Uterine body cancer is a malignant lesion of the endometrium lining the uterine cavity. Cancer of the uterine body is manifested by bloody discharge, watery whites from the genital tract, pain, acyclic or atypical uterine bleeding. Clinical recognition is carried out on the basis of gynecological examination data, cytological analysis of aspirates, ultrasound, hysteroscopy with separate diagnostic curettage, histology results. Treatment is combined, including surgical (pangisterectomy), radiation, hormonal, and chemotherapeutic components.
Cancer of the uterine body occupies the first place among malignant neoplasms of the female genital organs, and in the structure of all female oncopathology it occupies an intermediate place between breast cancer and cervical cancer. The trend towards an increase in the incidence of endometrial cancer in gynecology is partly explained by an increase in the total life expectancy of women and their time in postmenopause, as well as a rapid increase in the frequency of such pathologies as chronic hyperestrogenism, anovulation, infertility, uterine fibroids, endometriosis, etc. More often, uterine body cancer develops in women of the perimenopausal and postmenopausal period (the average age is 60-63 years).
Causes and stages of development
In oncogynecology, the etiology of uterine body cancer is considered from the point of view of several hypotheses. One of them is hormonal, which links the occurrence of uterine body cancer with manifestations of hyperestrogenism, endocrine and metabolic disorders, which is noted in 70% of patients. Hyperestrogenism is characterized by anovulatory cycles and bleeding, infertility, late menopause, tumor and hyperplastic processes in the ovaries and uterus. Hormone-dependent cancer of the uterine body is more common in patients with obesity, hypertension, diabetes mellitus, feminizing ovarian tumors, repeated abortions of pregnancy, receiving HRT with estrogens, having hereditary ovarian, endometrial, breast, colon cancer.
Endometrial hyperplasia, uterine polyps serve as background diseases for cancer of the uterine body. Against the background of hyperestrogenism, as a rule, a highly differentiated cancer of the uterine body develops, having a slow rate of progression and metastasis, which generally proceeds relatively favorably. This variant of endometrial cancer is highly sensitive to progestogens.
Another hypothesis is based on data indicating the absence of endocrine-metabolic disorders and ovulation disorders in 30% of patients with uterine body cancer. In these cases, oncopathology develops against the background of an atrophic process in the endometrium and general depression of immunity; the tumor is predominantly low-differentiated with a high ability to metastasize and insensitivity to gestagen-type drugs. Clinically, this variant of uterine body cancer proceeds less favorably.
The third hypothesis links the development of endometrial neoplasia with genetic factors.
In its development , uterine body cancer resembles the stages:
- functional disorders (hyperestrogenism, anovulation)
- morphological background changes (glandular endometrial hyperplasia, polyps)
- morphological precancerous changes (atypical hyperplasia and dysplasia)
- malignant neoplasia
Metastasis of cancer of the uterine body occurs by lymphogenic, hematogenic and implantation method. In the lymphogenic variant, the inguinal, iliac, paraaortic lymph nodes are affected. In the case of hematogenous metastasis, tumor screenings are found in the lungs, bones, and liver. Implantation spread of cancer of the uterine body is possible with the germination of the tumor of the myometrium and perimetrium, involvement of the visceral peritoneum, large omentum.
According to the histopathological classification, among the forms of cancer of the uterine body, adenocarcinoma, mesonephroid (light-cell) adenocarcinoma; squamous, serous, glandular, mucinous and undifferentiated cancer are distinguished.
According to the type of growth, endometrial cancer is distinguished with exophytic, endophytic and mixed (endoexophytic) growth. According to the degree of cell differentiation, uterine cancer can be highly differentiated (G1), moderately differentiated (G2) and low-differentiated (G3). Most often, cancer of the uterine body is localized in the fundus, less often in the lower segment.
In clinical oncology, classifications by stages (FIGO) and the TNM system are used to assess the prevalence of primary tumor (T), lymph node lesion (N) and the presence of distant metastases (M).
Stage 0 (Tis) is preinvasive cancer of the uterine body (in situ).
Stage I (T1) – the tumor does not spread beyond the uterine body:
- IA (T1a) – infiltrates less than 1/2 of the thickness of the endometrium
- IB (T1b) – infiltrates half of the thickness of the endometrium
- IC (T1c) – infiltrates more than 1/2 thickness of the endometrium
Stage II (T2) – the tumor passes to the cervix, but does not spread beyond its borders:
- IIA (T2a) – endocervix involvement is noted
- IIB (T2b) – cancer invades the cervical stroma
Stage III (T3) – characterized by local or regional spread of the tumor:
- IIIA (T3a) – spread or metastasis of the tumor into the ovary or serous membrane; presence of atypical cells in ascitic effusion or washing waters
- IIIB (T3b) – spread or metastasis of the tumor into the vagina
- IIIC (N1) – metastasis of uterine cancer to pelvic or paraaortic lymph nodes
IVA stage (T4) – the spread of the tumor to the mucosa of the large intestine or bladder.
Stage IVB (M1) – metastasis of the tumor to distant lymph nodes and organs.
