Reproductive Neoplasm

Benign & Malignant Tumors of Uterus

Uterine Fibroids

Uterine fibroids are benign tumors that originate in the uterus. It is the most frequent kind of uterine  Because this tumor is made up of smooth muscles and fibrous connective tissue, it is known as uterine leiomyoma, myoma, or fibromyoma.

Incidence

• It is estimated that at least 20% of women at the age of 30 have got fibroid, most of them remaini asymptomatic.
  • 10% prevails in England, more higher in black women.
  • These are more common in nuliparous or in those having one child.

Causes of Uterine Fibroids

• Exact etiology still unclear
• Chromosomal abnormalities (abnormal cellular proliferation)
• Positive Family history
• Estrogen- it is predominantly estogen-dependent tumor
  • Limited during child bearing period
  • Increased growth during pregnancy
  • Do not occur before menarche
  • Cessation of growth after menopause

Body of Uterus

• Interstitial (intramural)
• Subserous
• Submucous - sessile and pedunculated

Cervical

• Anterior
• Posterior
• Central
• Lateral 
• Interstitial (intramural) - located within the muscular wall of the uterus.
• Subserous - located beneath the serosa (the lining membrane on the outside of the uterus).
• The fibroids are either partially or completely covered by peritoneum. When completely covered it usually attains a pedicle - pedunculated submucosal fibroids.
• The pedicle turn through peritonium and gets nourishment from omental or mesenteric adhesion-wandering or parasitic fibroids.
• If in between the layers of broad ligament- broad ligament fibroids.
• Submucous-located inside the uterine cavity beneath the lining of the
• Pedunculated submucous- may come out through the cervix.

Clinical Features

Most women with uterine fibroids have no symptoms. The site of the fibroid is more important than size- a small submucous fibroid may produce more symptoms than big subserous fibroid.

Symptoms

• Menorrhagia, metrorrhagia, dysmenorrhoea- If fibroids are near the uterine lining, or interfere with the blood flow to the lining, they can cause heavy periods, painful periods, prolonged periods or spotting between menses.
• Infertility
• Pregnancy related problems-abortion, preterm labor, IUGR,
• Lower abdominal pain • Abdominal swelling (lump)
• Pressure symptoms- constipation, dysuria, retention of urine, hydroureteric leading to pyelitis
• Anemia

Signs

• On abdominal examination; firm or hard cyst, mobile from side to side but restricted from above downwards
• On percussion -dull
• On pelvic examination- uterus is not felt separated from swelling and as such groove is not felt between uterus and the mass
• Cervix moves with the movement of tumor felt per abdomen

Investigations

• Blood investigations
• MRI
• Hysteroscopy
•  Pelvic examination
• Ultrasound and color doppler
• Laparoscopy
• Uterine curettage

Management of Fibroid uterus

• Medical Management: To control abnormal uterine bleeding
• Anti-progesterones, danazol, GnRH agonist, GnRH antagonist, antifibrinolytics, prostaglandin synthetase inhibitors
• Low dose formulation of oral contraceptives

• Surgical management

• Myomectomy
• Hysterectomy- total or subtotal
• Cryosurgery
• MRI guided high intensity focused ultrasound
• Uterine Artery Embolization (UAE)

Endometrial Carcinoma

The inner lining of the uterus, or endometrium, is where endometrial cancer develops. Additionally, uterine muscle tissue and supporting connective tissue can develop into cancer. These malignancies are part of the sarcoma cancer subtype.

Most endometrial carcinomas are malignancies of the endometrium's gland-forming cells. They are referred to as adenocarcinomas.

Endometrioid adenocarcinoma, the most frequent form of endometrial cancer,

Squamous cell and undifferentiated endometrial carcinomas are two more, less frequent forms.

Incidence

• Highest incidence amongst white population of US and lowest in India and Japan
• The American Cancer Society estimates for cancer of the uterus in the US for 2013 are: Ho 8,190 women will die from cancers of the uterine body.
• About 2% of uterine body cancers are sarcomas
• Endometrial cancer is rare in women under the age of 45. Most (about 3 out of 4) cases are found in women aged 55 and over

Etiology

• The risk of endometrial cancer in women rises as estrogen levels rise (menopausal hormone therapy, pills).
• A median age is 60 and a postmenopausal percentage of roughly 75%. Parity is more prevalent in single women, while around 30% of married women are nulliparous.
• If menopause happens after age 52, it will be late. High levels of free estradiol are a result of obesity.
• Polycystic ovarian syndrome, granulosa-theca cell tumor, and ovary (PCOS) Breast cancer prevention and treatment using tamoxifen. Tamoxifen behaves like an estrogen in the uterus but works as an antiestrogen in breast tissue.
• Colon, ovarian, or breast cancer in one's family or personally. hyperplasia of the endometrium.
• A diet heavy in fat.

Signs and Symptoms of Endometrial Cancer

• Unusual vaginal bleeding, spotting
• Postmenopausal bleeding- slight, irregular or continuous. At times, may be excessive In Premenopausal women, irregular and excessive bleeding:
• About 90% of patients have abnormal vaginal bleeding, such as a change in their periods or bleeding between periods or after menopause.
• Losing weight without trying
• Pain in the pelvis- due to attempt to expel the polypoidal growth.
• Non- bloody vaginal discharge in about 10% of cases, the discharge associated with endometrial cancer is not bloody.

Signs

• The uterus is either atrophic, normal or may be enlarged due to spread of tumor, associated fibroid or pyometra.

Pelvic examination:

• Healthy cervix
• Bloody or purulent offensive discharge

Diagnosis

• History and physical exam
•  Hysteroscopy
• MRI and CT
• Blood tests-CBC
• Endometrial biopsy
•  Dilation and curettage (D&C) Positron emission tomography (PET)
• CA 125 blood test

Staging of Invasive Endometrial Carcinoma

• Stage 0: Carcinoma in-situ
• Stage I: The cancer is only growing in the body of the uterus
•  Stage II: The cancer has spread from the body of the uterus and is growing into the supporting connective tissue of the cervix (called the cervical stroma).
• Stage III: Either the cancer has spread outside of the uterus or into nearby tissues in the pelvic area.
• Stage IV: The cancer has spread to the inner surface of the urinary bladder or the rectum (lower part of the large intestine), to lymph nodes in the groin, and/or to distant organs, such as the bones, omentum or lungs.

