Вінницький національний медичний університет ім. М.І. …
MINISTRY OF HEALTH OF UKRAINE
VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY
"CONFIRM"
at the methodical meeting
Department of Ray diagnostics,
Ray therapy and Oncology
Head of the department
As. of Prof., M.S.D. Kostyuk A.G.
________________________
"______" ________ 2013 year
METHODICAL GUIDELINES
For self-study for students in preparing for the practical (seminary) lessons
|Subject of Study | Oncology |
|Module No | 1 |
|Theme No | 19 |
|Topic of Lesson |Cervical and Endometrial Cancer. |
| |Distribution Risk factors, dysplasia. Classification by TNM. Methods of diagnosis. Clinics. |
| |Differential diagnosis. Treatment: surgery, radiotherapy, chemotherapy, combined. |
|Course | 5 |
|Faculty | General Medicine |
Cervical Cancer
1. Background.
The cervix is the lower third portion of the uterus (womb). It serves as a neck to connect the uterus to the vagina. The opening of the cervix, called the os , remains small and narrow, except during childbirth when it widens to allow a baby to pass from the uterus into the vagina.
Cervical cancer develops in the thin layer of cells called the epithelium , which cover the cervix. Cervical cancer usually begins slowly with precancerous abnormalities, and even if cancer develops, it generally progresses very gradually. Cervical cancer is the most preventable type of cancer and is very treatable in its early stages. Regular Pap tests and human papilloma virus (HPV) screening can help detect this disease early.
2. Specific goals.
1. To know the etiology of cervical cancer and the role of endocrine pathology in the development of these diseases, their prevalence among different groups of the female population, the overall results of a special treatment (( = I)
2. To know the main cause of cervical cancer, histologic classification and classification system for TNM, clinical manifestations, and cervical cancer, depending on the stage of the main methods of diagnosis and principles of radical and symptomatic treatment. (( = II)
3. To be able to examine patients with cervical cancer, to conduct a bimanual examination, the samples with dyes - Schiller and Tetrazolova, registering patients at the dispensary into the registration Form 30. ((=III)
4. To be able to interpret the sonogram and hysterogram in patients with cervical cancer.
5. To be able to define a differentiated treatment policy in patients with different stages of cervical cancer and uterus. (( = III)
6. To acquire a deontological view when working with patients with cancer of the uterus and those who have complications which is the manifestation of the underlying disease
7. Develop a sense of responsibility for the timeliness proper medical diagnosis CIN and the correct choice of treatment tactics in this pathology.
3. Basic knowledge, skills, abilities, necessary for studying the topic (inter-disciplinary integration).
|Preceding Subject |To know |To be able |
|Normal anatomy |Operative surgery and topographic anatomy of the |Featuring a look uterus, ovaries, fallopian|
| |external and internal anatomy of female genital |tubes. |
| |mutilation, the characteristic features of their | |
| |structure, blood supply (both arterial and venous flow | |
| |characteristics) innervation. | |
| |Menstrual cycle, its humoral and neuro-endocrine | |
| |regulation. Features of oocyte maturation in the | |
| |follicle. | |
|Normal physiology |The role of the lymphoid tissue of the pelvis was | |
| |normal. | |
| |The major classes of female hormones, their synthesis | |
| |and degradation. | |
| |Pathogenesis of endocrine disorders in patients with | |
| |cervical cancer. | |
|Biochemistry |Macroscopic forms of tumors of the uterus. Histological| |
| |classification of cervical cancer and | |
| | | |
|Physiopathology |Methods of examination of patients with cervical | |
| |cancer: a survey, physical and bimanual examination. | |
| |Additional studies: Ultrasound hysterography, |Determine the stage of cervical cancer and |
|Morbid anatomy |hysteroscopy with biopsy. |according to the histological |
| |The main types of surgery in patients with tumors of |classification and classification TNM. |
| |the body and cervix. |Conduct a focused and systematic collection|
| |Diatherocoagulation, indications and techniques of |of complaints and medical history of |
|Obstetrics and Gynecology |conducting. |patients with suspected cervical cancer. |
| |Total hysterectomy (TEM): indications, |Conduct physical and bimanual examination |
| |contraindications, technique execution. |of the female genital organs. |
| |TEM at Wertheim: indications, technique execution. |Surgical approaches to define the line of |
| |Featuring a look uterus, ovaries, fallopian tubes |the abdominal wall and above the vagina |
| | |during gynecological cancer operations. |
| | | |
| | | |
|Operative Surgery and topographical anatomy | | |
|Interdisciplinary Intergation |Key diagnostic symptoms of diseases gynecological |Identify specific manifestations in |
