Ca cervix:

Ca cervix:
    Most common genital ca.
AETIOLOGY:
1) Age 35-45 yrs
2) sexual intercourse b4 18 yrs of age.
3) multiple sexual partners
4) 1st baby b4 age of 20 yrs
5) multiparity
6) poor personal hygiene
7) poor socio-economic status
8) exposure to smegma from uncircumcised partner.
9) smoking
10) infections like STD, HIV infection, herpes, HPV
11) immunosuppresion
12) preinvasive lesions
13) COC and progesteron use over 8 yrs or more
14) diethylstilboesterol exposure

PATHOLOGY:
 Two types of cancer of cx.
  1) epidermoid ca (80%): arises frm stratified squamous epithelium
  2) endocervical ca (20%): arises frm mucous membrane of endocervical canal.
95% ca are squmous Ca only 5% are adenocarcinomas.

CLINICAL FEATURES:
Symptoms:
1) irregular menses
2) menometrorrhagia
3) continuous bleeding, postcoital bleeding
4) leucorrhoea, blood stained discharge

Signs:
1) cx reveals growth or ulceration which bleeds on touch
2) bulky uterus due to pyometra in adv stage
3) rectal examination reveals induration of uterosacral ligaments
4) biopsy reveals:
    A) alterd morphology
    B) nuclear: cytoplamic ratio is increased
    C) hyperchromatism
    D) thickening of nuclear memb
    E) clumping of cromatin material
    F) leaking of cancer cells into stroma (evident of cellular infiltration)

DDs:
*tubercular or syphilitic ulcer
*polypus
*sarcoma of cx

STAGING:
STAGE 1~~CA CONFINED TO CX
 * 1A ~ microinvasive ca
 * 1A1 ~ measured stromal invasion of less than 3.0mm in depth and less than 7.0 mm in horizontal spred
 * 1A2 ~ measured stromal invasion bet. 3 and 5 mm in depth and not exceeding 7 mm in horizontal spred
 * 1B ~ clinically visible lesion
 * 1B1 ~ clinically visible lesion 4cmor less in size
 * 1B2 ~ clinically visible lesion more than 4 cm in size

STAGE 2~~cancer spred beyond the cervix but not to pelvic wall or third of the vagina
  2A ~~tumour without parametrial invasion
  2B~~tumour with parametrial invasion

STAGE 3~~tumour exceeds lateral pelvic wall . Involves lower third of vagina
 3A ~~tumour involves the lower third of the vagina  no extention to lateral wall
 3B ~~tumour extends to the pelvic wall and or involves kidney

STAGE 4 tumour spreds ty the pelvic organ or distal metastatis
 4A ~~tumour involves bladder or rectum or spreds beyond the true pelvis
 4B ~~widespred tumour with distal metastatis

Δ DIAGNOSIS:
Investigations:
 * routine investigations like,
Haemogram, urine analysis, blood sugar, LFT, RFT, serum electrolytes, ABO and Rh grouping, pylography, cystography, ECG etc.
* CT and MRI : these techniqes offer imroved imaging and staging and ca can be detected in early stages
* positron emission tomography (PET): detects tissue biochemical changes
*FDG-PET using F-18 fluro-2-deoxy-D-glucose:
  Useful in determination of primary rx, lymph node detection and local reccurence detection.

TREATMENT:
Stage IA1:
* conization with clear margin is adequate.
* Hysterectomy may be suggested in elderly or parous women.
* lymphadenectomy is not required
* lifelong follow up is necessary

Stage IA2:
* extended hysterectomy and lymph node sampling (if growth < 2cm)
* postoperative radiotherapy is required in nodal involvement
* conservative rx comprises of laproscopic lymphadenectomy followed by vaginal trachelectomy-- consist of 80% removal of cx, upper vagina and Mackenrodt's ligaments. Done in women desirous of childbearing. 30-40% success.

Stage IB and IIA:
* Wertheim's hysterectomy:  comprises of removal of entire uterus, both adnexa,pelvic LNs, medial one-third of parametrium, upper one-third of vagina, sacral glands r spared. Overies may be retaind.
* Schauta's operation: consists of removal of entire uterus, adnexa, most of vagina, medial part of parametrium. Later it is followed by extraperitoneal lymphadenectomy. PO radiotherapy may b given.
* Radiotheray: surgical and radiotherapy combined incrases the morbidity in the woman. It consists of brachytherapy followed external radiation
* Combined therapy: required in,
   Postoperative radiotherapy in LN metastasis
   Preoperative chemoradiotherapy in endocevical ca.--- Neoadjuvant paclitaxel 90 mg and inj ifosfamide 2000 plus mesna 400 mg wkly for 3 cycles.
Cisplatine 50 mg wkly aft surgery

Stages IIB, III and IV:
Chenoradiotherapy to extend life.