Management of Endometrial Carcinoma

•  Preventive Management:
  • Strict weight control.
  • To restrict use of estrogen after menopause.
  • Early seeking of medical help if irregular pre and postmenopausal bleeding
  • Screening of 'high risk women.
  • Cytologic tests to detect early.
  • Judicial hysterectomy in premalignant lesions of the corpus.
• Curative Management:
  • The four basic types of treatment for women with endometrial cancer are:
    •  Surgery
    • Hysterectomy

Types of Hysterectomy

Depending upon the extent of removal of the uterus and adjacent structures, the following types are described

• Total hysterectomy: Removal of the entire uterus.
• Subtotal: Removal of the body or corpus leaving behind the cervix.
• Pan hysterectomy: Removal of the uterus along with removal of tubes and ovaries of both sides. The term 'hysterectomy' with bilateral salpingo-oophorectomy is preferred.
• Extended hysterectomy: Panhysterectomy with removal of cuff of vagina.
• Radical hysterectomy: Removal of the uterus, tubes and ovaries of both the sides, upper one third of vagina, adjacent parametrium and the draining lymph glands of the cervix.
• A Bilateral Salpingo: Oophorectomy is a surgery in which a woman's ovaries and fallopian tubes are removed. The surgery is of the procedure. This kind of surgery can be performed both laparoscopically and as an open procedure. The most common issues leading into a Bilateral Salpingo-Oophorectomy include: some forms of cancer, a pelvic inflammatory disease, or patients with especially bad endometriosis.
• Radiation therapy: Internal radiation therapy (brachytherapy) or external beam radiatio therapy
• Chemotherapy: Drugs used in treating endometrial cancer may include:
  • Paclitaxel
  • Doxorubicin
  • Carboplatin
  •  Cisplatin
• Hormonal Therapy: Progesterone-like drugs called progestins.
  • The 2 most commonly used progestins are medroxyprogesterone acetate (Provera, which can given as an injection or as a pill) and megestrol acetate (Megacef, which is given as a pill). Th drugs work by slowing the growth of endometrial cancer cells.

Uterine Sarcoma

• Uterine sarcoma is a cancer of the muscle and supporting tissues of the uterus (womb).
• Sarcomas are cancers that start from tissues such as muscle, fat, bone, and fibrous tissue (the material that forms tendons and ligaments).

Classification

Most uterine sarcomas fall into 1 of 3 categories, based on the type of cell they developed from:

• Endometrial stromal sarcomas- develop in the supporting connective tissue (stroma) of the endometrium. These cancers are rare, representing less than 1% (1 in 100) of all uterine cancers.
• Undifferentiated sarcomas- used to be considered a type of endometrial stromal sarcoma. These cancers make up less than 1% of all uterine cancers and tend to have a poor outlook.
• Uterine leiomyosarcomas- start in the muscular wall of the uterus known as the myometrium. These tumors make up about 2% of cancers that start in the uterus.

Risk factors for Uterine Sarcoma

•  Pelvic radiation therapy
• Race- Uterine sarcomas are about twice as common in African-American women as they are in white or Asian women. The reason for this increased risk is unknown.

Signs and Symptoms of Uterine Sarcomas

•  Irregular premenopausal vaginal bleeding
• Abnormal Vaginal discharge - offensive, watery associated at times with expulsion of fleshy necrotic mass
•  Abdominal pain - due to involvement of surrounding structures
• Pyrexia, weakness and anorexia

On Pelvic Examination

• No specific findings
• The uterus may be enlarged and irregular

On speculum examination;

• Polypoidal mass protruding out through the external os

Diagnosis

• History and physical exam
• Hysteroscopy
• MRI and CT
• Endometrial biopsy
• Dilation and curettage (D & C)
• Positron emission tomography (PET)

Management

• Same as endometrial carcinoma

There are 4 basic types of treatment for women with uterine sarcoma:

• Surgery
• Chemotherapy
• Hormone therapy
• Radiation therapy

Prognosis

The outlook for survival (prognosis) for women with a uterine sarcoma depends on many factors.

These include:

• The stage of the cancer
• The type of sarcoma (leiomyosarcoma or endometrial stromal sarcoma)
• The grade of the sarcoma (low grade versus high grade)
• The woman's general state of health
• The treatment received

Nursing Management

• Vital Signs should be taken routinely, blood pressure should not be taken from affected site.
• Elevation of the affected hand.
• Maintain hydration.
• Aseptic techniques used during dressing.
• Support on coping mechanism and body image.
• Continue follow up.

Nursing Diagnosis

• Hospital-related stress-related anxiety.
• Lack of expertise in surgical management and therapy.
• Suffering from a medical operation.
• Infection risk associated with surgical operations.
• Disturbed self-esteem caused by changes to female organs.

For Pain Relief

• Patient should be assessed for pain location level and characteristics.
• Patient should be encouraged to support the incision while moving
• Give prescribed pain medication.
• Encourage ambulation from the first postoperative day to decrease flatus & abdominal distension

For Infection Prevention

• Assess vaginal discharge for amount color, odor & assessed incision site
• Take temperature every four hourly Give prescribed antibiotics timely
• Encourage coughing and deep breathing exercise to prevent pulmonary infection

Strengthening Self-esteem

• Encourage patient to discuss her feelings
• Explain patient that she will go through premature menopause because her ovaries are removed.
• Advise to consult to gynae doctors if she has hormonal disorders syndromes

Patient Education/Health Maintenance

• Inform the patient that she will first feel exhausted and that she has to take it easy for a few weeks before being able to carry out the majority of her regular activities in a month. The patient was told to report any instances of a high temperature, significant vaginal discharge, or bad discharge odor. bleeding from the wound site
• For one month, avoid lifting any heavy objects.
• Consult a doctor as soon as possible if you are coughing and sneezing.
• To prevent constipation.
• Describe the significance of a follow-up visit.

For Cough Relief

• Encourage patient for ambulation
• Encouraged for deep breathing and coughing exercise
• Give prescribed cough expectorant

Vaginal Cancer

The Vagina

The vagina is a tube measuring 3 to 4 inches (7 to 10 cm). It is referred to as the birth canal at times. The vulva, which is the upper region of the uterus, is where the vagina opens up from the cervix (the external genitals). Squamous cells, a kind of flat cell, are used to lining the vagina. Because epithelial cells make up this layer of cells, it is also known as an epithelium (or epithelial lining). Under the epithelium, the vaginal wall is made up of connective tissue, muscle, lymphatic vessels, and nerves. Typically, the vagina is collapsing and its walls are contacting. The numerous folds in the vaginal walls aid in the vagina's opening and expansion during sexual contact or childbirth.y. Glands near the opening of the vagina secrete mucus to keep the vaginal lining moist.The vagina is the passageway that connects the cervix, or uterine opening, to the outside of the body. A baby emerges from the body through the vagina at birth. Malignant (cancer) cells develop in the vagina in a condition known as vaginal cancer.

Types of Vaginal Cancer

Squamous Cell Carcinoma

Squamous cell carcinomas make up around 70% of all vaginal cancer cases. These cancers start in the squamous cells that make up the vaginal epithelial lining. These cancers tend to occur more frequently in the upper vaginal region close to the cervix.

The development of vaginal squamous cell tumors is frequently sluggish. The normal cells of the vagina first develop precancerous alterations. Afterward, a few of the pre-cancer cells develop into cancerous cells. This procedure could go on for years.