| |cancer field. |patients with cervical cancer, |
| | |interpretable additional methods of |
| | |examination in these diseases. |
4. Tasks for independent work in preparation for the occupation.
4.1. Theoretical issues to employment:
1. The spread of cancer of the uterus, cervical cancer.
2. Histological classification and TNM classification system and cervical cancer.
3. Mandatory and special methods of examination.
4. Differential diagnosis of cervical cancer and other diseases.
5. Surgical treatment of cervical cancer and uterus.
6. Indications and contraindications for surgery.
7. Technique of radical surgery in patients with cervical cancer.
8. Palliative surgery.
9. Preoperative preparation of patients, post-operative treatment and postoperative complications.
10. Long-term results of treatment of cervical cancer and uterus.
11. Combined treatment of cervical cancer and uterus. Forecast.
12. Question dispensary patients on cervical cancer.
4.2. Practical work (jobs) that need to perform in class:
1. Carefully collect history. Determine the history of symptoms of cervical cancer;
2. Physical examination the patient: palpation and assessment of lymph nodes, including regional, palpation of the abdomen, liver, detection of ascites balloting and percussion of abdomen;
3. Conduct vaginal, rectal, recto-abdominal and recto-vaginal examination;
4. Determine the methods of investigation: Ultrasound, cytology of exudates from peritoneal cavities, chest radiography, laboratory tests of blood and urine, laparoscopy if indicated, X-ray of the stomach, Irrigoscopy, fibrogastroscopy, colonoscopy and sigmoidoscopy;
5. Determine the stage of disease in patients with cervical cancer of the uterus;
6. Identify complications of cervical cancer;
7. The indications for surgery, chemotherapy and combined treatments;
8. Assess the condition of the patient in the early postoperative period.
4.3. Content of the topic
Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb) that opens at the top of the vagina.
Causes
Worldwide, cervical cancer is the third most common type of cancer in women. It is much less common in the United States because of the routine use of Pap smears.
Cervical cancers start in the cells on the surface of the cervix. There are two types of cells on the cervix's surface: squamous and columnar. Most cervical cancers are from squamous cells.
Cervical cancer usually develops very slowly. It starts as a precancerous condition called dysplasia. This precancerous condition can be detected by a Pap smear and is 100% treatable. It can take years for precancerous changes to turn into cervical cancer. Most women who are diagnosed with cervical cancer today have not had regular Pap smears or they have not followed up on abnormal Pap smear results.
Almost all cervical cancers are caused by HPV (human papilloma virus). HPV is a common virus that is spread through sexual intercourse. There are many different types of HPV. Some strains lead to cervical cancer. (Other strains may cause genital warts, while others do not cause any problems at all.)
A woman's sexual habits and patterns can increase her risk for cervical cancer. Risky sexual practices include having sex at an early age, having multiple sexual partners, and having multiple partners or partners who participate in high-risk sexual activities.
Risk factors for cervical cancer include:
• Not getting the HPV vaccine
• Poor economic status
• Women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1960s to prevent miscarriage
• Weakened immune system
Symptoms
Most of the time, early cervical cancer has no symptoms. Symptoms that may occur can include:
• Abnormal vaginal bleeding between periods, after intercourse, or after menopause
• Continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling
• Periods become heavier and last longer than usual
Cervical cancer may spread to the bladder, intestines, lungs, and liver. Patients with cervical cancer do not usually have problems until the cancer is advanced and has spread. Symptoms of advanced cervical cancer may include:
• Back pain
• Bone pain or fractures
• Fatigue
• Leaking of urine or feces from the vagina
• Leg pain
• Loss of appetite
• Pelvic pain
• Single swollen leg
• Weight loss
Exams and Tests
Precancerous changes of the cervix and cervical cancer cannot be seen with the naked eye. Special tests and tools are needed to spot such conditions.
• Pap smears screen for precancers and cancer, but do not make a final diagnosis.
• If abnormal changes are found, the cervix is usually examined under magnification. This is called colposcopy. Pieces of tissue are surgically removed (biopsied) during this procedure and sent to a laboratory for examination.
• Cone biopsy may also be done.
