Uterine body cancer

Malignant tumors of the uterine body include: cancer, sarcoma, mesodermal tumors and choriocarinoma. Cancer of the uterine body means cancer of the endometrium (the mucous membrane of the uterus). Endometrial cancer is a hormone-dependent tumor, i.e. it is caused by endocrine-metabolic disorders, and is often combined with uterine myoma, endometrioid disease, and ovarian tissue hyperplasia.

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Epidemiology

Endometrial cancer is a widespread malignant neoplasm. It ranks second in the structure of oncological diseases in women. It is the fourth most common type of cancer, after breast, lung and colon cancer. Uterine body cancer is predominantly found in postmenopausal patients with bleeding; it is detected in 10% of cases during this period of life. Diagnostic errors in women at this age are caused by incorrect assessment of bloody discharge, which is often explained by climacteric dysfunction.

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Causes uterine cancer

A special place in the development of endometrial cancer is occupied by background (glandular hyperplasia, endometrial polyps) and precancerous (atypical hyperplasia and adenomatosis) conditions of the endometrium.

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Risk factors

The risk group includes women who have a high probability of developing a malignant tumor in the presence of certain diseases and conditions (risk factors). The risk group for developing uterine cancer may include:

1. Women in the period of established menopause with bloody discharge from the genital tract.
2. Women with continued menstrual function after 50 years of age, especially with uterine fibroids.
3. Women of any age suffering from hyperplastic processes of the endometrium (recurrent polyposis, adenomatosis, glandular-cystic hyperplasia of the endometrium).
4. Women with impaired fat and carbohydrate metabolism (obesity, diabetes) and hypertension.
5. Women with various hormonal disorders causing anovulation and hyperestrogenism (Stein-Leventhal syndrome, postpartum neuroendocrine diseases, myoma, adenomyosis, endocrine infertility).

Other factors that contribute to the development of endometrial cancer:

• Estrogen replacement therapy.
• Polycystic ovary syndrome.
• No history of childbirth.
• Early onset of menarche, late menopause.
• Alcohol abuse.

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Symptoms uterine cancer

1. Leucorrhoea. Is the earliest sign of uterine cancer. Leucorrhoea is thin, watery. Blood often joins this discharge, especially after physical exertion.
2. Itching of the external genitalia. May occur in patients with endometrial cancer due to irritation from vaginal discharge.
3. Bleeding is a late symptom that occurs as a result of tumor decay and may manifest itself as discharge in the form of meat-like “slops,” smearing, or pure blood.
4. Pain - cramping in nature, radiating to the lower limbs, occurs when discharge from the uterus is delayed. Dull pain, aching in nature, especially at night, indicates the spread of the process beyond the uterus and is explained by compression of the nerve plexuses in the small pelvis by the tumor infiltrate.
5. Dysfunction of adjacent organs due to tumor growth into the bladder or rectum.
6. These patients are characterized by obesity (rarely weight loss), diabetes, and hypertension.

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Stages

Currently, several classifications of uterine cancer are used in clinical practice: the 1985 classification, the international FIGO classification and TNM.

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FIGO Classification of Uterine Cancer by Stages

The extent of the lesion

• 0 - Pre-endometrium carcinoma (atypical glandular hyperplasia of the endometrium)
• 1 - The tumor is limited to the body of the uterus, regional metastases are not detected
  • 1a - Tumor is limited to the endometrium
  • 1b - Invasion into the myometrium up to 1 cm
• 2 - The tumor affects the body and cervix of the uterus, regional metastases are not determined
• 3 - The tumor extends beyond the uterus but not beyond the pelvis
  • 3a - The tumor infiltrates the serosa of the uterus and/or there are metastases in the uterine appendages and/or in the regional lymph nodes of the pelvis
  • 3b - The tumor infiltrates the pelvic tissue and/or there are metastases to the vagina
• 4 - The tumor extends beyond the pelvis and/or there is invasion of the bladder and/or rectum
  • 4a - Tumor invades bladder and/or rectum
  • 4b - Tumor of any degree of local and regional spread with detectable distant metastases

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International classification of uterine cancer according to the TNM system

• T0 - Primary tumor is not detected
• Tis - Preinvasive carcinoma
• T1 - Tumor is limited to the body of the uterus
  • T1a - The uterine cavity is no more than 8 cm in length
  • T1b - Uterine cavity more than 8 cm in length
• T2 - The tumor has spread to the cervix but not beyond the uterus
• T3 - The tumor has spread beyond the uterus but remains within the pelvis
• T4 - The tumor extends into the lining of the bladder, rectum, and/or extends beyond the pelvis

N - regional lymph nodes

• Nx - Insufficient data to assess the status of regional lymph nodes
• N0 - No evidence of metastasis to regional lymph nodes
• N1 - Metastases in regional lymph nodes