Vaginal intraepithelial neoplasia is the medical term most frequently used to describe this precancerous condition. The term "intraepithelial" denotes that the abnormal cells are only present in the skin's top layer in the vagina. VAIN comes in three different varieties: VAIN1, VAIN2, and VAIN3.

There are 3 types of VAIN: VAIN1, VAIN2, and VAIN3, with 3 indicating furthest progression toward a true cancer.

VAIN is more common in women who have had their uterus removed (hysterectomy) and in those who were previously treated for cervical cancer or pre-cancer

Squamous cell vaginal cancer spreads slowly and usually stays near the vagina, but may spread to the lungs, liver, or bone.

Adeno Carcinoma

Adenocarcinoma is a kind of cancer that develops from a glandular cell. Adenocarcinoma accounts for around 15 out of every 100 occurrences of vaginal cancer.

Women over 50 are more likely than younger women to get the typical kind of vaginal adenocarcinoma. DES (diethylstilbestrol) is a man-made (synthetic) form of estrogen, a female hormone given to the mother during pregnancy in the belief that it will help some pregnant women who had miscarriages or premature deliveries. One specific type, called clear cell adenocarcinoma, occurs more frequently in young women who were exposed to DES while they were in their mother's womb.

Melanoma

The pigment-producing cells that give skin its color give rise to melanomas. Although they can develop on the vagina or other internal organs, these tumors are typically discovered on skin that has been exposed to the sun. Melanomas account for around 9 out of every 100 instances of vaginal cancer. The lower or outer part of the vagina frequently becomes infected with melanoma. The size, color, and growth pattern of the tumors vary greatly. Our document, Melanoma Skin Cancer, contains more details about this disease.

Sarcoma

A cancer that starts in the cells of the bones, muscles, or connective tissue is called a sarcoma. Up to 4 out of every 100 occurrences of vaginal cancer are sarcomas. Instead of growing on the vagina's surface, these tumors start deep inside the wall. Vaginal sarcomas can take many different forms. Vaginal sarcomas are most frequently rhabdomyosarcomas. Children typically have it, whereas adults seldom do. Adults are more likely to develop the sarcoma leiomyosarcoma. Over-50-year-old women are more likely to experience it. Cancers that begin in other organs (like the cervix, uterus, rectum, or bladder) and then spread to the vagina are much less frequent than cancers that begin in the vagina. These tumors bear the names of the locationsThese cancers are named after the place where they started. Also, a cancer that involves both the cervix and vagina is considered a cervical cancer. Likewise, if the cancer involves both the vulva and the vagina, it is considered a vulvar cancer

Risk Factors For Vaginal Cancer Include the following:

• Being aged 60 or older.
• Being exposed to DES while in the mother's womb. In the 1950s, the drug DES was given to some pregnant women to prevent miscarriage (premature birth of a fetus that cannot survive). Women who were exposed to DES before birth have an increased risk of vaginal cancer. Some of these women develop a rare form of vaginal cancer called clear cell adeno carcinoma.
• Having Human Papilloma Virus (HPV) infection.
• Having a history of abnormal cells in the cervix or cervical cancer.
• Having a history of abnormal cells in the uterus or cancer of the uterus.
• Having had a hysterectomy for health problems that affect the uterus.

Sign and Symptoms

• Pain or unusual vaginal bleeding are potential indicators of vaginal cancer.
• Oftentimes, vaginal cancer develops slowly and is only discovered during a normal pelvic check and Pap test. When symptoms appear, vaginal cancer or other disorders may be at blame. bleeding or leaking that is unrelated to menstrual cycles.
• Discomfort during sexual activity.
• Discomfort around the pelvis.
• A mass in the cervix.
• Difficulty urinating (such as blood in the urine, the need to pass urine frequently and the need to pass urine at night )
• Constipation.

Diagnosis

Internal Vaginal Examination

• A full pelvic examination: They will examine the inside the vagina to check for any lumps or swellings. Check for swollen lymph nodes for groin and pelvic area and may also check rectum
•  Cervical screening: Liquid-based cytology test or smear test to see if there are any abnormalities in the cells of the cervix.
• Colposcopy: This is an examination of the vagina using a colposcope, which is a small, low powered microscope.
• Biopsy- A small sample of tissue will be taken from any abnormal areas. This sample will be examined under a microscope.
•  Chest x-ray and blood tests to assess general health and to check whether the cancer has spread to the lungs.
• CT (computerized tomography) scan: A CT scan takes a series of x-rays that build up a three dimensional picture of the inside of the body. The scan is painless and takes 10-30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm and will not harm anyone come into contact with.
• MRI (magnetic resonance imaging) scan: This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of body. Before the scan complete and sign a checklist. This is to make sure that it's safe for the patient to have an MRI scan.

Staging

Cancers are classified according to their size and whether or not they have spread by their stage. The best suitable treatment for you is determined in part by the kind and stage of your cancer.

Typically, FIGO and AJCC (TNM) classifications are combined to stage ovarian malignancies. Depending on the tumor's size in the vagina and surrounding tissues, as well as if it has migrated to the lymph nodes or other organs, a number between 0 and 4 is assigned to it.

Tumor Extent (T)

Tis: Cancer cells are only in the most superficial layer of cells of the vagina without growth into the underlying tissues. This stage is also called carcinoma in situ (CIS) or vaginal intraepithelial neoplasia 3 (VAIN 3). It's not included in the FIGO system.

• TI: The cancer is only in the vagina.
• T2: The cancer has grown through the vaginal wall, but not as far as the pelvic wall.
• T3: The cancer is growing into the pelvic wall.
• T4: The cancer is growing into the bladder or rectum or is growing out of the pelvis.

Lymph node spread of cancer (N)

• NO: The cancer has not spread to lymph nodes
• N1: The cancer has spread to lymph nodes in the pelvis or groin (inguinal region)

Distant Spread of Cancer (M)

• MO: The cancer has not spread to distant sites
• M1: The cancer has spread to distant sites.

Stage Grouping

Once the T, N, and M categories have been assigned, this information is combined to assign an overall stage in a process called stage grouping. The stages identify tumors that have a similar outlook and are treated in a similar way.

• Stage 0 (Tis, NO, MO): In this stage, cancer cells are only in the top layer of cells lining the vagina (the epithelium) and have not grown into the deeper layers of the vagina. Cancers of this stage cannot spread to other parts of the body. Stage 0 vaginal cancer is also called carcinoma in situ (CIS) or vaginal intraepithelial neoplasia 3 (VAIN 3). This stage is not included in the FIGO system.
• Stage I (T1, NO, MO): The cancer has grown through the top layer of cells but it has not grown out of the vagina and into nearby structures (T1). It has not spread to nearby lymph nodes (NO) or to distant sites (MO).
•  Stage II (T2, NO, MO): The cancer has spread to the connective tissues next to the vagina but has not spread to the wall of the pelvis or to other organs nearby (T2). (The pelvis is the internal cavity that contains the internal female reproductive organs, rectum, bladder, and parts of the large intestine.) It has not spread to nearby lymph nodes (NO) or to distant sites (MO).
• Stage III: Either of the following:

T1 or T2, N1, MO: The cancer is in the vagina (T1) and it may have grown into the connective tissue nearby (T2). It has spread to lymph nodes nearby (N1), but has not spread to distant sites (MO).