If the woman is diagnosed with cervical cancer, the health care provider will order more tests to determine how far the cancer has spread. This is called staging. Tests may include:
• Chest x-ray
• CT scan of the pelvis
• Cystoscopy
• Intravenous pyelogram (IVP)
• MRI of the pelvis
Treatment
Treatment of cervical cancer depends on:
• The stage of the cancer
• The size and shape of the tumor
• The woman's age and general health
• Her desire to have children in the future
Early cervical cancer can be cured by removing or destroying the precancerous or cancerous tissue. There are various surgical ways to do this without removing the uterus or damaging the cervix, so that a woman can still have children in the future.
Types of surgery for early cervical cancer include:
• Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue
• Cryotherapy -- freezes abnormal cells
• Laser therapy -- uses light to burn abnormal tissue
A hysterectomy (removal of the uterus but not the ovaries) is not often performed for cervical cancer that has not spread. It may be done in women who have repeated LEEP procedures.
Treatment for more advanced cervical cancer may include:
• Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina.
• Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed.
Radiation may be used to treat cancer that has spread beyond the pelvis, or cancer that has returned. Radiation therapy is either external or internal.
• Internal radiation therapy uses a device filled with radioactive material, which is placed inside the woman's vagina next to the cervical cancer. The device is removed when she goes home.
• External radiation therapy beams radiation from a large machine onto the body where the cancer is located. It is similar to an x-ray.
Chemotherapy uses drugs to kill cancer. Some of the drugs used for cervical cancer chemotherapy include 5-FU, cisplatin, carboplatin, ifosfamide, paclitaxel, and cyclophosphamide. Sometimes radiation and chemotherapy are used before or after surgery.
Outlook (Prognosis)
How well the patient does depends on many things, including:
• The type of cancer
• The stage of the disease
• The woman's age and general physical condition
• If the cancer comes back after treatment
Pre-cancerous conditions are completely curable when followed up and treated properly. The chance of being alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area is 92%.
The 5-year survival rate falls steadily as the cancer spreads into other areas.
Possible Complications
• Some types of cervical cancer do not respond well to treatment.
• The cancer may come back (recur) after treatment.
• Women who have treatment to save the uterus have a high risk of the cancer coming back (recurrence).
• Surgery and radiation can cause problems with sexual, bowel, and bladder function.
When to Contact a Medical Professional
Call your health care provider if you:
• Have not had regular Pap smears
• Have abnormal vaginal bleeding or discharge
Prevention
A vaccine to prevent cervical cancer is now available. In June 2006, the U.S. Food and Drug Administration approved the vaccine called Gardasil, which prevents infection against the two types of HPV responsible for most cervical cancer cases.
Studies have shown that the vaccine appears to prevent early-stage cervical cancer and precancerous lesions. Gardasil is the first approved vaccine targeted specifically to prevent any type of cancer.
Practicing safe sex (using condoms) also reduces your risk of HPV and other sexually transmitted diseases. HPV infection causes genital warts. These may be barely visible or several inches wide. If a woman sees warts on her partner's genitals, she should avoid intercourse with that person.
To further reduce the risk of cervical cancer, women should limit their number of sexual partners and avoid partners who participate in high-risk sexual activities.
Getting regular Pap smears can help detect precancerous changes, which can be treated before they turn into cervical cancer. Pap smears effectively spot such changes, but they must be done regularly. Annual pelvic examinations, including a pap smear, should start when a woman becomes sexually active, or by the age of 20 in a nonsexually active woman.
If you smoke, quit. Cigarette smoking is associated with an increased risk of cervical cancer.
5. Tests for self evaluation.
A. Tests for self evaluation (test problem)
1. What is the most common histological form of cancer of the uterus:
1) adenocarcinoma
2) squamous cell carcinoma
3) undifferentiated carcinoma
4) anaplastic carcinoma
5) clear cell carcinoma
Correct answer: 1.
2. Radical surgery in cancer of the uterus:
1) hysterectomy
2) resection of the uterine
3) total hysterectomy
4) ovariohysterectomy
5) hysterectomy
Correct answer: 3.
3. The first symptom of cervical cancer:
1) spotting
2) weakness
3) pain in the genitals
4) watery discharge
5) pain during intercourse
Correct answer: 4.
4. Immature morphological variant of cervical cancer:
1) G2
2) G1
3) G4
4) G3
5) G0
Correct answer: 4.
5. T2 cervical cancer are:
1) The tumor extends beyond the uterus
2) The tumor extends to the pelvic wall
3) tumor limited to the cervix
4) The tumor extends to the vagina
5) the tumor grows into the surrounding tissue
Correct answer: 1.
