[Diagnosis]
I. Special previous medical history
1. History of menstrual disorders, especially history of endometrial hyperplasia, history of infertility, history of long-term use of estrogen drugs, history of ovarian tumors, etc.
2. History of combined obesity, hypertension, diabetes and infertility.
Clinical manifestations
1. Vaginal bleeding: vaginal bleeding after menopause, irregular vaginal bleeding during perimenopause, prolonged menstruation or menstrual disorders in women under 40 years old.
2. Abnormal vaginal fluid discharge: plasma or blood-water-like.
3. Pain in the lower abdomen or lumbosacral region due to tumor infiltration or compression of nerves.
4. Physical examination: There may be no special findings in the early stage, but in the later stage, the uterus may be enlarged or metastatic nodes or masses may be found.
Auxiliary examination
1. Cytological examination: Smear examination of the cervix or posterior vault.
2. Ultrasound or vaginal ultrasound supplemented by color Doppler ultrasound: to understand the size of the uterus, the occupancy of the uterine cavity, the thickness of the endometrium, the depth of myometrial infiltration and the blood supply and resistance to blood flow.
3. Segmental diagnosis and scraping: it is an important basis for determining this disease. First scrape the cervical canal, then probe the uterine cavity, followed by scraping the uterine cavity, scraping out the material were fixed and sent to pathological examination.
4. Hysteroscopy: to observe the lesion in the uterine cavity under direct vision and to do biopsy, which can help to detect early endometrial cancer that is easily missed by scraping.
5.Taking biopsy for pathological examination is the fundamental basis for diagnosis of the disease.
Differential diagnosis
1. Meritorious hemorrhage: symptoms and signs of perimenopausal meritorious hemorrhage are similar to those of endometrial cancer, and segmental scraping pathological examination can help to differentiate.
2. Old vaginitis: old vaginitis is bloody leucorrhea, vaginal wall is congested, and submucosal bleeding spots can be seen, sometimes it can coexist with endometrial cancer.
3. Submucosal fibroids or endometrial polyps, uterine sarcoma, fallopian tube cancer: ultrasound, segmental scraping, hysteroscopy and combined with pathological examination can help to identify.
4. Endometritis and pus accumulation in the uterine cavity: pus can be seen after dilation, and ultrasound can assist in diagnosis, but it should be noted that sometimes endometrial cancer is combined with pus accumulation in the uterine cavity.
V. Staging Staging is an important basis for deciding the treatment plan.
1. Clinical staging can be used for patients without surgery or preoperatively (FIGO, 1971).
Stage I Cancer is confined to the uterine body Stage Ia The length of the uterine cavity is ≤8cm Stage Ib The length of the uterine cavity is >8cm Stage II Cancer has invaded the cervix Stage III Cancer has spread beyond the uterus but not beyond the true pelvis Stage IV Cancer has spread beyond the true pelvis or invaded the bladder or rectal mucosa Stage IVa Cancer has invaded nearby organs, such as the rectum and bladder Stage IVb Cancer has distant metastasis 2. Post-operative patients can be staged by surgical pathology (FIGO, 1988) 1988).
Stage I
Stage Ia Cancer confined to the endometrium
Stage Ib Invasion of myometrium ≤1/2
Stage Ic Invasion of myometrium >1/2
Stage II
Stage IIa Invasion of mucosal glands of the uterine cervix
Stage IIb Invasion of cervical mesenchyme
Stage III
Stage IIIa Invasion of plasma membrane and/or adnexa, and/or positive abdominal cytology
Stage IIIb Vaginal metastasis
Stage IIIc Metastasis to the pelvis and/or para-aortic lymph nodes
Stage IV
Stage IVa Invasion of the bladder and/or rectal mucosa
Stage Ivb Distant metastasis, including intra-abdominal and/or inguinal lymph node metastasis related to staging
VI. Histological types
1. Endometrioid adenocarcinoma adenokeratotic carcinoma (adenocarcinoma with squamous epithelial metaplasia) adenosquamous carcinoma (mixed squamous cell carcinoma and adenocarcinoma)
2. Mucinous adenocarcinoma
3.Papillary plasma adenocarcinoma
4. Clear cell carcinoma
5. Squamous carcinoma
6. Undifferentiated carcinoma
7. Mixed carcinoma
[Treatment]
The treatment plan is individualized according to the patient’s cervical involvement, muscle invasion and histological type, cell differentiation and the patient’s specific situation. The main treatment tools include surgery, radiotherapy, chemotherapy and endocrine therapy.