T3, any N, MO: The cancer has spread to the wall of the pelvis (T3). It may (or may not) have spread to nearby lymph nodes (any N), but it has not spread to distant sites (MO). 

Stage IVA (T4, Any N, MO): The cancer has grown out of the vagina to organs nearby (such as the bladder or rectum) (T4). It may or may not have spread to lymph nodes (any N). It has not spread to distant sites (MO).

Stage IVB (Any T. Any N, M1): Cancer has spread to distant organs such as the lungs (M1).

Treatment of Vaginal Cancer

• The treatment for vaginal cancer depends on a number of factors, including general health and the stage, grade and type of cancer.
• Radiotherapy, surgery and chemotherapy may be used to treat vaginal cancer. It may be one, or a combination, of these treatments.
•  Before starting treatment, it's important to ask the specialist to explain things again if there's anything you don't understand.

Radiotherapy

The best treatment for many vaginal cancer patients is radiation. Chemoradiation, also known as radiochemotherapy, is a treatment option for certain younger women who are receiving radiotherapy. High-energy radiation (radiotherapy) is used to treat cancer by killing cancer cells while causing the least amount of damage to healthy cells. It is administered in the hospital's radiotherapy department. The exact type of cancer and whether or not it has spread to nearby tissue will determine the required dose. Some female patients receive both external and internal radiotherapy.

External radiotherapy

Similar to getting an x-ray, radiation beams are aimed towards the tumour from outside the body. The patient will be required to go to the radiation department for treatment every weekday for 4-6 weeks while receiving external radiotherapy. Each procedure just lasts a little while and is painless. For therapy, the patient might be required to have a full bladder. During radiotherapy treatment, some women may receive chemotherapy once a week.

Internal Radiotherapy (Brachytherapy)

• This type of radiotherapy is used to give an extra dose of radiation to the tumor. It also limits the radioactive substance is inserted into vagina. It is connected to a machine which sends radiation exposure of normal tissue to radiation. An applicator (similar to a plastic tampon) containing a into the applicator. The treatment may last several minutes or a few hours, depending on the equipment used. Having the applicator inserted into the vagina should be no more uncomfortable than having an internal pelvic examination. Patient will not be radioactive after the treatment and can continue their normal activities
• Sometimes, as well as the applicator, radioactive needles may be placed into the area surrounding the vagina. If these are needed, they are put in under general anaesthesia and are removed once the treatment ends.

Side Effects of Radiotherapy

• The treated area's skin becomes red and swells up. This might be painful, particularly when urinating.
• After the therapy is done, the patient can have a very small vaginal discharge. It is crucial to let the doctor know if it lasts more than a few weeks or gets heavier.
• The side effects of radiotherapy to the pelvic region include fatigue, diarrhea, and a burning sensation when urinating. Depending on the strength of the radiotherapy dose and the length of the treatment, these side effects may be minor or more bothersome.
• Although rare, radiotherapy might make a patient feel ill.
• Radiotherapy for vaginal cancer damages the ovaries and triggers the menopause in younger patients who have not previously gone through this process. This typically occurs three months after the start of the treatment and results in infertility. Menopausal side effects of the menopause include hot flushes, dry skin, and perhaps loss of concentration.

Possible Long-term Side Effects of Radiotherapy

• The radiation may have a long-term impact on the intestines or bladder in a tiny percentage of patients. If this occurs, you could continue to have more bowel movements and diarrhea or you might need to pee more frequently than usual.
• After radiation treatment, the blood vessels in the gut and bladder may become more brittle, which might lead to bloody urine or bowel movements (feces).
• Additionally, radiotherapy might result in the development of tiny, delicate blood vessels in the vagina, which may produce very minor vaginal bleeding.
• The vaginal skin may become drier and less elastic over time. Some women might discharge, and others might be more prone to infections.
• Some people also find that the radiotherapy affects the lymph nodes in the pelvic area and can cause swelling of the legs. This is called lymphoedema and is more likely if the patients have had surgery as well as radiotherapy.

Surgery

• Sometimes a surgical procedure is necessary to remove the cancer. An procedure to remove the malignancy and part of the surrounding healthy tissue can be an option. Depending on how much tissue was removed, the patient could still be able to engage in sexual activity with the help of the remaining vaginal tissue.
• Some women could require a more involved procedure when the whole vagina is removed (vaginectomy). It is occasionally feasible to create a new vagina (vaginal reconstruction) using tissue from different body areas.
• The removal of the uterus, cervix, ovaries, and fallopian tubes may also be required. The procedure is known as a radical hysterectomy. Some of the pelvic lymph nodes may also be removed during this procedure.

Chemotherapy

• Chemotherapy is the process of killing cancer cells with anti-cancer (cytotoxic) medications. They function by preventing cell division and proliferation.
• Advanced vaginal malignancies or cancer that has reappeared after initial treatment are the major conditions that chemotherapy is used to treat. Additionally, it is occasionally administered before to surgery as well as sometimes with radiation.

Sexual relationship after treatment of Vaginal Cancer

• A vaginal orgasm could not be feasible after the removal of the cervix and uterus and vaginal reconstruction. However, vaginal surgery does not damage the clitoris, thus oral sex or masturbation can be used to induce an orgasm.
• Sexual activity may be difficult and unwanted for those receiving radiation due to the adverse effects. Although the client and partner can still express their affections for one another and remain close by other means, such as hugging, kissing, and caressing
• The vagina becomes shorter and narrower as a result of radiation treatment. Use a dilator (a plastic or glass tube) every day while receiving therapy and for a while after to avoid this. Using a gentle dilator To prevent this, use a dilator (a plastic or glass tube) each day, during and for some time after the treatment. The dilator is gently inserted into the vagina to keep it open.

Health Education

• Nutritious or balanced diet
• Perineal hygiene
• Continue Sexual relationship (brachytherapy)

Noeplasm of the Breast

Breast Cancer

Carcinoma of Breast

It is an abnormal spread and proliferation of cells in the body. Mutations in somatic cell genes that control cell development are typically the reason. Nearly every tissue in the body has the capacity to produce cancer; some even do so in multiple forms. Cancer, however, mostly affects cells that divide and procreate more than other types of cells.