B. Situation tasks for self-control:
1. Patient K., 44 years old, seeking antenatal care with complaints of vaginal bleeding after sex. Vaginally: cervix hypertrophied. The front lip of the cervix - a tumor in the form of cauliflower 2x2 cm, which is bleeding in contact palpation. Uterus of normal size and empty inside. Rectal: supra-cervical portion of the cervix is sealed, but not increased. Formulate a complete diagnosis.
Correct answer: Cervical cancer stage I.
2. In patient M., 62 - years old, after 14 years of menopause, there spotting for a month. With bimanual study bleeding from the genital tract increased, uterus large, painless, appendages on both sides are not increased, their site is painless. The neck when viewed in the mirror clean. What kind of pathology in this case, is it?
Correct answer: Uterine cancer.
3. In the gynecological ward admissions M., 65. Complaints of pain in the left hip area, especially at night. The urine and feces appeared blood. For the first time a doctor asked 3 months ago. Vaginally: - narrow vagina infiltrated cancer, cervix look impossible. Rectal: vaginal wall and rectum also infiltrated cancer. The body of the uterus increased to 11 weeks of pregnancy, is dense. In the parameters of both sides palpable infiltration that reach the walls of the pelvis. What is your diagnosis? What do you associate pain at the site of the left Thigh? How does blood appear in the urine and feces? Which is your treatment strategy?
Correct answer: Uterine cancer stage IV. Stretching of n.pudenda by the mass-irradiation in the thigh, the spread of cancer into the bladder - blood in the urine; into rectum - blood in the stool. Symptomatic treatment: Analgesics, including narcotic drugs and haemostatic therapy.
6. Literature.
Basic.
1. Sorcin V, Popovich A, Dumanskiy Yu, et al. Clinical oncology. Simferopol, 2008; 192 p.
2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.
Additional.
1. National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Cervical Cancer Screening. v. 2012.
2. Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2010; 60(2): 99-119.
3. Pham H, Geraci SA, Burton MJ; CDC Advisory Committee on Immunization Practices. Adult immunizations: update on recommendations. Am J Med. 2011; 124(8): 698-701.
4. Kahn JA. HPV vaccination for the prevention of cervical intraepithelial neoplasia. N Engl J Med. 2009 16; 361(3): 271-8.
5. Noller KL. Intraepithelial neoplasia of the lower genital tract (cervix, vulva): Etiology, screening, diagnostic techniques, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: chap 28.
Endometrial Cancer
1. Background.
The uterus is the pelvic organ that holds the pregnancy and that bleeds each menstrual period. The cervix is that part of the uterus fixed at the top of the vagina. The normal size of the uterus is about that of a lemon. The uterus is divided into three parts. The great bulk of the uterus is composed of smooth muscle and forms a thick uterine wall. The inside of the uterus is lined with a glandular epithelium which is supported by the endometrial stroma. Together, the glandular lining and the endometrial stroma are referred to as the endometrium of the uterus. The endometrium is hormonally sensitive and changes throughout the menstrual cycle and during pregnancy.
2. Specific goals.
1. To know the etiology of uterine cancer and the role of endocrine pathology in the development of these diseases, their prevalence among different groups of the female population, the overall results of a special treatment (( = I)
2. To know the main cause of uterine cancer, histologic classification and classification system for TNM, clinical manifestations, and uterine cancer, depending on the stage of the main methods of diagnosis and principles of radical and symptomatic treatment. (( = II)
3. To be able to examine patients with uterine cancer and body, to conduct a bimanual examination, the samples with dyes - Schiller and Tetrazolova, registering patients at the dispensary into the registration Form 30. ((=III)
4. To be able to interpret the sonogram and hysterogram in patients with uterine cancer.
5. To be able to define a differentiated treatment policy in patients with different stages of uterine cancer and uterus. (( = III)
6. To acquire a deontological view when working with patients with cancer of the uterus and those who have complications which is the manifestation of the underlying disease
7. Develop a sense of responsibility for the timeliness proper medical diagnosis CIN and the correct choice of treatment tactics in this pathology.
