CA CERVIX

Presented by SHABANA R ANCHU MARIAM CHARLY

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Anatomy of uterus
measures 9 * 6.5*3.5cm Weight 50-80 gm Uterus is divided

anatomically into 3 segments-The fundus, corpus, cervix The cervix (or neck )is the lower, narrow portion of the uterus, where it joins with the top end of the vagina. It is cylindrical or conical in shape
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Anatomy of cervix
The portion projecting into

the vagina is referred to as the portio vaginalis or ectocervix. (3 cm * 2.5 cm) The ectocervix's opening is called the external os. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. The endocervical canal terminates at the internal os which is the opening of the cervix inside the www.similima.com uterine cavity.

histology
The ectocervix is

composed of nonkeratinized stratified squamous epithelium. The endocervix is composed of simple columnar epithelium. The border of the endocervix and ectocervix is known as the transformation zone or squamocolumnar junction. The Transformation zone undergoes metaplasia physiologicallywww.similima.com

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INTRODUCTION
Malignant neoplasm of cervix uteri. Occur in younger women in child

bearing age. The most common genital cancer in India (80%) She may have no symptom, or present with Irregular bleeding, Post coital bleeding Leucorrhoea Blood stained or offensive discharge.

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High Risk Features

Coitus before 18 yrs. Multiple sexual partners. Delivery before the age of 20 yrs. Multiparity with poor birth spacing. Poor personal hygiene. Poor socioeconomic status. Exposure to smegma from uncircumscribed partners. smoking., drug abuse, alcohol. Women with STD, HIV,HS virus 2 infection, HPV infection or

condylomata, or both. Immunosuppressed individuals. h/o pre invasive lesion. COC, and progestogens use over long periods
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Pathology
EPIDERMOID CARCINOMA
80% of CA CX Arise from stratified squamous epithelium of

cervix

ENDOCERVICAL CA
20% of CA CX Arise from mucus membrane of endoceeervical

canal
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Cin/cervical intra epithelial neoplasia/pre invasive ca/stage 0

CIN refers to the histopathological description in which a part or the full

thickness of the stratified squamous epithelium replaced by cells showing varying degrees of dysplasia , but basement membrane intact Mild dysplasia CIN I Undifferentiated cells are confined to lower 1/3 of epithelium Moderate dysplasia CIN II Undifferentiated cells occupy lower 50 to75 % of epithelial thickness. Severe dysplasia & CA insitu CIN III Entire thickness replaced by abnormal cells, but basement membrane intact CIN II ,III :HSIL/high grade squamous intra epithelial lesions
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Clinical Features
She may have no symptom or present with Irregular menses. Menometrorrhagia. Continuous bleeding. post coital bleeding. Leucorrhoea. Blood stained or offensive discharge. The cx reveals a growth, which bleeds on touch, Or an ulcer with edges that bleed on touch. Cervical cancers usually do not spread early. They tend to be slow growing and cause most of their

problems in the pelvis.

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Staging of ca Cervix

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Staging
Stage I - limited to the cervix. IA - Diagnosed only by microscopy; no visible lesions
IA1 -Stromal invasion less than 3 mm in depth and 7 mm or

less in horizontal spread. IA2 - Stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less.

IB - visible lesion or a microscopic lesion with more

than 5 mm of depth or horizontal spread of more than 7 mm

IB1 - visible lesion 4 cm or less in greatest dimension IB2 - visible lesion more than 4 cm
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Staging of ca Cervix

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Stage II - Invades beyond cervix.

IIA - Without parametrial invasion, but involve upper 2/3

of vagina. IIB - With parametrial invasion.

Stage III - Extends to pelvic wall or lower third of

the vagina
IIIA - Involves lower third of vagina IIIB - Extends to pelvic wall and/or

causes hydronephrosis or non-functioning kidney

Stage IV - Extends outside the vagina

IVA - Invades mucosa of bladder or rectum and/or

extends beyond true pelvis IVB - Distant metastasis

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Mode of Spread
Continuity :Involves vagina, parametrium & uterine body. Contiguity :Urinary bladder & bowel. Lymphatic spread. Vascular embolisation to distant sites like lung & liver.