Benign Breast Conditions

Numerous non-cancerous illnesses that can affect the breast are referred to as benign breast ailments. A variety of benign breast disorders are referred to as fibrocystic change. Some benign breast disorders can be painful or uncomfortable and require medical attention. Others don't require medical attention. For diagnosis, testing and occasionally a biopsy are required for a number of breast disorders that mirror the symptoms of cancer.

Risk of Benign Breast Conditions

• Hormonal factors (postmenopausal hormones)
• Family h / o of breast cancer
• Lifestyle factors (drinking alcohol)

Types of Benign Breast Conditions

• Cysts
• Intraductal papilloma
• Radial scars
•  Hyperplasia
• Fibroadenomas
• Sclerosing adenosis
• Benign phyllodes tumors
• Diabetic mastopathy (also called lymphocytic mastitis and sclerosing lymphocytic lobulitis

Hyperplasia

It is overgrowth (proliferation)of cell and most often found on the inside of the lobules or ducts in the breast . There are two main types of hyperplasia: usual and atypical. Both raise the risk of breast cancer.

Cysts

Cysts are sacs filled with fluid that are often benign. The majority of cysts are too tiny to feel and can only be discovered with ultrasonography. Cysts can cause breast pain and can feel like lumps in the breast if they are large. Ultrasound can be used to identify cysts (without needing a biopsy). Premenopausal women are more likely to develop cysts, but they do not raise the risk of breast cancer. Cysts become less common after menopause.

Fibroadenomas

Fibroadenomas are solid benign tumors that may feel like a rubbery or hard lump. They are most common in younger women between the ages of 15 and 35

Intraductal Papillomas

The majority of these small lumps, which can cause nipple discharge and develop in breast ducts, affect women between the ages of 30 and 50. Surgery is used to get rid of them. Unless they contain abnormal cells or the surrounding tissue has ductal carcinoma in situ, they do not raise the risk of breast cancer.

Sclerosing Adenosis

Small breast lumps known as sclerosing adenosis are brought on by enlarged lobules. It could hurt and present as a breast lump or an abnormal mammography finding. On a mammogram, it might be mistaken for breast cancer due to its distorted shape. The diagnosis might require confirmation through a biopsy. It is benign, though, and does not require treatment.

Radial Scars

A core of connective tissue fibers can be found in radial scars. From this point, lobules and ducts protrude. On a mammogram, radial scars can resemble breast cancer, but they are not. They are most frequently discovered during a biopsy on a breast tumor that was removed for another reason. After they are removed, they need no further treatment.

Benign Phyllodes Tumor

Phyllodes tumors can be benign or invasive (malignant). These tumors are rare, comprising 1% of all breast tumors in women, and more than half are benign. Benign phyllodes tumors  similar to fibroadenomas and tend to occur in women ages 30 to 50.

Diabetic mastopathy (lymphocytic mastitis, sclerosing lymphocytic lobulitis/ductitis)

Small, hard masses known as diabetic mastopathy develop in the ducts or lobules. The majority of premenopausal women with insulin-dependent (type 1 diabetes) have this condition. It might show up as a mammogram abnormality or a breast lump. The diagnosis could require confirmation by a biopsy. Treatment for diabetic mastopathy is not necessary.

Breast Cancer (Malignant)

It is one of the most common cancers. Around one in nine women develop breast cancer at some stage in their life. Most develop in women over the age of 50 but younger women are sometimes affected. Breast cancer can also develop in men, although this is rare. Breast cancer develops from a cancerous cell which develops in the lining of a duct or lobule in one of the breasts

Epidemiology

• Global issue with public health.
• Breast cancer is the most prevalent cancer in women, accounting for 1 million new cases worldwide each year and 18% of all cancers in women.
• By 2010, 500,000 women would die from breast cancer globally, with over 1.5 million receiving a new diagnosis each year.
• Three-quarters of breast cancer deaths worldwide and the majority of new cases now occur in women from low and middle income countries, where the incidence is rising by up to 5% annually.
• Gender: Although it is uncommon, breast cancer can also develop in men. Less than 0.5% of breast cancer patients are men.. It is about 100 times more common in female than in male.
• Among Nepalese women, the second most frequent cancer. When compared to older women in high-income countries, it affects more women under the age of 50 in Nepal, where it accounts for 6% of all cancer cases.
• Furthermore, since early breast cancer is frequently asymptomatic, many women present with the disease at an advanced stage, when it is usually too late to save their lives.

Breast Cancer in Nepal

It is the second leading cause of cancer deaths in women. It accounts for 6% of all cancers in Nepal Breast Cancer Deaths in Nepal reached 1,248 or 0.84% of total deaths. (WHO, 2010)

Types

Situ Breast Cancer

Situ Breast Cancer remains within the ducts or lobules of the breasts. This type of cancer is only detected by mammograms - not by a physical examination. If the cancer is in the duct it is called Ductal Carcinoma in situ. If the cancer is in the lobule of the breast, it is called Lobular Carcinoma in situ. It is most common among pre-menopausal women. There is also a slight chance that if a woman has this type of cancer she is at risk that it would occur in the other

Infiltrating Breast Cancer

Breast cancer is considered infiltrating or invasive if the cancer cells have penetrated the membrane that surrounds a duct or lobule. This type of cancer forms a lump that can eventually be felt by a physical examination. Breast cancer cells cross the lining of the milk duct or lobule, and begin to invade adjacent tissues. This type of cancer is called "infiltrating cancer".

Infiltrating Breast Cancer:

About 10 to 15% of breast cancers diagnosed are invasive lobular carcinoma. This means the the cancer started in the cells that line the lobules or lobes of the breast and has spread into the surrounding breast tissue

Invasive lobular cancer can develop in women of any age. But it is most common in women between 45 and 55 years old.

Factors that cannot be prevented

• Gender
• Genetic Risk Factors (inherited)
•  Aging
• Family History
• Race
• Personal History
• Menstrual Cycle

Lifestyle Risks

•  Oral Contraceptive Use
• Hormone Replacement Therapy
• Alcohol Use
•  Estrogen
•  Not having Children
•  Not Breast Feeding
• Obesity
• High Fat Diets
• Smoking
• Physical Inactivity

Breast Cancer Risk Factors

Gender: Female has the main risk for breast cancer. While less than 0.5% of patients with brea cancer are male. It is about 100 times more common in female than in male.

Age: Carcinoma of the breast is extremely rare below the age of 20 years but, thereafter incidence steadily rises, as age of female gets older. About 2 of 3 female with invasive bra carcinoma are 55 years or older at the time of diagnosis.

Family history of breast cancer: Women whose close blood relatives have breast cancer high risk for this disease. Having a first degree relative (mother, sister, and daughter) one ad every 10 women will obtain breast cancer by inheriting a gene from a family member

Personal history: A women with breast cancer, in one breast or in another part of the same br has increased risk for breast cancer.