3. Basic knowledge, skills, abilities, necessary for studying the topic (inter-disciplinary integration).
|Preceding Subject |To know |To be able |
|Normal anatomy |Operative surgery and topographic anatomy of the |Featuring a look uterus, ovaries, fallopian|
| |external and internal anatomy of female genital |tubes. |
| |mutilation, the characteristic features of their | |
| |structure, blood supply (both arterial and venous flow | |
| |characteristics) innervation. | |
| |Menstrual cycle, its humoral and neuro-endocrine | |
| |regulation. Features of oocyte maturation in the | |
| |follicle. | |
|Normal physiology |The role of the lymphoid tissue of the pelvis was | |
| |normal. | |
| |The major classes of female hormones, their synthesis | |
| |and degradation. | |
| |Pathogenesis of endocrine disorders in patients with | |
| |uterine cancer. | |
|Biochemistry |Macroscopic forms of tumors of the uterus. Histological| |
| |classification of uterine cancer and | |
| |Methods of examination of patients with uterine cancer:| |
|Physiopathology |a survey, physical and bimanual examination. | |
| |Additional studies: Ultrasound hysterography, | |
| |hysteroscopy with biopsy. |Determine the stage of uterine cancer and |
|Morbid anatomy |The main types of surgery in patients with tumors of |according to the histological |
| |the body and cervix. |classification and classification TNM. |
| |Diatherocoagulation, indications and techniques of |Conduct a focused and systematic collection|
| |conducting. |of complaints and medical history of |
|Obstetrics and Gynecology |Total hysterectomy (TEM): indications, |patients with suspected uterine cancer. |
| |contraindications, technique execution. |Conduct physical and bimanual examination |
| |TEM at Wertheim: indications, technique execution. |of the female genital organs. |
| |Featuring a look uterus, ovaries, fallopian tubes |Surgical approaches to define the line of |
| | |the abdominal wall and above the vagina |
| | |during gynecological cancer operations. |
| | | |
| | | |
|Operative Surgery and topographical anatomy | | |
|Interdisciplinary Intergation |Key diagnostic symptoms of diseases gynecological |Identify specific manifestations in |
| |cancer field. |patients with uterine cancer, interpretable|
| | |additional methods of examination in these |
| | |diseases. |
4. Tasks for independent work in preparation for the occupation.
4.1. Theoretical issues to employment:
1. The spread of cancer of the uterus, cervical cancer.
2. Histological classification and TNM classification system and uterine cancer.
3. Mandatory and special methods of examination.
4. Differential diagnosis of uterine cancer and other diseases.
5. Surgical treatment of uterine cancer and uterus.
6. Indications and contraindications for surgery.
7. Technique of radical surgery in patients with uterine cancer.
8. Palliative surgery.
9. Preoperative preparation of patients, post-operative treatment and postoperative complications.
10. Long-term results of treatment of uterine cancer and uterus.
11. Combined treatment of uterine cancer and uterus. Forecast.
12. Question dispensary patients on uterine cancer.
4.2. Practical work (jobs) that need to perform in class:
1. Carefully collect history. Determine the history of symptoms of uterine cancer;
2. Physical examination the patient: palpation and assessment of lymph nodes, including regional, palpation of the abdomen, liver, detection of ascites balloting and percussion of abdomen;
3. Conduct vaginal, rectal, recto-abdominal and recto-vaginal examination;
4. Determine the methods of investigation: Ultrasound, cytology of exudates from peritoneal cavities, chest radiography, laboratory tests of blood and urine, laparoscopy if indicated, X-ray of the stomach, Irrigoscopy, fibrogastroscopy, colonoscopy and sigmoidoscopy;
5. Determine the stage of disease in patients with uterine cancer of the uterus;
6. Identify complications of uterine cancer;
7. The indications for surgery, chemotherapy and combined treatments;
8. Assess the condition of the patient in the early postoperative period.
4.3. Content of the topic
TYPES OF UTERINE CANCERS
Each of these three parts gives rise to cancers. The smooth muscle cancers are called leiomyosarcomas(ly o myo sarcomas). There is also a benign tumor of smooth muscle called a leiomyoma. The common name for this benign tumor is myoma or fibroid. The endometrial stroma gives rise to a variety of cancers classified as sarcomas. The glandular lining gives rise to adenocarcinomas. Ninety-five percent, of uterine cancers are adenocarcinomas arising from the lining. The term uterine cancer usually refers to these adenocarcinomas.
Adenocarcinomas are graded. Grade I means well differentiated, that is, they are easily identified as originating from the glandular tissue and have easily identifiable glandular structures. Grade III means poorly differentiated with loss of the glandular structures. They are just solid cancer. Grade II cancers are intermediate in appearance. Grade I cancers are expected to behave the best, Grade III cancers the worst.
There are premalignant changes that can occur in the lining of the uterus. These changes are almost always due to excessive stimulation of the endometrial glands by an excess of estrogen or a prolonged estrogen influence. They can occur in younger women who do not ovulate regularly as well as in older women who are obese.
