grade-4 ureterohydronephrosis (UHN) on the right side. In 2026, one month prior to the current hospital admission, the patient had performed another CT scan that noted an increase in size of the pelvic tumor, which included the uterus, the cervico­vaginal segment, both ovaries, the perirectal fascia, the ureters, and was in close contact with the rectosigmoid junction and the posterior wall of the caecum. The right kidney appeared decreased in size, with grade-4 UHN. Progressive subdiaphragmatic lymphadenopathies were also noted. No new liver and lung metastases and no bone metastases were found. At the current admission, the patient had severe cervical bleeding, moderate to severe anemia (7.4 g/dl) and chronic kidney disease. She was stabilized, and uterine artery embolization was performed, with the remission of cervical bleeding at 24 hours after procedure (Figure 1). 

Case 2

A 25-year-old nulliparous woman presented with cervical bleeding and an abnormal Pap smear result (persistent HSIL, HPV-16 positive). Cervical biopsy was performed, and the histology result was nonkeratinized microinvasive (G2) squamous cell carcinoma of the cervix with intraglandular extension and CIN 3 areas. The radiology examinations (CT scan and MRI) revealed suspicious aspects of the cervix and the vagina, without other metastases. Radical total hysterectomy with removal of the lymph nodes was performed. The final HP result was nonkeratinized microinvasive (G2) squamous carcinoma of the cervix with intraglandular extension, FIGO stage IA1. The patient was referred to the oncology department, with good further outcomes.

Case 3

A 67-year-old woman arrived in the emergency care with vaginal bleeding, abdominal pain and difficulty at urination. The speculum examination revealed a grade-4 uterine prolapse with extended cervical erosion which involved the entire cervix, purulent discharge and bleeding (Figure 2). The clinical examination and ultrasound also revealed acute urinary retention and bilateral grade-3 ureterohydronephrosis. The patient was referred to the urology department for the treatment of acute urinary retention and insertion of bilateral JJ stents. In the obstetrics and gynecology department, cervical biopsy was performed. On histopathology, the results were keratinized squamous cervical carcinoma, moderately differentiated G2, with ulcerations and infection. Immunohistochemistry showed positive p63, diffuse en bloc positivity for p16, ER (ZR147) negative. The final diagnosis was keratinized HPV-associated, moderately differentiated G2, ulcered, infected, squamous cervical carcinoma. Radiology showed distant organ spread, therefore stage IVB was assigned, and the patient was referred to the oncology department for palliative chemotherapy.

Case 4

A 49-year-old multiparous woman presented with moderate anemia (hemoglobin 7 g/dl), macroscopic hematuria and pelvic pain. She had a Mirena hormonal intrauterine device (IUD) inserted two years before for heavy menstrual bleeding, and her last Pap smear was also two years before, with normal results. Two months prior to the current admission, she had addressed different medical units for pelvic pain and occasional hematuria. At inspection, her exocervix appeared almost normal, but a necrotic lesion was noted at the bottom of the cervix and on the anterior vaginal wall up to the urinary meatus. She had no active vaginal bleeding at that time. A biopsy was performed from the visible vaginal and cervical lesion, but with an inconclusive result. Before arriving in the emergency unit of our hospital, she had an MRI and a CT scan that described a voluminous tumor of the endocervix, with a diameter of 68 mm/65 mm/95 mm, which invaded the myometrium and the urinary bladder. The tumor also extended to the parametrium, bilaterally, to the vaginal wall and to the levator anni muscle on the left side. A tumor on the left renal pelvis was also noted. The patient presented in our unit with anemia and hematuria. She was stabilized, and cervical biopsy was performed, which revealed invasive squamous cervical carcinoma. The current stage is IVA, but her IHC results are in progress. The patient was referred to the oncology department for further treatment.