Symptoms of uterine cancer
With preserved menstrual function, cancer of the uterine body can manifest itself with prolonged copious menstruation, acyclic irregular bleeding, and therefore women can be mistakenly treated for ovarian dysfunction and infertility for a long time. In postmenopausal patients, blood secretions of a meager or abundant nature occur.
In addition to bleeding with cancer of the uterine body, leucorrhea is often observed – abundant watery liquid white; in advanced cases, the discharge may have the color of meat slops or purulent character, ichorous (putrid) odor. A late symptom of cancer of the uterine body is pain in the lower abdomen, lower back and sacrum of a permanent or cramping nature. Pain syndrome is noted when the serous lining of the uterus is involved in the oncoprocess, compression of the nerve plexuses by parametral infiltration.
With the downward spread of cancer of the uterine body into the cervix, it is possible to develop stenosis of the cervical canal and pyometra. In the case of compression of the ureter by a tumor infiltrate, hydronephrosis occurs, accompanied by pain in the lumbar region, uremia; when the tumor grows into the bladder, hematuria is noted. With tumor invasion of the rectum or sigmoid colon, constipation occurs, mucus and blood appear in the feces. Pelvic organ damage is often accompanied by ascites. With advanced cancer of the uterine body, metastatic (secondary) often develops lung and liver cancer.
The task of the diagnostic stage is to establish the localization, the stage of the process, the morphological structure and the degree of differentiation of the tumor. Gynecological examination allows to determine the increase in the size of the uterus, the presence of infiltration of cancer parametral and rectovaginal tissue, enlarged appendages.
Cytological examination of cervical canal smears and the contents of aspiration biopsy from the uterine cavity is mandatory for cancer of the uterine body. The material for histological examination is obtained by endometrial biopsy with a micro-curette or separate diagnostic curettage during hysteroscopy. Pelvic ultrasound is an important diagnostic screening test for cancer of the uterine body. Ultrasound scanning determines the size of the uterus, its contours, the structure of the myometrium, the nature of tumor growth, the depth of tumor invasion, localization, metastatic processes in the ovaries and lymph nodes of the pelvis.
In order to visually assess the prevalence of uterine cancer, diagnostic laparoscopy is performed. To exclude distant metastasis of uterine cancer, the inclusion of abdominal ultrasound, chest X-ray, colonoscopy, cystoscopy, excretory urography, CT of the urinary system and abdominal cavity in the examination is indicated. When diagnosing uterine cancer, it is necessary to differentiate with endometrial polyps, endometrial hyperplasia, adenomatosis, submucosal uterine myoma.
The treatment option is determined by the stage of the oncoprocess, the accompanying background, and the pathogenetic variant of the tumor. For cancer of the uterine body, gynecology uses methods of surgical, radiation, hormonal, and chemotherapeutic treatment.
Treatment of the initial cancer of the uterine body may include ablation of the endometrium – destruction of the basal layer and part of the underlying myometrium. In other operable cases, a pangisterectomy or an extended removal of the uterus with bilateral adnexectomy and lymphadenectomy is indicated. During the formation of the pyometra, the cervical canal is booged with Gegar dilators and the evacuation of pus is carried out.
With invasion of the myometrium and the prevalence of uterine cancer in the postoperative period, radiation therapy is prescribed for the vaginal area, pelvis, and regional metastasis zones. The complex therapy of uterine cancer according to indications includes chemotherapy with cisplatin, doxorubicin, cyclophosphamide. Taking into account the sensitivity of the tumor to hormonal therapy, courses of treatment with antiestrogens, progestogens, estrogestagenic agents are prescribed. In the organ-preserving treatment of uterine cancer (endometrial ablation), the ovulatory menstrual cycle is further induced using combined hormonal drugs.
The further development of the situation depends on the stage of uterine cancer, the age of the patient, the pathogenetic variant and differentiation of the tumor, the presence of metastasis and dissemination. A more favorable prognosis is observed in patients under 50 years of age with a hormone-dependent variant of uterine cancer and the absence of metastases: 5-year survival in this group reaches 90%. The worst prognosis is observed in women over 70 years of age with an autonomous variant of uterine cancer – their 5-year survival threshold does not exceed 60%. Detection of metastatic lymph node lesions increases the likelihood of endometrial cancer progression by 6 times.
All patients with uterine cancer are under the dynamic control of oncogynecologist and gynecologist-endocrinologist. In women who have undergone organ-preserving treatment for uterine cancer, pregnancy may occur after hormonal rehabilitation and restoration of ovulatory cycles. The management of pregnancy in these individuals requires taking into account the existing gynecological situation. After radical treatment of uterine cancer by hysterectomy, post-hysterectomy syndrome may develop in patients of reproductive age.
The complex of preventive measures includes the elimination of hyperestrogenism: control of body weight and the course of diabetes mellitus, normalization of menstrual function, competent selection of contraception, timely surgical removal of feminizing tumors, etc.
Secondary prevention is reduced to timely detection and treatment of background and precancerous proliferative pathology, regular cancer screening for women, observation of patients at risk for cancer endometrium.