These changes are called endometrial hyperplasias. They are diagnosed usually by endometrial biopsy. They are not cancers but are often best treated by hysterectomy. They can also be treated by high dose progesterone therapy. If they occur in a young woman she will probably also be relatively infertile due to irregular or infrequent ovulation. In these cases, the treatment is by drugs that cause ovulation. If you ovulate you will no longer have unopposed estrogen stimulation because you now have the progesterone phase to the menstrual cycle. If you get pregnant then that will reverse the hyperplasia also. For most women the best treatment will probably be hysterectomy.
Papillary serous adenocarcinomas and clear cell adenocarcinomas are a subtype of uterine adenocarcinomas. They are different because of their increased potential to spread throughout the abdomen. In this they sometimes behave like an ovarian cancer. The diagnosis and staging is the same as for the more usual endometrial cancer. The best treatment has yet to be demonstrated. There is a good reason to consider treating the entire abdomen, but there is no good way to do it. Whole abdominal radiation can be done, but it can have a lot of side effects. This is a situation where several opinions should be obtained.
RISK FACTORS FOR UTERINE ADENOCARCINOMA
Age is the most important risk factor. This is a cancer of postmenopausal and perimenopausal women. There is also a well-recognized association with estrogen. Estrogen is a hormone produced by the ovary. The ovary does several things under the direction of the pituitary gland in the head. First, the pituitary directs the ovary to start maturing an egg. It does this by sending the ovary the pituitary hormone Follicle Stimulating Hormone (FSH). The ovary develops a small cyst or follicle about one half inch in size within which is the egg. During the maturation process the ovary is making estrogen. One of the effects of the estrogen is to stimulate the endometrial glands to grow and proliferate. Then the pituitary tells the ovary to ovulate which means break the follicle and release the egg. The pituitary hormone for this is called Luteinizing Hormone (LH).
The egg is ejected and floats into the fallopian tube. The remnant of the follicle, under the influence of LH starts to make progesterone. Progesterone converts the lining of the uterus to accept the pregnancy. If pregnancy does not occur that cycle then the ovary stops making progesterone. When the progesterone level falls the support for the uterine lining is lost and it falls off. This is the menstrual period. Then, it all starts over again: estrogen, ovulation, progesterone, and the period.
If the woman has a problem that prevents ovulation then the ovary will continue to make estrogen. This will result in prolonged unopposed estrogen stimulation to the endometrial glands and this will increase the risk for cancer of these glands. Postmenopausal women who are taking estrogen also will have an unopposed estrogen stimulation to the uterine glands and be at increased risk for developing an adenocarcinoma of the uterus. This is why a progestin such as Provera is also prescribed. Postmenopausal women who are obese have an increased level of estrogen because the adipose tissue converts other normal body chemicals into estrogen, so they are also at increased risk. Women who take Tamoxifen for breast cancer are also thought to be at increased risk because Tamoxifen is an estrogen. These increased risks are on the order of about 5-12 times the normal risk.
Conditions that increase the progesterone influence on the uterus decrease the risk for adenocarcinoma of the endometrium. Pregnancy is a time of increased progesterone levels, so women who have been pregnant most of their lives are at decreased risk. Women who have taken birth control pills for a long time are at decreased risk. Birth control pills contain both an estrogen and a progestin, but the net effect is that of the progestin. Prolonged progestin influence on the endometrium produces a thinning and atrophy of the glands which is just the opposite of the effects of estrogen. There are other minor risk factors but almost all are mediated through an estrogen progestin link.
SYMPTOMS OF UTERINE CANCER
The most frequent symptom of cancer of the uterus is abnormal bleeding. In postmenopausal women any bleeding is considered cancer of the uterus until proven not to be. The only way to prove that there is or is not a cancer inside the uterus is by removing some of the uterine lining as a biopsy. This can often be done easily in the office without any anesthesia, or it can be done in the operating room with an anesthetic. The procedure is called a D&C, dilatation of the cervix and curettage of the uterine lining. Sometimes a scope can be inserted through the cervix into the uterus and the lining visualized and biopsied directly. This is called hysteroscopy.
Whatever the procedure, you must be convinced that the bleeding is not due to a cancer inside the uterus. The Pap test cannot assess the inside of the uterus and is of no value. A trial of hormones is inappropriate. Any postmenopausal bleeding must be taken seriously and evaluated. Occasionally a sonogram or ultrasound test that assesses the thickness of the endometrial lining can be helpful, especially in an elderly debilitated woman who cannot be easily biopsied and who is also an anesthetic risk. If the lining can be seen and measures less than 5mm, then there is unlikely to be a cancer present.