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Pre Invasive ca in Pregnancy

Symptoms :
Bleeding during pregnancy. Post coital bleeding.

Sign :

CX appear normal or show chronic cervix or erosion.

Diagnosis :
Pap smear. Colposcopy directed biopsy.

Management :

Woman allowed a vaginal delivery if invasive leision excluded.6wks postpartum another papsmear followed by colposcopy will confirm diagnosis.
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Invasive ca Cervix & Pregnancy

Symptoms :
Antipartum bleeding. Cervix presents similar picture as in non pregnant condition.

Diagnosis :

Multiple biopsy or colposcopy directed biopsy.

Management :
If pregnancy approaching term wait until foetus is viable. Elective classical caesarean delivery followed 4weeks later by surgery or radiotherapy.

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Diagnosis
Pap test. Tissue biopsy. Cervicography. Colposcopy. Schillers iodine test.

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Tissue biopsy
In invasive cancer, loss of

stratification and cellular polarity. Cells show alteration of morphology. Nucleocytoplasmic ratio reduced. Hyperchromatism. Thickening of nuclear memb. Clumping of chromatin material. Leakage of CA cells to underlying stroma.
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Pap smear
Screening test only. women over the age of 35 should undergo pap test. Can detect 98%of CA CX &70%of CA endometrium. Smear should be obtained prior vaginal examination as

fingers may remove the desquamated cx cells. Patient in dorsal position, labia parted & cuscos self retaining speculum gently introduced without lubricant.CX exposed &squamocolumnar jn is now scraped with ayre spatula.scrapings spread on slide & fixed by dipping it in jar containing equal parts of 95% ethyl alcohol &ether. Positive test requires further investigations like colposcopy cervical biopsy &fractional curettage.
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Pap smear

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Colposcopy
Accurate delineation of suspicious

areas for tissue biopsy. Suspicious areas appear as acetowhite areas.

Indications
Abnormal papsmear cytology. To locate abnormal areas. To obtain directed biopsy.
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Cervicography
Photograph of entire external os taken after

application of 5% acetic acid & send to colposcopist for selecting areas for biopsy.

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Investigations
Urine analysis. Haemogram. FBS, PPBS. LFT. Renal function test. Serum electrolytes. Blood ABO &Rh group. Descending pyelography. Cystoscopy. Radiography of chest. ECG. Biopsy types
surface biopsy. Punch biopsy. Wedge biopsy. Ring biopsy. Cone biopsy.
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Prognosis
Most early cancers are cured; Most advanced cancers are not.
If a cancer was removed surgically then it cannot

come back. If it recurs that means that a cancer cell had already spread by the time the cancer was removed, and it will take a couple of years to grow large enough to be detected. If a cervical cancer is destined to recur, about 85% will recur within the first two years after treatment. If there has been no recurrence by five years, then the cancer is unlikely to recur and is considered cured.
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SURVIVAL RATES FOR CERVICAL CANCER (FIVE YEAR )

Stage I

80% Stage II 65% Stage III 30% Stage IV 15%

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Management of ca Cervix

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t/t of dysplasia & cin

Mild dysplasia : Treat inflammation & advise follow up pap test

every 3 to6 months Moderately severe to severe dysplasia/CIN II,III

1. Local destructive a. Cryosurgery b. Fulguration c. Laser ablation d. Cauterisation 2. Excition of abnormal tissue : a. Cold knife conization b. Laser conization c. LLETZ /laser large loop excision of the transformation zone 3. Surgery a. Hysterectomy b. Therapeutic conization www.similima.com

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Surgical management
Wertheims hysterectomy : Recommended for patients with stage I-A2 , I-B & IIA. Abdominal hysterectomy Schautas operation:
Extended vaginal hysterectomy

Brunswig exenteration operation: Employed for centrally placed extensive cancer involving bladder or rectum.
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Homoeopathic management

