Uterine cancer are neoplasms of the cervix and the body of the uterus that develop from cells of epithelial, muscular or connective tissue, with a tendency to invasive growth, germination of surrounding organs and vessels, recurrence and formation of metastases. The development of pathology may be indicated by discharge from the genital tract (watery, bloody, pus-like), cramping or constant pain, urination and defecation disorders. The diagnosis is based on the data of gynecological examination, colposcopy, ultrasound, oncocytology, biopsy, hysteroscopy, SDC. The treatment combines surgical, radiation methods, chemotherapy, hormone therapy.
The term “uterine cancer” unites a group of morphologically heterogeneous tumors originating from the endometrium, muscle or connective layer of the uterus. In gynecology and oncology, these include adenocarcinoma, cancer and sarcoma (leiomyosarcoma) of the uterus. Malignant tumors can affect the body and cervix. Cervical cancer is the most common oncological disease of the female genital organs; the greatest frequency of cervical cancer is observed in perimenopause, but women of reproductive age are also susceptible to the disease. Uterine body cancer is about 10 times less common than cervical cancer, mainly in patients older than 50 years. In recent years, there has been an increase in the proportion of malignant uterine tumors in the structure of female oncological morbidity, which puts the issues of prevention and early detection of pathology among the most urgent medical and social problems.
The incidence of uterine cancer is closely related to age, the state of menstrual, reproductive and sexual function, social conditions, geographical and other factors. An important role in the development of uterine cancer belongs to hormonal disorders, primarily hyperestrogenism and luteal insufficiency.
Risk factors for cervical cancer are early onset of sexual activity, frequent change of sexual partners, unprotected sex. Viruses – highly oncogenic strains of HPV and HSV type 2 – can initiate background precancerous processes that have a high risk of transformation into invasive cancer. Changes in the cervix, which are regarded as facultative precancerous, include true erosion and pseudo-erosion, leukoplakia, condyloma, cervical canal polyps.
The state of the cervical epithelium is greatly influenced by vaginal microbiocenosis. Therefore, STDs, recurrent nonspecific colpitis and cervicitis lead to changes in the microecology of the vagina, violation of protective physiological barriers of the genital tract. The occurrence of malignant tumors of the cervix is largely promoted by smoking, occupational hazards, heredity.
In the pathogenetic aspect, cancer of the uterine body is considered as a predominantly hormone-dependent pathology. From this position, patients with feminizing ovarian tumors, PCOS, adenomyosis, uterine fibroids, and dysfunctional uterine bleeding are in the zone of greatest risk for the occurrence of uterine body cancer. Polyps and atypical endometrial hyperplasia are isolated as background precancerous processes. In addition, the probability of uterine cancer is greater in women with no history of pregnancy, childbirth, with late menopause, living in industrial cities. Uterine sarcoma usually develops from a fast-growing fibromyoma.
From extragenital pathology, uterine cancer are most often accompanied by liver diseases (liver failure, hepatitis, fatty hepatosis, cirrhosis), endocrine disorders (diabetes mellitus, obesity), hypertension. It is known that with an increase in body weight by 10-25 kg compared to the norm, the risk of developing endometrial cancer increases by 3 times, and with a gain of over 25 kg of excess weight – by 9 times.
Malignant neoplasms of the uterine body can be represented by the following morphological types: adenocarcinoma (up to 80% of tumors), squamous cell, glandular cell, undifferentiated cancer and leiomyosarcoma. Endometrial cancer can have exophytic, endophytic or mixed growth.
The clinical classification identifies 4 stages of cancer of the uterine body:
Stage 0 — atypical endometrial hyperplasia (precancerous).
Stage I — the tumor is localized within the body of the uterus:
- Ia – limited by the endometrium
- Ib – germinates into the myometrium less than 1 cm
- Iv – grows deeper into the myometrium than 1 cm, but does not affect the serous membrane
Stage II — the tumor spreads to the body and cervix (cervical canal).