The problem with postmenopausal hormone replacement is that it often causes some irregular bleeding which may require a biopsy. If the hormones are taken on a cyclic basis where there are several days each month when bleeding may occur and if the bleeding is light and occurs on those days then biopsy need not be done. If it occurs at any other time in the cycle then a biopsy should be done. If the hormones are both being taken on a continuous basis each day and bleeding occurs then a biopsy should be performed
SCREENING FOR UTERINE CANCER
There are no recommendations for screening for cancers of the uterus. The only screening procedure is an endometrial biopsy. Some have suggested that women who are taking replacement estrogen only, without the progesterone, should have an annual biopsy. Also women on Tamoxifen should probably be biopsied annually. The Pap test is inadequate for cancers inside the uterus although occasionally this cancer will be found on a Pap test. If the Pap test shows endometrial cells then this is abnormal and should be evaluated with an endometrial biopsy.
DIAGNOSIS
Cancers of the uterus are diagnosed by endometrial biopsy, D&C, hysteroscopy and sometimes only after hysterectomy. The important point is that any postmenopausal bleeding must be considered a cancer of the uterus until proven otherwise. It is fortunate that uterine cancers bleed early so symptoms are early and if the bleeding is not ignored, diagnosis is early. Three-fourths of all uterine cancers are diagnosed at an early stage. Of these about three-fourths are of favorable grade. This is why the number of deaths from uterine cancer is low even though it is the most frequently diagnosed gynecologic cancer.
STAGING OF UTERINE CANCER
Cancers of the uterus are staged by surgical exploration with removal of the uterus, tubes and ovaries. In addition, an assessment of the pelvic and aortic lymph nodes is done.
| SURGICAL STAGES OF CANCER OF THE UTERUS |
| |
|Stage I Cancer limited to the lining of the uterus |
|IA No invasion into the uterine wall |
|IB Invasion into less than one half of the uterine wall |
|IC Invasion into more than one half the uterine wall |
| |
|Stage II Extends into the cervix |
|IIA Extends only superficially along the endocervix |
|IIB Extends deep into the cervix |
| |
|Stage III Cancer has spread beyond the uterus |
|IIIA Cancer involves the tubes or ovaries |
|IIIB Spread to the vagina |
|IIIC Spread to the pelvic or aortic lymph nodes |
| |
|Stage IV Distant metastases |
|IVA Is inside the bladder or rectum |
|IVB Throughout the abdomen or other distant sites |
In addition, these cancers are also graded; Grade I, II and III. To determine the correct stage the uterus, tubes and ovaries will have to be removed as well as sampling the pelvic and aortic lymph nodes. An early stage is assigned by excluding the more advanced stage. Some cases that are obviously in an advanced stage by physical examination will not benefit from surgery and can be treated without operative staging.
TREATMENT
Treatment of uterine cancers is usually by a combination of surgery and radiation. Those that are at an early stage will be operated first with removal of the uterus, tubes and ovaries, to confirm the stage. If there is only limited invasion into the wall of the uterus and the grade is good, i.e. grade I or II, then the surgery will be sufficient and no radiation will be recommended. If of higher stage and grade then radiation to the pelvis will often be advised. Some doctors prefer to give radiation prior to surgery but that is becoming less prevalent. Advanced stages are treated by radiation if possible, or chemotherapy. Fortunately, progesterone, which has few side effects, is a good chemotherapeutic. Other types of chemotherapy have limited effectiveness but are often used and can give an initially good response.
Most patients will be in an early stage when diagnosed and there will be several options for treatment. Often these are elderly women who may have other medical problems. Nevertheless, a maximum effort should be taken to bring these patients to surgery since the cure rate drops by 20% if a hysterectomy is not performed. With no other gynecologic cancer is treatment so individualized as with early stage endometrial cancer.
PROGNOSIS
Since most patients are diagnosed at an early stage and with an optimal grade, most patients are cured. Nevertheless, stage for stage it is just as bad a cancer as any other. Most recurrences will occur in the first two years. If none have occurred by five years the patient is considered cured.
|FIVE YEAR SURVIVAL FOR UTERINE ADENOCARCINOMA |
| |
|Stage I 80% |
|Stage II 65% |
|Stage III 30% |
|Stage IV 10% |
Stage IA, grade I, cancers have a five year survival in excess of 95%. The prognosis depends on the substage and the grade.
ODDS AND ENDS
Adenocarcinomas of the endometrium are often hormonally sensitive cancers and occasionally estrogen and progesterone receptors will be determined, but this is not commonly done.
