Carcinoma of The Cervix

Essential of diagnosis:

• Abnormal uterine bleeding and vaginal discharge
• Cervical lesion may be visible on inspection as a tumor or ulceration
• Vaginal cytology usually positive; must be confirmed by biopsy

General Consideration
Cancer appears first in intraepithelial layers (the preinvasive stage, or carcinoma in situ). preinvasive cancer (CIC III) is a common diagnosis in eomen 25-40 years of age and is etiologically related to infection with the human papillomavirus. two to 10 years are required for carsinoma to penetrate the basement membrane and invade the tissue. after invasion, death usually occurs within n3-5 years in untreated or unresponsive patients

Clinical Findings
A. symptoms and Signs
The most common signs are metrorrhagia, postcoital spotting, and cervical ulceration. Bloody or purulent, odorous, nonpruitic discharge may appear after invasion. Bladder and rectal dysfunction or fistulas and pain are late symptoms.
B.Cervical Biopsy and Endocervical Curettage, or Conization
these procedures are necessary steps after a positive Papanicolaou smear to determine the extent and depth of invasion of the cancer. Een if the smear is positive, treatment is never justified until definitive diagnosis has been established through biopsy.
C.Staging or Estimate of Gross Spread of Cancer of the Cervic
The depth penetration of the malignant cells beyond the basement membrane is a reliable clinical guide to extent of primary cancer within the cervix and the likeihood of metastases.

Complications
Metastases to regional lymph nodes occur with increasing frequency from stage I to stage IV. Paracervical extenson occur in all directions from the cervix.
the ureters are often obstructed lateral to the cervix, causing hydroureter and hydronephrosis and consequently impaired and kidney function, Almost two thirds of patiens with untreated carcinoma of the cervix die of uremia when ureteral obstruction is bilateral. pain in the back, int he distribution of lumbosacral plexus, is often indicative of neurologic involvement. Gross edema of the legs may be indicative of vascular and lymphatic stasis due to tumor.

Treatment
A.Emergency Measures
baginal hemorrhage originates from gross ulceration and cavitation in stage II-IV. Ligation and suturing of the cervix are usually not feasible, but ligation of the uterine or hypogastric arteries may be lifesaving when other measures fail. styptics such as Monsel's solution or acetone are effective, although delayed sloughing may result in further bleeding. wet vaginal packing is helpful. Emergency irradiation usually controls bleeding.

B.Specific Measures
1.Carcinoma in situ (stage 0)
in women who have completed childbearing, total hysterectomy in the treatment of choice. In women who wish to retain the uterus, acceptable alternatives include cervical conization or ablation of the lession with cryotheraphy or laser. Choose follow up with Papanicolaou smears every 3 months for 1 years and every 6 moths for another yeas is necessary after cryotherapy or laser

2.Invasive Carcinoma
Microinvasive carcinoma (stage IA) is treated with simple, extrafascial hysterectomy. Stage IB and stage IIA cancers may be treated with either radical hysterectomy or radiation therapy. Stage IIB and stage III and IV cancers must be treated with radiation therapy. because radical surgery results in fewer long-term complications than irradiation and may allow preservatioin of ovarian function, it may be the preferred mode of therapy in younger women without contraindications to major surgery