I. Overview
Carcinoma of endometrium, also known as uterine body cancer, refers to a group of epithelial malignant tumors originating from the endometrium. In China, it is the third common gynecological malignant tumor after cervical cancer and ovarian cancer, accounting for about 7% of female malignant tumors and 20%-30% of female genital tract malignant tumors. The peak age of incidence is 50-59 years old, and the median age is 61 years old. With the increase of average life expectancy and the increase of senior women, the incidence of endometrial cancer worldwide has been slowly increasing in recent years, for example, the incidence of endometrial cancer in the United States has been higher than that of cervical cancer. Most of the patients are still confined to the uterus at the time of consultation, and the stage is early, so the prognosis is better, and the overall 5-year survival rate is 67%, and the 5-year survival rate of stage I is over 80%.
Clinical manifestations
1.Vaginal bleeding
Vaginal bleeding is the main complaint of patients, especially after menopause. Because the cancer tissue is brittle and easy to bleed, about 80% of the patients have vaginal bleeding as the first symptom, which is also the primary factor for patients to consult the doctor. Young patients mostly show disorder of menstrual cycle, prolonged menstrual period or increased menstrual volume.
2. Vaginal discharge
About 1/3 of patients have increased vaginal discharge as a result of exudation from the tumor or secondary infection, which may be in the form of bloody fluid or plasma discharge. In case of combined infection, the vaginal discharge will be purulent or purulent, accompanied by odor, but it is not as significant as that of cervical cancer.
3.Pain
It is not common. A few patients have pain in the lower abdomen, which may be related to the contracture of the uterus caused by a large lesion that has entered the uterine cavity. If the lesion is in the lower part of the uterus or invades the cervical canal, it may cause pain due to poor drainage and accumulation of blood or pus in the uterine cavity. If the tumor compresses the nerve plexus, it may cause continuous lower abdominal, lumbosacral and lower limb pain, which is the manifestation of the patient in the advanced stage.
4.Anaemia, emaciation and cachexia may also appear in advanced stage patients.
If there are the following conditions, endometrial cancer should be suspected and further examination is needed
(1) Irregular vaginal bleeding during menopause and postmenopausal vaginal bleeding.
(2) Watery or bloody vaginal discharge that cannot be explained by general inflammation of the reproductive tract.
(3) Recurrent abnormal vaginal cytologic findings with negative cervical biopsy.
(4) Patients with ovarian granulosa cell tumor and follicular membrane cell tumor, pay attention to check whether it is combined with endometrial cancer.
(5) Pay attention to the factors related to the development of endometrial cancer, such as excessive endometrial hyperplasia, estrogen use and family history of tumor.
Comprehensive physical examination (including lymph nodes) and careful gynecological triple examination should be performed, paying attention to the site of bleeding, uterine size, mobility, infiltration of cervical and parametrial tissues and metastases in other areas, etc. There are not many positive signs of endometrial cancer, about half of them have uterine enlargement, but such enlargement is mostly mild, and the uterine body is usually slightly soft and uniform. If the examination reveals special enlargement of the uterus or abnormal protrusion on the surface, it is often a manifestation of concurrent myoma or leiomyosarcoma, but the possibility of cancer tissue penetrating the plasma membrane and forming tumor on the surface of the uterus must be considered.
Auxiliary examination
1.Exfoliative cytology examination
Endometrial cells usually do not shed easily, and once shed, they often undergo a series of changes such as degeneration, deformation and lysis, which make them difficult to identify. Therefore, the positive rate of applying cytology to diagnose endometrial cancer is generally not high, about 50%.
2.Endometrial examination
Histological examination of endometrium is the final basis for diagnosis. There are two ways to obtain endometrium: biopsy and curettage. Biopsy is easy and less invasive, and the positive rate is higher, 88.4%. Since biopsy can only reflect part of the endometrium, the presence of cancer cannot be ruled out when it is negative. A complete curettage must be performed. Using a combination of biopsy and curettage, the positivity rate was 94.0%.
In order to find out whether the lesion involves the cervical canal, “segmental scraping” is adopted, that is, the cervical canal tissue is scraped first, then the uterine cavity is explored, the cervix is expanded if necessary, and the uterine body and uterine fundus tissue are scraped afterwards, and the scraped out tissue parts are marked and sent to pathological examination separately to avoid mutual contamination or confusion.
3.Hysteroscopy
Over the past 20 years, hysteroscopy and operation have been widely used and are particularly useful for the diagnosis of endometrial lesions. Endometrial cancer can be shown as polyps, nodules, papillae, ulcers and diffuse types under the microscope, and biopsy of suspicious areas under the microscope can confirm the diagnosis, avoiding the misdiagnosis of routine scraping.
4.Imaging examination
Preoperative vaginal ultrasonography is applied to predict the depth of cancer infiltration into the muscular layer. It has been reported that the rate of vaginal ultrasound for those with muscle layer infiltration ≥33% is 100%. Preoperative ultrasonography is used to determine whether there is deep myxomatous infiltration and the postoperative pathological diagnosis rate is 92%; MRI and CT: mainly used to observe the uterine cavity and cervical lesions, especially the depth of myxomatous infiltration and lymph node metastasis. Because of the strong resolution of MRI on soft tissue, MRI is better than CT examination in the diagnosis of uterine lesions.
5.Lymphography
It is used to detect lymphatic metastasis before operation. According to its lymphatic drainage and metastatic pathway, cancer cells can directly reach the presacral and para-abdominal aortic lymph nodes, and can also metastasize to inguinal lymph nodes via the round ligament. If the tumor has invaded the cervical canal, its metastatic pathway is the same as the primary cervical cancer, after invading the lymph nodes, it spreads to the iliac lymph nodes.
6.Tumor markers
There is no specific sensitive marker for endometrial cancer, but in recent years, it is found that the serum CA125 level of endometrial cancer patients can be increased, but the positive range is large, 11%-90%.
CA125 is present due to glandular components, and CA125 is not high due to glandular reduction in tumors. CEA and CA199 may be mildly elevated in some patients.
IV. Treatment plan and principles
The treatment of endometrial cancer is mainly based on surgery, radiotherapy and the combination of both. For some patients with adverse factors or advanced stage, extra-pelvic metastasis and recurrence, chemotherapy and hormone therapy can be used.