There are several different cell types included in the designation adenocarcinoma. Some trend to behave in a more virulent manner but all are treated about the same.
The Ca-125 blood test is often elevated in endometrial adenocarcinomas, and if so, can serve as a tumor marker.
Endometriosis is a benign condition in which endometrial tissue (glands and stroma) is misplaced onto other structures. Often there are implants on the surface of the outside of the uterus or on the lining of the pelvis. They can even occur inside the ovary. Each time the lining of the uterus bleeds during menses these implants also bleed and can cause pain and adhesions. If inside the ovary it can cause a blood filled ovarian cyst called an endometrioma. Endometriosis is a benign condition but one that can cause a lot of problems. Very rarely an endometrial adenocarcinoma can arise in an endometrial implant.
NEVER, NEVER IGNORE POSTMENOPAUSAL BLEEDING, AND DO NOT LET YOUR DOCTOR IGNORE IT EITHER. YOU MUST PROVE THAT IT IS NOT DUE TO A UTERINE CANCER.
5. Tests for self evaluation.
A. Tests for self evaluation (test problem)
1. What is the most common histological form of cancer of the uterus:
1) adenocarcinoma
2) squamous cell carcinoma
3) undifferentiated carcinoma
4) anaplastic carcinoma
5) clear cell carcinoma
Correct answer: 1.
2. Radical surgery in cancer of the uterus:
1) hysterectomy
2) resection of the uterine
3) total hysterectomy
4) ovariohysterectomy
5) hysterectomy
Correct answer: 3.
3. The first symptom of cervical cancer:
1) spotting
2) weakness
3) pain in the genitals
4) watery discharge
5) pain during intercourse
Correct answer: 4.
4. Immature morphological variant of cervical cancer:
1) G2
2) G1
3) G4
4) G3
5) G0
Correct answer: 4.
5. T2 cervical cancer are:
1) The tumor extends beyond the uterus
2) The tumor extends to the pelvic wall
3) tumor limited to the cervix
4) The tumor extends to the vagina
5) the tumor grows into the surrounding tissue
Correct answer: 1.
B. Situation tasks for self-control:
1. Patient K., 44 years old, seeking antenatal care with complaints of vaginal bleeding after sex. Vaginally: cervix hypertrophied. The front lip of the cervix - a tumor in the form of cauliflower 2x2 cm, which is bleeding in contact palpation. Uterus of normal size and empty inside. Rectal: supra-cervical portion of the cervix is sealed, but not increased. Formulate a complete diagnosis.
Correct answer: Cervical cancer stage I.
2. In patient M., 62 - years old, after 14 years of menopause, there spotting for a month. With bimanual study bleeding from the genital tract increased, uterus large, painless, appendages on both sides are not increased, their site is painless. The neck when viewed in the mirror clean. What kind of pathology in this case, is it?
Correct answer: Uterine cancer.
3. In the gynecological ward admissions M., 65. Complaints of pain in the left hip area, especially at night. The urine and feces appeared blood. For the first time a doctor asked 3 months ago. Vaginally: - narrow vagina infiltrated cancer, cervix look impossible. Rectal: vaginal wall and rectum also infiltrated cancer. The body of the uterus increased to 11 weeks of pregnancy, is dense. In the parameters of both sides palpable infiltration that reach the walls of the pelvis. What is your diagnosis? What do you associate pain at the site of the left Thigh? How does blood appear in the urine and feces? Which is your treatment strategy?
Correct answer: Uterine cancer stage IV. Stretching of n.pudenda by the mass-irradiation in the thigh, the spread of cancer into the bladder - blood in the urine; into rectum - blood in the stool. Symptomatic treatment: Analgesics, including narcotic drugs and haemostatic therapy.
6. Literature.
Basic.
1. Sorcin V, Popovich A, Dumanskiy Yu, et al. Clinical oncology. Simferopol, 2008; 192 p.
2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.
Additional.
1. National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Uterine Cancer Screening. v. 2012.
2. "Detailed Guide: Endometrial Cancer." American Cancer Society. 2012.
3. Chiang, Jing Wang. "Uterine Cancer." eMedicine. Eds. John J. Kavanagh, et al. Medscape. 2009.
4. "Detailed Guide: Uterine Sarcoma." American Cancer Society. 2012.
5. Creasman, William T. "Endometrial Carcinoma." eMedicine. Eds. John J. Kavanagh, et al. Medscape. 2009.
Methodical guidelines written
by Assistant oncology department PhD. Lysenko S.A.
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