Cancer of the body of the uterus

Malignant tumors of the uterus body include: cancer, sarcoma. Mesodermal tumors and chorionic carinoma. Under the cancer of the body of the uterus, endometrial cancer (the mucous membrane of the uterus) is implied. Endometrial cancer refers to hormone-dependent tumors, i.e. Due to endocrine-metabolic disorders, often combined with uterine myoma, endometriosis, ovarian tissue hyperplasia.

[1], [2],

Epidemiology

Endometrial cancer is a common malignant tumor. In the structure of oncological diseases, women occupy the second place. This is the fourth most common type of cancer, after breast, lung and colon cancer. Cancer of the uterus body is mainly found in postmenopause in patients with bleeding during this period of life, it is detected in 10% of cases. Diagnostic errors in women at this age are due to an incorrect evaluation of bloody discharge, which is often explained by climacteric dysfunction.

[3], [4], [5], [6], [7], [8],

Causes of the cancer of the uterus

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

[9]

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 uterine cancer may include:

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

Other factors contributing to the development of endometrial cancer:

• Estrogen-replacement therapy.
• Polycystic ovary syndrome.
• Lack of a birth in the anamnesis.
• Early onset of menarche, late menopause.
• Alcohol abuse.

[10], [11], [12], [13], [14]

Symptoms of the cancer of the uterus

1. Beli. They are the earliest sign of manifestations of uterine cancer. They were lean, watery. To these secretions, blood is often attached, especially after physical exertion
2. Itching of the vulva. Can appear in patients with endometrial cancer due to irritation with discharge from the vagina.
3. Bleeding - a late symptom arising from the disintegration of the tumor, can manifest as secretions in the form of meat "slops", smearing or pure blood.
4. Pain - cramp character, giving in the lower limbs, arise when the secretions from the uterus are delayed. Dull pains, aching, especially at night, indicate the spread of the process outside the uterus and are explained by the compression of the nerve plexuses in the pelvis by a tumor infiltrate.
5. Violation of the functions of adjacent organs, due to the germination of the tumor in the bladder or rectum.
6. Characteristic for these patients obesity (rarely losing weight), diabetes, hypertension.

[15], [16], [17]

Stages

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

[18]

Classification of FIGO uterus cancer by stages

The amount of damage

• 0 - Preinvasive carcinoma (atypical glandular hyperplasia of the endometrium)
• 1 - Tumor is limited to the uterus body, regional metastasis is not determined
  • 1a - Tumor limited by endometrium
  • 1b - Invasion into the myometrium to 1 cm
• 2 - Tumor affects the body and cervix, regional metastases are not determined
• 3 - The tumor extends beyond the uterus, but not beyond the small pelvis
  • 3a - The tumor infiltrates the serous uterine envelope and / or there are metastases in the uterine appendages and / or in the regional pelvic lymph nodes
  • 3b - Tumor infiltrates the pelvic floor and / or there are metastases in the vagina
• 4 - The tumor extends beyond the small pelvis and / or there is germination of the bladder and / or rectum
  • 4a - Tumor sprouts the bladder and / or rectum
  • 4b - Tumor of any degree of local and regional distribution with detectable distant metastases

[19], [20], [21]

International classification of cancer of the uterus by TNM

• Т0 - Primary tumor is not detected
• Tis - Preinvasive carcinoma
• T1 - Tumor is limited to the body of the uterus
  • Т1а - Cavity of uterus no more than 8 cm in length
  • T1b - uterine cavity more than 8 cm in length
• T2 - Tumor spreads to the cervix, but not beyond the uterus
• T3 - The tumor extends beyond the uterus, but remains within the small pelvis
• T4 - The tumor extends to the mucosa of the bladder, rectum and / or extends beyond the small pelvis

N - regional lymph nodes

• Nx - Insufficient data to assess regional lymph node condition
• N0 - There are no signs of regional lymph node metastases
• 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. With limited form, the tumor grows in the form of a polyp, clearly delimited from the unaffected mucous membrane of the uterus; when diffuse - cancer infiltration extends to the entire endometrium. A tumor most often occurs in the region of the bottom and tube corners of the uterus. Approximately 80% of patients have adenocarcinoma of different degrees of differentiation, 8-12% have adenoacanthoma (adenocarcinoma with benign squamous cell differentiation), which has a favorable prognosis.

More rare tumors with a worse prognosis include glandular squamous cell carcinoma, in which the squamous cell component resembles squamous cell carcinoma, the prognosis is worse because of the presence of an undifferentiated glandular component.

Squamous cell carcinoma, like the light cell, has much in common with similar cervical tumors, 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. Has also 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 potency for metastasis.

[22], [23], [24], [25]

Diagnostics of the cancer of the uterus

Gynecological examination. When examining with the help of mirrors, the condition of the cervix and the nature of the discharge from the cervical canal are clarified - the extracts are taken for cytological studies. With vaginal (recto-vaginal) study, attention is drawn to the size of the uterus, the condition of the appendages and peri-endopathy.