Inherited Genes

• BRCA1 (Breast Cancer 1)
• BRCA2 (Breast Cancer 2)
• TP53 gene
• ATM gene

Menstrual Periods

Women who have had more cycles because they started menstruating at an early age (before the age of 12) and or went through menopause at a later age(after the age of 55) have slightly higher risk of breast cancer.

Not Having Children or Having Them Later in Life

Women who have not had children or who had their first child after the age of 30 have slightly higher risk of breast cancer.

Oral Contraceptives Use

Studies have been found that women using oral contraceptive (birth control pills) have a slightly greater risk of breast cancer than women who have never used them. Women who stopped using contraceptives more than 10 years ago do not appear to have any increased breast cancer risk.

No Breast Feeding

Some studies suggest that breast feeding lower breast cancer risk, especially if it is continued for 1.5 to 2 years

Alcohol Consumption

The risk increases with the amount of alcohol consumed.

Lack of Physical Activities

Evidence is growing that physical activities in the form of exercise reduce breast cancer risk.

Overweight or Obese

Being overweight or obese has been found to breast cancer risk especially for women after menopause. Before menopause ovaries produce most of estrogens and fat tissue produce small estrogens comes from fat tissue. Having more fat tissues after menopause (increases the chance of getting breast cancer by raising estrogens level).

Exposure to Radiation

Using Postmenopausal Hormone Therapy

Post-menopausal hormone therapy is also known as Hormonal Replacement Therapy, has been used for many years to help relieve symptoms of menopause and to help prevent osteoporosis.

Clinical Stages of Breast Cancer

Clinical Staging is determined by considering the size of the original tumor (T), the lymph nodes (L), and metastasis (M). This is called the TNM Criteria.

TNM Criteria

• T= Primary Tumor
• Tis = carcinoma in situ
• T1-less than 2 cm in diameter
• T 2 = between 2 and 5 cm in diameter
• T 3 = more than 5 cm in diameter
• T 4 = any size, but extends to the skin or chest wall

N = Regional Lymph nodes

• NO = no regional node involvement
• N 1 = metastasis to movable same side axillary nodes
• N 2 = metastasis to fixed same side axillary nodes
• N 3 = metastasis to same side internal mammary nodes

 M = Distant Metastasis

• MD = no distant metastasis
• M 1 = distant metastasis

Clinical Manifestations

• Swelling of all or part of the breast
• Skin irritation or dimpling
• Breast pain
• Nipple pain
• Redness, scaliness, or thickening of the nipple or breast skin
• A nipple discharge other than breast milk
• A lump in the underarm area

Warning Signs of Breast Cancer

The most common sign of breast cancer is a new lump or mass. A mass that is painless hard and has irregular edge is more likely to be concern us but breast cancer can be tender soft and rounded.

Other Possible Signs of Breast Cancer are:

• Full or partial breast swelling (even if no distinct lump is felt)
• Nipple soreness or skin irritation
• Lipstick retracting
• Skin on the nipple or breast that is reddened, scaling, or thickening
• A nipple leak that is not breast milk (mixed with blood)

There may occasionally be a lump or swelling where breast cancer has spread to the lymph nodes under the arm.

Diagnosis

• Physical examination of the breasts
• Mammography
• Ultrasound
• Breast MRI
• Biopsy. Fine needle aspiration biopsy, Core needle biopsy
• Incisional biopsy
• Excisional biopsy Complete blood count

Management of Breast Cancer

• Lumpectomy (for a tumor that is small enough to remove, with some margin of surrounding tissue)
• Mastectomy (if the tumor has invaded much of the breast, or is large in comparison to the breast)
• Chemotherapy
•  Radiation
• Hormone Therapy (for estrogen-receptor positive breast cancer)

Surgical Management

• Radical mastectomy: Removal of the breast tissue along with pectoralis major and minor muscles in conjunction with an axillary lymph node dissection.
•  Modified radical mastectomy (MRM): Removal of the breast tissue and an axillary lymph node  dissection the pectoralis major and minor muscles remain intact.
• Total mastectomy: Removal of the breast tissue only, this procedure is generally done for the treatment of carcinoma in situ, typically ductal.

Breast Conserving Surgery

• Lumpectomy
• Partial mastectomy
•  Quadrantectomy 
• Segmental mastectomy
• Wide excision

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy or slow the growth of rapidly multiplying cancer cells.

 Neo Ajuvant Chemotherapy

• Given before surgery to shrink the size of a tumor.
• If it shrinks the cancer successfully, only part of the breast may be removed, avoiding the need for a mastectomy.

Adjuvant Chemotherapy

• Given after surgery to reduce the risk of recurrence. In early-stage invasive breast cancer, it is given to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back

Palliative Chemotherapy

• Used to control (but not cure) the cancer in settings in which the cancer has spread beyond the breast and localized lymph nodes.
• In advanced-stage breast cancer to destroy or damage the cancer cells as much as possible

The drugs are:

• Cyclophosphamide
• Fluorouracil (5FU)
•  Mitomycin
• Doxorubicin
•  Epirubicin
• Methotrexate
• Mitoxantrone
• Docetaxel (Taxotere)

Hormonal Therapy

• Treatments called hormonal therapies aim to lower hormone levels in the body or stop them from having an impact on cancer cells. To lessen the likelihood of the disease returning, they are frequently administered following chemotherapy, radiation, and surgery for breast cancer.
• Hormone-receptor-positive breast cancer: systemic therapy
• Sometimes referred to as estrogen treatment.

Cervical Cancer

The third most frequent type of cancer in women worldwide is cervical cancer. With the use of numerous preventative and screening measures over the past several decades, significant progress has been achieved in lowering the incidence and death of cervical cancer. The Human Papilloma Virus is the causative agent linked to the development of cervical cancer and its precursors. When the body's cells start to proliferate out of control, cancer develops. Cancerous cells can develop in almost any part of the body and spread to other organs. The cells lining the cervix, or lower portion of the uterus, are where cervical cancer first develops.This is sometimes called the uterine cervix. The fetus grows in the body of the uterus (the upper part).

The cervix joins the vagina to the uterus's body (birth canal). The endocervix is the portion of the cervix that is most closely connected to the uterus. The exocervix is the area adjacent to the vagina (or ectocervix). Squamous cell carcinoma and adenocarcinoma are the two most common forms of cervical cancer. Squamous cell carcinomas make up the majority of cervical malignancies (up to 9 out of 10). These malignancies develop from exocervical cells, and under a microscope, the cancer cells resemble squamous cells. The transformation zone is where squamous cell carcinomas most frequently start.

Adenocarcinomas make up the majority of the other cervical malignancies. Glands cells can become cancerous tumors called adenocarcinomas. The endocervical gland cells that produce mucus give rise to cervical cancer. In the past thirty years, cervical adenocarcinomas appear to have increased in frequency. Less frequently, cervical cancers resemble squamous cell carcinomas and adenocarcinomas in their characteristics. Adenosquamous carcinomas or mixed carcinomas are the names given to these.

