Ca cervix:

Ca cervix:
    Most common genital ca.
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

 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.

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

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)

*tubercular or syphilitic ulcer
*sarcoma of 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

 * 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.

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.

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