Aspiration biopsy (cytology of aspirate from the uterine cavity) and the study of aspiration washing water from the uterine cavity and the cervical canal. The latter is performed at the age of postmenopause 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 a small percentage of positive results, the method can be widely used in polyclinic conditions, excludes trauma, does not stimulate the tumor process.

Separate diagnostic curettage of the uterine cavity and cervical canal, under the control of hysteroscopy. It is advisable to obtain soskob from the areas where pre-tumoral processes often occur: the area of the external and internal pharynx, and also the tube angles.

Hysteroscopy. The method helps to identify the cancer process in places hard to reach for scraping, allows to reveal the localization and spread of the tumor process, which is important for choosing the method of treatment and for the subsequent monitoring of the effectiveness of radiotherapy.

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

To identify 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 diagnosis is about 70%. In some cases, the cancer node for acoustic characteristics is practically no different from the muscle of the uterus.

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

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

[26], [27]

Treatment of the cancer of the uterus

When choosing a method of therapy for patients with uterine cancer, three main factors must be considered:

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

Only in view of these factors can the correct staging of the process and adequate treatment.

About 90% of patients suffering from uterine cancer are undergoing surgical treatment. Performing usually extirpation of the uterus with appendages. By opening the abdominal cavity, the organs of the small pelvis and the abdominal cavity, retroperitoneal lymph nodes are examined. In addition, they take flushes from the Douglas space for cytological investigation.

Surgical treatment of uterine cancer

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

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

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

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

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

Stage 3: the optimal volume of surgery should be considered extirpation of the uterus with appendages with the performance of lymphadenectomy. When detecting metastases in the ovaries, a large omentum resection should be performed. In the future, external irradiation of the pelvis is carried out. When metastases are detected in the para-aortic lymph nodes, it is advisable to remove them. In the event that it is not possible to remove the metastatically altered lymph nodes, it is necessary to perform external irradiation of this area. At the IV stage, treatment is carried out according to an individual plan with the use of a surgical method of treatment, radiation and chemo-hormone therapy, if possible.

Chemotherapy

This type of treatment is carried out mainly in a widespread process, with autonomous tumors (hormone-independent), as well as in the detection of recurrence of the disease and metastases.

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

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

Among the most effective drugs, which give a full and partial effect in more than 20% of cases, doxorubicin (adriamycin, rastocin, etc.), pharmaburicin, platinum and platinum preparations, platinum, cisplatin, platinum, platinum, carboplatin).

The greatest effect - up to 60% - is given by a combination of adriamycin (50 mg / m ² ) with cisplatin (50-60 mg / m ² ).

With the common cancer of the uterus, its relapses and metastases both in the monochemotherapy regime and in combination with other drugs, it is possible to use taxol. In mono mode taxol is used in a dose of 175 mg / m ² as a 3-hour infusion every 3 weeks. With the combination of taxol (175 mg / m ² ), cisplatin (50 mg / m ² ) and epirubicin (70 mg / m ² ), the effectiveness of therapy is significantly increased.

[28], [29]

Hormonotherapy

If, at the time of surgery, the tumor is outside the uterus, then the local regional surgical or radiation exposure does not solve the underlying problem of treatment. It is necessary to use chemotherapy and hormone therapy.

To conduct hormonal treatment most often use progestogens: 17-OPK. Depo-probe, provera, farugal, depostat, megase in combination with or without tamoxifen.

At metastatic process in case of inefficiency of progestin therapy it is expedient to appoint zoladek

Conducting any organ-preserving treatment is possible only in a specialized institution, where there are conditions for performing in-depth diagnostics both before and during the treatment. It is necessary to have not only diagnostic equipment, but also highly skilled personnel, including morphologists. All this is required for the timely detection of the ineffectiveness of the treatment and the subsequent operation. In addition, constant dynamic observation is necessary. Possibilities of organ-preserving hormonal treatment of minimal endometrial cancer in young women using progestogens: 17-OPK or depot-test in combination with tamoxifen. With a moderate degree of differentiation, a combination of hormone therapy with chemotherapy (cyclophosphamide, adriamycin, fluorouracil or cyclophosphamide, methotrexate, fluorouracil) is used.

It is advisable to administer hormone therapy to patients with high or moderate degree of tumor differentiation. With a high degree of tumor differentiation, surface invasion of the tumor into the myometrium, localization of the tumor in the region of the bottom or upper 2/3 of the uterus. Age of a patient under 50 years of age, absence of metastases - hormone therapy is carried out within 2-3 months. If there is no effect, it is necessary to switch to chemotherapy.

Prevention

Prevention of uterine cancer is to identify high-risk groups. These groups of individuals should undergo regular gynecological examinations with cytological control of the endometrium. If a woman has precancerous diseases, and conservative treatment is ineffective, she should be promptly treated.

[30], [31], [32],