Risk Factors

Infection by men is the main risk factor for cervical cancer. the gepilloma virus (P) Py is a collection of more than 150 connected diseases, some of which lead to a kind of d that affects the tissues lining the mouth, throat, anos, and genitalia but not the blood vessels or internal organs like the heart or longs. HPV may be transmitted from one person to another during intercourse, including vaginal, anal, and even oval sex. Various forms of HPV can cause warts on various body areas. Some people cause warts to appear on the hands and feet, lips, or tongue. Certain types of HPV may cause warts on or around the female and male genital organs and in the anal area.

Smoking

Smokers and those around them are exposed to a variety of cancer-causing substances that harm organs outside the lungs when they smoke. These dangerous compounds are absorbed through the lungs and transported throughout the body by the bloodstream. Cervical cancer is nearly two times more likely to affect women who smoke than non-smokers.

Immunosuppression

Human immunodeficiency virus (HIV), the virus that causes Alt, damages the immune system and puts women at higher risk for HPV infections. This might explain why women with ADS have a higher risk for cervical cancer.

Chlamydia Infection

A somewhat frequent kind of bacterium that can affect the reproductive system is chlamydia. Sexual contact is how it spreads. Some studies have found an increased risk of cervical cancer in women whose blood test results reveal signs of prior or present chlamydia infection. Chlamydia infection can induce pelvic inflammation, which can result in infertility (compared with women who have normal test results).

A diet low in fruits and vegetables: Women whose diets don't include enough fruits and vegetables may be at increased risk for cervical cancer. Being overweight women are more likely to develop adenocarcinoma of the cervix

Long-term use of oral contraceptives (birth control pills). There is evidence that taking oral contraceptives (OCs) for a long time increases the risk of cancer of the cervix.

Intrauterine Device Use

A recent study found that women who had ever used an intrauterine device (IUD) had a lower risk of cervical cancer. The effect on risk was seen even in women who had an IUD for less than a year, and the protective effect remained after the IUDs were removed.

Having Multiple full-term Pregnancies

Cervical cancer risk is higher in women who have had three or more full-term pregnancies. The real reason this is the case is unknown. According to one explanation, these women may have been more exposed to HPV since they needed unprotected sexual activity to become pregnant. The risk of developing cervical cancer later in life is roughly two times higher for women under the age of 17 who had their first full-term pregnancy than for those who waited until they were 25 or older.

Poverty

Cervical cancer risk factors may include poverty. Many low-income women lack easy access to sufficient medical treatments, such as Pap screenings. As a result, they could not undergo screening cervical pre-cancers were treated

Diethylstilbestrol (DES)

Between 1940 and 1971, DES, a hormone medication, was prescribed to certain women to stop miscarriages. Clear-cell adenocarcinoma of the vagina or cervix develops more frequently in women whose mothers used DES (when carrying them). Women who have not been exposed to DES are extremely unlikely to develop this type of cancer.

Family History of Cervical Cancer

Sign and Symptoms

The most common finding in patients with cervical cancer is an abnormal Papanicolaou (Pap) test result. Physical symptoms of cervical cancer may include the following:

• Abnormal vaginal bleeding
• Vaginal discomfort
• Mal-odorous discharge
• Dysuria

Staging Cervical Cancer

Stage 0 (Tis, NO, MO): The cancer cells are only in the cells on the surface of the cervix (the layer of cells lining the cervix), without growing into (invading) deeper tissues of the cervix. This stage is also called carcinoma in situ (CIS) which is part of cervical intraepithelial neoplasia grade 3 (CIN3).

• Stage I (T1, NO, MO): In this stage the cancer has grown into (invaded) the cervix, but it is not growing outside the uterus. The cancer has not spread to nearby lymph nodes (NO) or distant sites (MO).
• Stage IA (Tia, NO, MO): This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope. Stage IA1 (T1a1, NO, MO): The cancer is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide. The cancer has not spread to nearby lymph nodes (NO) or distant sites (MO).

Stage IA2 (T1a2, NO, MO): The cancer is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide. The cancer has not spread to nearby lymph nodes (NO) or distant sites (MO).

• Stage IB (T1b, NO, MO): This includes stage I cancers that can be seen without a microscope as well as cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm. These cancers have not spread to nearby lymph nodes (NO) or distant sites (MO).
• Stage IB1 (T1b1, NO, MO): The cancer can be seen but it is not larger than 4 cm. It has not spread to nearby lymph nodes (NO) or distant sites (MO).
• Stage IB2 (T1b2, NO, MO): The cancer can be seen and is larger than 4 cm. It has not spread to nearby lymph nodes (NO) or distant sites (MO).

Stage II (T2, NO,MO):In this stage ,the cancer has grown beyond the cervix and uterus , but hasn't spread to wall of the pelvis or lower part of the vagina.

• Stage IIA (T2a, NO, MO) The cancer has not spread into the set or eve the parametria) The cancer may have grown into the upper part spread to nearby lymph nodes (NO) or distant sites (MO)
• Stage IIA1(T2a1, NO, MO) The cancer can be seen t is not larger than 4 cm ( H * 3/8 inches). It has not spread to nearby lymph nodes (6) or distant sites (MO)
• Stage 11A2 (T2a2, NO, MO): The cancer can be seen and is larger than 4cm
• Stage 118 (12b, NO, MO): The cancer has spread into the issues next to the cervix (e parametria).

Stage III (TS, NO, MO): The cancer has spread to the lower part of the reg of the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). It has not spread to nearby lymph nodes (NO) or distant sites (MO)

• Stage IIA (T3, 50, 90 The cancer has spread to the lower third of the vagina but not to the walls of the pelvis. It has not spread to nearby lymph nodes (NO) or distant sites (MO)
• Stage HIB (T3b, NO, MO, OR T1 T3, N1, Muj, either: The cancer has grown into the walls of the pelvis and/or has blocked one or both ureters (a condition called hydronephrost) OR The cancer has spread to lymph nodes in the pelvis (1) but not to distant sites (MO). The tumor can be any size and may have spread to the lower part of the vagina or walls of the pelvis (T1 to 13).

Stage IV: This is the most advanced stage of cervical cancer. The cancer has spread to nearly organs or other parts of the body.

• Stage IVA (T4, NO, MO): The cancer has spread to the bladder or rectam, which are organs close to the cervix (T4). It has not spread to nearby lymph nodes (NO) or distant sites (MG)
• Stage IVB (any T, any 8 ,M1) The cancer has spread to distant organs beyond the pelvic area, such as the lungs or liver.