M - distant metastases

• Mx - Insufficient data to determine distant metastases
• M0 - No signs of metastases
• M1 - There are distant metastases

G - histological differentiation

• G1 - High degree of differentiation
• G2 - Average degree of differentiation
• G3-4 - Low degree of differentiation

Forms

There are limited and diffuse forms of uterine cancer. In the limited form, the tumor grows as a polyp, clearly delimited from the unaffected mucous membrane of the uterus; in the diffuse form, cancer infiltration spreads to the entire endometrium. The tumor most often occurs in the area of the fundus and tubal angles of the uterus. Approximately 80% of patients have adenocarcinoma of varying degrees of differentiation, in 8-12% - adenoacanthoma (adenocarcinoma with benign squamous cell differentiation), which has a favorable prognosis.

Less common tumors with a worse prognosis include glandular squamous cell carcinoma, in which the squamous cell component is similar to squamous cell carcinoma, but the prognosis is worse due to the presence of an undifferentiated glandular component.

Squamous cell carcinoma, like clear cell carcinoma, has much in common with similar tumors of the cervix, occurs in older women and is characterized by an aggressive course.

Undifferentiated cancer is more common in women over 60 years of age and occurs against the background of endometrial atrophy. It also has an unfavorable prognosis.

One of the rare morphological variants of endometrial cancer is serous-papillary cancer. Morphologically, it has much in common with serous ovarian cancer, it is characterized by an extremely aggressive course and a high potential for metastasis.

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Diagnostics uterine cancer

Gynecological examination. During examination with the help of mirrors, the condition of the cervix and the nature of the discharge from the cervical canal are clarified - the discharge is taken for cytological examination. During vaginal (rectovaginal) examination, attention is paid to the size of the uterus, the condition of the appendages and parauterine tissue.

Aspiration biopsy (cytology of aspirate from the uterine cavity) and examination of aspiration washings from the uterine cavity and cervical canal. The latter is performed in postmenopausal age if there is no possibility of aspiration biopsy and diagnostic curettage.

Cytological examination of vaginal smears taken from the posterior fornix. This method gives a positive result in 42% of cases.

Despite the small percentage of positive results, the method can be widely used in outpatient settings, eliminates trauma, and does not stimulate the tumor process.

Separate diagnostic curettage of the uterine cavity and cervical canal, under hysteroscopy control. It is advisable to obtain scrapings from areas where precancerous processes most often occur: the area of the external and internal os, as well as tubal angles.

Hysteroscopy. The method helps to identify the cancer process in places difficult to access for curettage, allows to identify the localization and prevalence of the tumor process, which is important for choosing the treatment method and for subsequent monitoring of the effectiveness of the radiation therapy.

Tumor markers. To determine the proliferative activity of endometrial carcinoma cells, it is possible to determine monoclonal antibodies Ki-S2, Ki-S4, KJ-S5.

To detect distant metastases, it is recommended to perform chest X-ray, ultrasound and computed tomography of the abdominal organs and retroperitoneal lymph nodes.

Ultrasound examination. The accuracy of ultrasound diagnostics is about 70%. In some cases, the cancerous node is practically indistinguishable from the uterine muscle in terms of acoustic characteristics.

Computed tomography (CT). It is performed to exclude metastases in the uterine appendages and primary multiple ovarian tumors.

Magnetic resonance imaging (MRI). MRI in endometrial cancer allows to determine the exact localization of the process, differentiate stages I and II from III and IV, as well as determine the depth of invasion into the myometrium and distinguish stage I of the disease from the rest. MRI is a more informative method in determining the prevalence of the process outside the uterus.

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Treatment uterine cancer

When choosing a treatment method for patients with uterine cancer, three main factors must be taken into account:

• age, general condition of the patient, severity of metabolic and endocrine disorders;
• the histological structure of the tumor, the degree of its differentiation, size, localization in the uterine cavity, and the prevalence of the tumor process;
• the institution where the treatment will be carried out (not only the oncological training and surgical skills of the doctor are important, but also the equipment of the institution).

Only by taking into account the above factors can the process be correctly staged and adequately treated.

About 90% of patients suffering from uterine cancer undergo surgical treatment. Usually, extirpation of the uterus with appendages is performed. After opening the abdominal cavity, revision of the pelvic organs and abdominal cavity, retroperitoneal lymph nodes is performed. In addition, swabs are taken from the Douglas space for cytological examination.

Surgical treatment of uterine cancer

The scope of surgical treatment is determined by the stage of the process.

Stage 1a: if only the endometrium is affected, regardless of the histological structure of the tumor and the degree of its differentiation, a simple extirpation of the uterus with appendages is performed without additional therapy. With the advent of endoscopic surgery methods, ablation (diathermocoagulation) of the endometrium has become possible at this stage of the disease.

