Lecture on endometrial cancer

2021-03-22 12:00 AM

Bleeding in menopausal people is a valuable sign, sometimes pre-menopausal bleeding, which confuses us with the disorders of this period. Bleeding is often accompanied by a lot of bad gas.

Outline

Endometrial cancers are tumors that develop from the lining of the uterus, common cancer in the elderly. There are more than 80% of endometrial cancer patients encountered in menopause, of which about 95% originated from the glandular epithelium of the endometrium.

Risk factors 

Age: between 50-70.

Do not give birth or give birth sparingly.

Obesity (over 25kg compared to normal).

Diabetes.

High blood pressure.

Pathology in the uterus: endometrial hyperplasia.

Late menopause: after 55 years of age.

Use simple, long-lasting estrogen.

History of ovarian, breast, and colon cancer.

Pathology

General

The uterus has a soft, fragile mass that can look like a polyp that has grown into the uterus.

Details

As a type of adenocarcinoma, from which the prognosis depends on the degree of differentiation of the cell:

Grade 1: Picture of atypical hyperplasia, but malignant cells, the muscle layer is not invaded. Good prognosis.

Grade 2: Smaller glands, squeezing together, new muscle layer is invaded, where malignant cells are clearly visible. Medium differentiation.

Grade 3: Small glandular structures and undifferentiated cells are visible. Most malignant type.

Spread of cancer of the lining of the uterus

Endometrial cancer does not spread as quickly as cervical cancer, because the uterine muscle is a barrier that works quite well.

Spread in place:  A slow invasion of the uterine muscle layer is the most common invasive method. It can cause the uterus to grow significantly.

Lymphatic spread:  About 30-40% of cancers spread this way, in the body of the uterus, the cancer develops down the waist of the uterus and then down to the bottom of the ligament, to the inner pelvic ganglia outer pots and beyond; This spread is more likely to occur when the tumor has regressed and the wall of the uterus is deeply invaded by cancer.

Natural pathway spread (uterine tube): Cancer cells can follow the uterine tube, following the same pathway into the peritoneum of the menstrual blood, which explains the cases of ovarian metastases. Simple.

Spread to other organs in the abdomen: Rarely, metastasis can be seen to the liver, lungs.

Intravenous spread:  Uncommon.

Symptoms and diagnosis

Often patients come to the doctor because:

Abnormal bleeding ( 95% of cases)

Bleeding in menopausal people is a valuable sign, sometimes pre-menopausal bleeding, which confuses us with the disorders of this period. Bleeding is often accompanied by a lot of bad gas.

Asked the disease

Risk factors are detectable now as well as in history.

Physical examination

Platypus examination: Sometimes, the vagina is normal, slightly atrophy in menopausal people. Often the gas damage a lot, thin mucus, foul, sometimes pus. This is often accompanied by pain and heaviness in the hypotenic region.

Manual vaginal exam, the uterus is usually of normal size, and may also be slightly large and soft. There are times when uterine fibroids accompany.

Test

Pathology:  The specimen is the fluid drawn from the uterus. This is the hallmark of the diagnosis.

Advantages: Easy to perform, with few complications.

Disadvantage: Early cases of cancer can be difficult to detect.

Hysteroscopy:  only injecting a contrast agent with light pressure enough to be absorbed in the uterus without spreading the two ovaries, the image can be seen as a defect, irregular margins, rough, large uterine cavity. image translation. This procedure is currently rarely indicated. 

Hysteroscopy:  direct visualization of the endometrium as well as the correct lesions such as buds, bleeding necrotic ulcers, or images of endometrial hyperplasia, easy to bleed, and easy to touch endometrium. determines the spread and helps locate the biopsy site.

Advantages: Easy to do, can be done quickly in the clinic.

Not convenient: The vehicle is expensive.

Biopsy of the entire uterus:  proceed carefully, prevent perforation. It is best to do from the outside in and keep the specimens separate: the cervical canal and the uterine cavity. Use a scraper or a Novak straw. Biopsy results help classify histology.

Ultrasound:  especially vaginal ultrasound for physical images of the uterus, thick endothelium or to evaluate the spread and thickness of the muscle layer. uterine fibrosis, ovarian cysts ...

CT scan:  is a fairly effective method to determine the extent of the invasion and spread of cancer, especially in the late stages. This method is indicated in cases where it is necessary to make a differential diagnosis.

It is important to evaluate for another adenocarcinoma, such as breast or colon cancer.

Clinical stages 

Theo FIGO 1988 (International Federation of Gynecology and Obstetrics).

Stage I

IA: limited lesions in the uterine lining (superficial).

IB: deep penetration of the uterine muscle layer <50%.

IC: penetration of uterine muscle layer> 50%.

Stage II

IIA: lesions spread to the cervical canal, only in the mucosa.

IIB: Spill-over lesion of the cervical canal.

Stage III

IIIA: positive infiltrates into the serosa or appendage or peritoneum.

IIIB: vaginal metastatic damage.

IIIC: metastatic lesions of the aortic or sub-frame of the aorta.

Stage IV

IVA: cancerous lesions that enter the bladder or intestines.

IVB: distant metastatic cancer including intra-abdominal or inguinal lymph node metastasis.

Treatment

Indications for treatment

Need to consider carefully according to the state and stage.

By stage (According to FIGO classification):

Stage 1: complete hysterectomy, take lymph nodes along the veins, if the lymph nodes are infected, radiotherapy outside With high differentiation, the endocrine supplementation.

Stage 2: spot radiation and extensive total hysterectomy and lymph node removal. After 4-6 weeks, external radiation if the lymph nodes become infected.

Stage 3: If the surgery can be operated, then remove and radiotherapy, otherwise radium with radium needle placed in place and combined hormone therapy (done in the oncology department).

Stage 4: Symptomatic treatment with progestatif. In the case of recurrence in the vaginal apex, a radium needle is inserted.

Surgical treatment 

Surgery is the basic method. Depending on the case that only complete hysterectomy, two appendages, or extensive hysterectomy with lymphadenectomy, cut off the large fibrillation, should cut the uterus through the abdomen to clearly observe the combined lesions. .

Radiation

Indicated for late-stage cancer or postoperative supportive treatment

Radium, cobalt in situ (in the oncology department).

Hormone therapy

Progestatif high doses (depending on the receptors) such as using Depoprovera 150mg x 3 times / week. The effect is not obvious, usually indicated in the case of a positive peritoneal wash.

Chemotherapy

Less effective, only used when relapses in young women.

5 Fluoro-uracil and calcium folate (helps reduce the toxicity of 5-FU).

Adriamycin.

Treatment results

At stage I there is # 90% alive after 5 years.

At stage II it's # 75%.

Stage III has # 30%.

Stage IV is less than 9% alive after 5 years.

70% of relapses occur in the first 2 years after treatment.