Diagnosis

• History and Physical Exam: Regular screening with a Pap test (which may be paired with a test for human papilloma virus or PV) is the best approach to discover cervical cancer early. Pre-invasive lesions (pre-cancers) of the cervix should be found more frequently than invasive cancer. Ectocervical Biopsy: Using a sharp device like a Tischler biopsy forceps and direct colposcopic vision, suspicious lesions on the ectocervix are biopsied. Colposcopy: To see the cervix, a speculum is inserted into the vagina. With the colposcope's magnifying lenses, the doctor will check the cervix (like binoculars)
• Cervical Biopsies: A variety of biopsies can be done to identify pre-malignancies and cancers of the cervical region.
• Colposcopic Biopsy: In order to identify the abnormal spots for this sort of biopsy, the cervix is first checked with a colposcope. A little (1/8-inch) piece of the abnormal region on the cervix's surface is removed using biopsy forceps.
• Endocervical Curettage (scraping of the endocervix): When the colposcope cannot view the transformation zone, which is the region susceptible to HPV infection and pre-cancer, another method of cancer detection must be used. This entails taking an endocervical scraping, which involves inserting a narrow instrument (called a curette) into the endocervical canal (the portion of the cervix closest to the uterus) and scraping the interior of the canal to remove some tissue, which is then sent to a lab for analysis.
• Cone Biopsy: In this procedure, also known as conization to remove a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the exocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal. The tissue removed in the cone includes the transformation zone (the border between the exocervix and endocervix, where cervical pre cancers and cancers are most likely to start).
• Cold Knife Cone Biopsy: This method uses a surgical scalpel or a laser instead of a heated wire to remove tissue. You will receive anesthesia during the operation (either a general anesthesia, where you are asleep, or a spinal or epidural anesthesia, where an injection into the area around the spinal cord makes you numb below the waist) and is done in a hospital, but no overnight stay is needed. After the procedure, you might have cramping and some bleeding for a few weeks.
• Loop Electrosurgical Procedure (LEEP, LLETZ): In this method, the tissue is removed with a thin wire loop that is heated by electrical current and acts as a scalpel.
• Vaginoscopy
• Human papillomavirus (HPV) infection must be present for cervical cancer to occur. Complete evaluation starts with Papanicolaou (Pap) testing.

How Biopsy Results are Reported:

Pre-cancerous changes in a biopsy are called cervical intraepithelial neoplasia (CIN). Sometimes the term dysplasia is used instead of CIN. CIN is graded on a scale of 1 to 3 based on how much of the

cervical tissue looks abnormal when viewed under the microscope.

• In CIN1, not much of the tissue looks abnormal, and it is considered the least serious cervical pre-cancer (mild dysplasia).
• In CIN2 more of the tissue looks abnormal (moderate dysplasia).
• In CIN3 most of the tissue looks abnormal; CIN3 is the most serious pre-cancer (severe dysplasia) and includes carcinoma in situ).
• If a cancer is found on a biopsy, it will be identified as either squamous cell carcinoma or adenocarcinoma.

Screening Recommendations

Current screening recommendations for specific age groups, based on guidelines from the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), the American Society for Clinical Pathology (ASCP), the US Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG), are as follows:

•  < 21 years: No screening recommended
•  21-29 years: Cytology (Pap smear) alone every 3 years
• 30-65 years: Human papillomavirus (HPV) and cytology Cotesting every 5 years (preferred) or cytology alone every 3 years (acceptable)
• >65 years: No screening recommended if adequate prior screening has been negative and high risk is not present

1. Cystoscopy, proctoscopy, and examination under anesthesia
2. Chest x-ray
3. Computed tomography (CT)
4. Magnetic resonance imaging (MRI)
5. Intravenous urography Intravenous urography (also known as intravenous pyelogram, or IVP): Is an x-ray of the urinary system taken after a special dye is injected into a vein.

• Positron emission tomography (PET) scans uses glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. This test can help see if the cancer has spread to lymph nodes.

Treatment

Common types of treatments for cervical cancer include:

Surgery

• Cryosurgery-A metal probe cooled with liquid nitrogen is placed directly on the cervix. This kills the abnormal cells by freezing them.
• Laser surgery- A focused laser beam, directed through the vagina, is used to vaporize (burn off)abnormal cells or to remove a small piece of tissue for study.•
• Conization- A cone biopsy can also be used as a treatment to completely remove many pre cancers and some very early cancers. Having had a cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely. The methods commonly used for cone biopsies are the loop electrosurgical excision procedure (LEEP), also called the large loop excision of the transformation zone (LLETZ), and the cold knife cone biopsy.
• Hysterectomy
• Radical hysterectomy-see above in the same chapter.
• Radiation therapy Chemotherapy (chemo) Targeted-therapy
• For the earliest stages of cervical cancer, either surgery or radiation combined with chemo may be used. For later stages, radiation combined with chemo is usually the main treatment. Chemo (by itself) is often used to treat advanced cervical cancer.

Cervical Cancer in Pregnancy

Pregnant women are at a modest increased risk of developing cervical cancer. Most medical professionals agree that carrying the baby to term is safe if your cancer is at an extremely early stage. A cone biopsy or hysterectomy is advised a few weeks after birth. The decision to carry the pregnancy on must be made if the cancer is staged higher.

Radiation and/or a radical hysterectomy would be used as therapy if not. if you decide to carry the pregnancy out. As soon as the infant can survive outside the womb, a cesarean section should be performed to deliver it. Cancers that are more advanced need to be treated right away.

Brachytherapy:

Brachytherapy, often known as internal radiation therapy, is a different kind of radiation treatment. This entails putting a radiation source within the malignancy or close by. Intracavitary brachytherapy, the form of brachytherapy used most frequently to treat cervical cancer, uses a device inside the vagina to house the radiation source (and sometimes the cervix).

The radioactive substance is inserted into a cylinder in the vagina to treat cervical cancer in women who have had hysterectomy. In order to treat a lady who still has a uterus, radioactive material can be inserted into a tiny metal tube called a tandem and tiny circular metal containers called ovoids that are positioned close to the cervix.

This is sometimes called tandem and ovoid treatment.

Screening of Reproductive Neoplasm

When cancer may be detected early for successful treatment, cancer screening tests are effective. Diagnostic procedures are frequently employed when a person exhibits signs and symptoms. Diagnostic procedures are used to identify, or diagnose, the origin of symptoms. As a preventive measure, diagnostic tests may also be used to check someone who is thought to be at high risk for cancer.

Pap test

Pap test can be done in order to find cancer early and the treatment works best. The Pap test also helps prevent cervical cancer by finding precancers, cell changes on the cervix that might become cervical cancer if they are not treated appropriately.

HPV Test

HPV test identify HPV infection and used for screening women aged 30 years and older. It is especially important to recognize warning signs and go for the investigation is essential.

• Laproscopy
• Hysterosalpingography
• Mamography
• Breast Self-Examination
• High vaginal swab
• Trans-Vaginal Sonography
• Pap smear
• Colposcopy
• Cervical biopsy, FNAC