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KENTS REPERTORY
RUBRIC:GENITALIA-FEMALE,CANCER,uterus 3 MARK MEDICINES ARGENTUM MET,ARS A,ARS-

I,CON,GRAPH,HYDR,KREOS,LACH,LYC,MURX,PHOS,SE P,SIL,THUJ ,

2 MARK MEDICINES ARG-m,ARG-n,BUFO,CALC,CARBO AN, CARB-V CROT-

H,IOD,NAT-C,NAT-M,NIT-AC,PHYT,SEC,STAPH,

RARE MEDICINES AURUM MURIATICUM NATRO

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NATUM,BUFO,ELAPS,LAPIS ALBA,

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Arsenicum album
Menses too profuse ,too soon. Burning in ovarian region. Leucorrhoea acrid, burning, offensive, thin. Menorrhagia.

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Arsenicum iodatum
Persistently irritating corrosive discharges. The

discharge may be foetid, watery and mucous membrane red, angry, swollen. Profound prostration, emaciation and emaciation.

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Arg-met
Eroded spongy cervix. Leucorrhoea foul, excoriating. Climacteric haemorrhage, worse by jarring.

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Aur-m-n
Indurated cervix. c/c metritis and prolapse. Leucorrhoea with spasmodic contraction of vagina.

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Bufo
Ulceration of cervix. Offensive bloody discharge. Menses too early ,copious, clots and bloody

discharge at other times. Excitement with epileptic attack. Watery leucorrhoea.

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Carbo animalis
Cancer of uterus. Painful induration in breast. Menses too early, frequent, long lasting; followed by

great exhaustion; so weak can hardly speak. Flow only in morning.

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Conium maculatum
Induration of os and cevix Menses delayed and scanty

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Elaps
Discharge of black blood between menses. Itching of vulva and vagina.

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Erigeron
Metrorrhagia-bright red. Profuse leucorrhoea with urinary irritation. Bloody lochia on least motion ; in gushes. Nose bleed instead of menses.

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Hydrastis
Erosion & excoriation of CX. Leucorrhoea worse after menses acrid, corroding,

shreddy, tenacious. Pruritis vulvae. Menorrhagia.

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Kali bichromicum
Yellow , tenacious leucorrhoea. Pruritis vulva with burning.

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IODUM
UTERINE HAEMORRHAGE MENSES IRREGULAR WEDGE LIKE PAIN FROM OVARY TO UTERUS DWINDLING OF MAMMARY GLAND ACRID LEUCORRHOEA CORRODING THE LINEN

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Kreosotum
Leucorrhoea yellow, acrid, odour of green

corn; worse b/w periods Corrosive itching within vulva Menses too early too prolonged Menstrual flow intermits Ceases on sitting or walking; reappears on lying

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Lapis alba
Pre-ulcerative stage of CA. Burning, stinging pain in uterus. Ulcerative CA.

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NITRIC ACID
LEUCORRHOEA BROWN,FLESH

COLOURED,WATERY,OFFENSIVE MENSES EARLY,PROFUSE,LIKE MUDDY WATER WITH PAIN IN BACK,HIP AND THIGHS

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Phosphorus
Slight haemorrhage from uterus between periods. Menses too early, scanty, but lasts too long. Weeps before menses. Metritis. Leucorrhoea profuse, smarting, corrosive; instead

of menses. Amenorrhoea with vicarious menstruation.

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Silicea
Discharge of blood between periods. Increased menses with paroxysms of icy coldness

over whole body. Milky, acrid leucorrhoea during urination. Discharge of blood from vagina every time child is nursed. Vaginal cyst.

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Secale cornutum
Passive haemorrhage in feeble, catchetic women. Burning pain in uterus. Brownish offensive leucorrhoea. Continuous oozing of watery blood until next period. Threatened abortion about third month.

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Thuja
Vagina very sensitive. Warty excrescence on vulva & perineum. Profuse leucorrhoea-thick, greenish. Severe pain in left ovary & left inguinal region. Menses scanty, retarded.

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