Case 5

A 46-year-old woman presented with moderate cervical bleeding. She was a smoker, had three pregnancies carried to term and multiple abortions. Her last cervical screening was at her last pregnancy, 15 years before. She entered menopause at 45 years old, and she had been diagnosed two years prior with stage IVB cervical cancer. The histopathology result was keratinized, invasive, moderately differentiated squamous carcinoma of the cervix. The patient received four cycles of chemotherapy until presentation in our unit. The clinical examination revealed a large tumoral cervix with a vegetative tumor of 3/3 cm, and the tumor mass extended to the superior third of the vagina and the parametrium. The pelvic MRI and CT scan before starting chemotherapy described the cervical tumor that reached the wall of the sigmoid, left ureterohydronephrosis, multiple lymphadenopathy and bone metastases at L2 and L5 vertebrae (Figures 3 and 4), the sacrum, the right iliac wing and the proximal humeral epiphysis. At the current admission, the patient was stabilized, she received hemostatic treatment, and a hemostatic mesh was placed in the vagina. The CT scan of thorax, abdomen and pelvis revealed an increase in cervical tumor size, but a decrease in the size of the iliac and mediastinal lymphadenopathies, the remission of the hydronephrosis and a stagnation in the evolution of bone metastases. The patient continued chemotherapy.

Discussion

Our results showed that most cancer types analyzed were diagnosed in an advanced stage. An explanation would be that these patients lacked regular medical checkups, discontinued investigations after unfavorable results, did not participate in any screening program, and lacked information about women’s health⁽⁶⁾. The average age for cervical cancer noted in our study group was 56 years old, and more than half of the analyzed cases were women under 60, meaning they were young women, with family and economic responsibilities. Compared with an older study performed a decade ago in the same unit, we noted an increase in the number of cervical cancer patients who address this hospital for advanced stages, needing a multidisciplinary approach⁽⁷⁾. Also, we observed a decrease in the minimum age at which cervical cancer was diagnosed (Case 2). It was interesting to note that the cases that were diagnosed in advanced stages, with more complications, were those of tumors of the endocervix. These cases often come with an initial inconclusive cervical biopsy (Case 4), urinary symptoms and less important cervical bleeding, which delays an accurate diagnosis and bring the patient at a later, more advanced stage. Another category is represented by patients with severe cervical bleeding, unresponsive to medical treatment, who are already diagnosed with cervical tumor and undergo oncological treatment (Case 1). These patients need stabilization to continue the oncology treatment scheme. Our unit offers the possibility of uterine artery embolization, and this is the last resort for the patients in advanced stages with severe bleeding.

Incidence and mortality have remained high but relatively stable since 2020, indicating persistent burden rather than rapid increase⁽⁸⁾.

A positive encouraging aspect is that, in 2025, Romania has restarted the vaccination program against HPV, offering the vaccine free of charge for girls and boys aged 11-26 years old and with 50% reimbursement for the ages of 26-45. This is a major step ahead for women and the medical system, as Romania’s public health objectives are to increase vaccination coverage toward the European target of 90% by 2030^(9,10). 

Conclusions

Cervical cancer is a very high disease burden in Romania compared with western Europe, driven mainly by low screening coverage (low organized participation) and a historically low HPV vaccination until late 2025. A large proportion of patients present at advanced stages (II-III), indicating late detection, consistent with low screening coverage. University Emergency Hospital Bucharest is among the few public centers in Romania that offers a multidisciplinary approach for cervical cancer patients, including interventional radiology and oncology. The case series we presented highlight the complexity and severity of this pathology. Patients with cervical cancer are young women, and the stage at the time of diagnosis is the main factor that influences prognosis. Moreover, patients who receive an unfavorable diagnosis should be guided and offered a more rapid access to specialized medical care. Furthermore, information and screening campaigns along with HPV vaccination remain the most reliable weapons against cervical cancer, and all forces should be joined in this direction. 

Autor corespondent: Oana-Maria Cosma E-mail: oanamb8@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.