I. Surgical treatment
1. Surgery is the first choice of treatment for endometrial cancer patients.
2. Pre-operative laboratory examination
(1) Routine surgical examination: blood, urine and stool routine, blood type, biochemistry 20, electrolytes, coagulation complete, HBsAg, anti-HIV, anti-HCV, Cornwall’s reaction, chest X-ray, electrocardiogram.
(2) Special gynecological examinations: cervical cancer smear, transvaginal gynecologic ultrasound.
(3) Tumor-related examinations: biopsy pathology; tumor markers, such as CA125, etc.
(4) Others: CT, pulmonary function and other tests if necessary.
3. Pre-operative preparation
(1) Preoperative vaginal preparation for 3 days.
(2) Skin preparation, blood preparation, penicillin skin test, preoperative water fasting.
(3) 20% mannitol 250ml diluted 3 to 5 times orally in the afternoon 1 day before surgery, 2 enemas in the evening before surgery, clean enema before surgery.
(4) Vaginal filling, if the cervix is not invaded to gentian violet mark, leave the urinary catheter.
4. Surgical method
(1) Extracorporeal hysterectomy or subextensive hysterectomy + double adnexal resection: suitable for stage Ia and Ib patients with highly or moderately differentiated cancer cells; for stage Ia and Ib patients with poorly differentiated cancer cells, special histological types (plasmacytoid papillary carcinoma, clear cell carcinoma, adenosquamous carcinoma) and stage Ic patients, pelvic and para-aortic lymph node biopsy or resection should be performed at the same time.
(2) Extensive hysterectomy + double adnexal resection + pelvic and para-aortic lymph node biopsy or resection: applicable to stage II patients.
5. Precautions
(1) Preoperative preparation of chemotherapeutic drugs and preparation for intraoperative interventional applications.
(2) Intraoperative attention should be paid to the retention of peritoneal washings or ascites for cytological examination and to the exploration of the pelvic abdominal cavity and retroperitoneal lymph nodes, etc.
(3) Attention should be paid to dissecting the surgical specimen, observing the tumor site, the depth of muscle invasion, and measuring the length of the resected ligaments and vagina. The pathology sheet indicates the need for estrogen and progesterone receptor examination for postoperative decision of adjuvant treatment plan.
6. Postoperative observation
(1) Changes in body temperature, pulse, respiration, blood pressure and other vital signs.
(2) The drainage flow and properties of the drainage tube.
(3) wound exudation and healing.
(4) recovery of intestinal motility; (5) the recovery of intestinal motility
(5) Determine the duration of urinary catheter retention according to the scope of surgery and be alert to the occurrence of urinary retention.
(6) Regular rechecking of blood routine, biochemistry, electrolytes, etc.
II. Radiotherapy
1. Patients with stage I or II low differentiated cancer cells and infiltration in the parametrium can be treated with preoperative radiotherapy first. Intracavitary radiotherapy is often used, and the dose of point A and point F is 3000~4000Gy/3~4 weeks according to different conditions, and surgery is performed 2 weeks after radiotherapy.
2. Patients with hypofractionated cancer cells, deep muscle infiltration, infiltrated cervix, metastatic foci in pelvis, cancer thrombus in vascular lymphatic vessels and retroperitoneal lymph node metastasis should be given additional radiotherapy after surgery.
3. Patients with stage I-II disease who are not suitable for surgery can be treated with radiotherapy alone.
Chemotherapy can be combined with chemotherapy in advanced or recurrent cases, and CAP regimen (cisplatin, adriamycin, cyclophosphamide) is commonly used. For specific chemotherapy administration and precautions, see the section on chemotherapy for ovarian cancer.
Endocrine therapy
Endocrine therapy is suitable for the following conditions
(1) Cases that are not suitable for surgery or are advanced/recurrent.
(2) Patients with good early differentiation who require fertility preservation; (3) Combined with other treatments.
2. Commonly used drug regimen
(1) Medroxyprogesterone acetate (MPA) 200-500mg/d orally.
(2) Megestrol acetate (MA) 160-320mg/d orally.
(3) Progesterone caproate 1~3g/week by intramuscular injection, etc.
3. The following cases should be noted
(1) It should be closely followed up when used for patients who require fertility preservation.
(2) Although the side effects are relatively minor, attention should be paid to the occurrence of thromboembolism.
(3) The use of the drug is generally considered to be no less than 1 year.
(4) The efficacy of the drug is not proportional to the amount of the drug.
(5) For progesterone receptor-negative patients, a combination of tamoxifen (TAM) 10-40 mg/d orally may be considered as appropriate.
V. Treatment for patients with stage III and IV is the same as that for ovarian cancer, using a combination of the above treatment modalities.