Stage 1b: in case of superficial invasion, localization of a small tumor, high degree of differentiation in the upper-posterior part of the uterus, a simple extirpation of the uterus with appendages is performed.

In case of invasion up to 1/2 of the myometrium, G2 and G3 degrees of differentiation, large tumor sizes and localization in the lower parts of the uterus, extirpation of the uterus with appendages and lymphadenectomy are indicated. In the absence of metastases in the lymph nodes of the small pelvis, endovaginal intracavitary irradiation is performed after the operation. If lymphadenectomy is not feasible after the operation, external irradiation of the small pelvis should be performed to a total focal dose of 45-50 Gy.

At stage 1b-2a G2-G3; 2b G1, extirpation of the uterus with appendages and lymphadenectomy are performed. In the absence of metastases in the lymph nodes and malignant cells in the peritoneal fluid, with shallow invasion, endovaginal intracavitary irradiation should be performed after surgery. With deep invasion and a low degree of tumor differentiation, radiation therapy is performed.

Stage 3: the optimal volume of surgery should be considered extirpation of the uterus with appendages with lymphadenectomy. If metastases are detected in the ovaries, it is necessary to resect the greater omentum. Then, external irradiation of the small pelvis is performed. If metastases are detected in the para-aortic lymph nodes, it is advisable to remove them. In the case when it is not possible to remove metastatically changed lymph nodes, it is necessary to perform external irradiation of this area. At stage IV, treatment is carried out according to an individual plan using, if possible, surgical treatment, radiation and chemohormonal therapy.

Chemotherapy

This type of treatment is carried out mainly in the case of a widespread process, autonomous tumors (hormonally independent), as well as when a relapse of the disease and metastases are detected.

Currently, chemotherapy for uterine cancer remains palliative, since even with sufficient effectiveness of some drugs, the duration of action is usually short - up to 8-9 months.

Combinations of drugs such as first-generation (cisplatin) or second-generation (carboplatin) platinum derivatives, adriamycin, cyclophosphamide, methotrexate, fluorouracil, phosphamide, etc. are used.

Among the most effective drugs, which provide a complete and partial effect in more than 20% of cases, are doxorubicin (adriamycin, rastocin, etc.), pharmarubicin, platinum drugs of the first and second generation (platidiam, cisplatin, platimite, platinol, carboplatin).

The greatest effect - up to 60% - is achieved by a combination of adriamycin (50 mg/m2 ⁾ with cisplatin (50-60 mg/m2 ⁾.

In widespread uterine cancer, its recurrences and metastases, both in monochemotherapy and in combination with other drugs, taxol can be used. In monotherapy, taxol is used at a dose of 175 mg/m2 ^as a 3-hour infusion every 3 weeks. With a combination of taxol (175 mg/m2 ⁾, cisplatin (50 mg/m2 ⁾ and epirubicin (70 mg/m2 ⁾, the effectiveness of therapy increases significantly.

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Hormone therapy

If by the time of the operation the tumor has spread beyond the uterus, then local regional surgical or radiation treatment does not solve the main problem of treatment. It is necessary to use chemo- and hormone therapy.

For hormonal treatment, progestogens are most often used: 17-OPC, depo-provera, provera, farlugal, depostat, megace in combination with or without tamoxifen.

In case of metastatic process, in case of ineffectiveness of progestin therapy, it is advisable to prescribe Zoladec

Any organ-preserving treatment can only be performed in a specialized institution with conditions for in-depth diagnostics both before and during treatment. It is necessary to have not only diagnostic equipment, but also highly qualified personnel, including morphologists. All this is required for timely detection of treatment inefficiency and subsequent surgery. In addition, constant dynamic monitoring is necessary. Possibilities of organ-preserving hormonal treatment of minimal endometrial cancer in young women using progestogens: 17-OPK or depo-provera in combination with tamoxifen. With a moderate degree of differentiation, a combination of hormone therapy and chemotherapy is used (cyclophosphamide, adriamycin, fluorouracil or cyclophosphamide, methotrexate, fluorouracil).

Hormonal therapy is advisable to prescribe to patients with a high or moderate degree of tumor differentiation. With a high degree of tumor differentiation, superficial tumor invasion into the myometrium, tumor localization in the fundus or upper 2/3 of the uterus. Patients under 50 years of age, no metastases - hormone therapy is administered for 2-3 months. If there is no effect, it is necessary to switch to chemotherapy.

Prevention

Prevention of uterine cancer consists of identifying high-risk groups. These groups of people should undergo regular gynecological examinations with cytological control of the endometrium. If a woman is diagnosed with precancerous diseases and conservative treatment is ineffective, she should undergo surgical treatment.

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