Stage III — the tumor goes beyond the uterus, but is localized within the pelvis:
- IIIa – germinates the serous membrane of the uterus, metastases to regional lymph nodes or appendages can be determined
- IIIb – sprouts parametral fiber, metastases in the vagina can be determined
Stage IV — the tumor extends beyond the pelvis, sprouts the bladder and / or rectum.
Identification of cervical cancer
Stage 0 — cervical intraepithelial neoplasia.
Stage I — the tumor is localized within the cervix:
- Ia – invasion into the stroma to a depth of no more than 3 mm
- Ib – invasion into the stroma to a depth of more than 3 mm
Stage II — the tumor spreads to the upper and middle third of the vagina, the uterine body or parametral tissue.
Stage III — the tumor spreads to the walls and lower part of the vagina, parametral tissue up to the walls of the pelvis, metastasizes to the lymph nodes of the pelvis.
Stage IV — the tumor sprouts the bladder and / or rectum, gives distant metastases.
The initial forms of cervical cancer are asymptomatic or with mild manifestations. Malignant tumors of this localization are characterized by spotting of varying intensity (more often smearing), which are acyclic in reproductive age, and during menopause – the nature of erratic, prolonged bleeding. Spotting often appears after sexual intercourse, defecation, physical exertion. Between bleeding, patients pay attention to the appearance of abundant watery whites, which in the later stages become serous-bloody, with a putrid odor.
Pain in malignant tumors of the cervix are localized in the lower abdomen, in the sacrum and lower back, spread to the thigh and rectum. At first, the pain syndrome occurs at night, then it becomes permanent, and the pain takes on an unbearable character. When the lymphatic and blood vessels are compressed by a tumor conglomerate, edema of the external genitals and lower extremities appears. With advanced forms of cervical cancer, the functions of the rectum and bladder are disrupted, with tumor invasion of organs, blood impurities appear in urine and feces, urinary or rectal fistulas are formed.
Cancer of the uterine body
Malignant tumors localized in the body of the uterus have the following characteristic manifestations: bloody discharge from the genital tract, abdominal pain and dysfunction of adjacent organs. The earliest signs of uterine cancer include the appearance of smearing or abundant blood secretions. They can take the form of metrorrhagia, menorrhagia, or periodic bleeding during menopause. Sometimes neoplasia manifests with whites of a serous-bloody or pus-like nature.
In the early stages of the development of uterine cancer, cramping pains occur. After another painful attack, as a rule, pathological discharge from the uterine cavity appears or increases. In the later stages, the pain becomes constant, intense – they are caused by compression of the nerve plexuses of the pelvis by cancer infiltrate. Somewhat later, symptoms of impaired bladder and rectum function appear: increased urination, tenesmus, difficulty emptying the intestines. With a far-reaching oncoprocess, cancer intoxication joins, cachexia develops.
It refers to non-epithelial uterine cancer. It can affect both the cervix and the body of the uterus. It is often formed inside fibromatous nodes, so it can resemble a clinic of one of the forms of uterine fibromyoma. Sarcoma accounts for about 3-5% of all uterine cancer. The absence of the capsule causes rapid invasive growth of the neoplasm.
The first clinical signs are usually menstrual irregularities or acyclic bleeding, which sometimes have the character of profuse. There is a pronounced pain syndrome and a rapid increase in the size of the uterus. In the later stages, anemia, cancerous cachexia, ascites develop. Uterine sarcoma gives early distant metastases, mainly to the lungs, liver and spine.
It is almost impossible to recognize uterine cancer in the early stages, based only on the collected anamnesis and clinical picture, due to the nonspecificity of symptoms and complaints. Therefore, during the examination of patients, additional instrumental and laboratory methods are used to clarify the structure, localization and prevalence of neoplasia.
At the first appointment, the gynecologist, along with a standard survey, clarifies the presence and number of pregnancies, childbirth and abortions in the patient; gynecological diseases (especially background processes, sexual infections), the nature of the menstrual cycle. When examined with the help of mirrors, attention is paid to the visible changes in the tissues of the cervix, its mobility and shape. Vaginal or rectovaginal examination for endometrial cancer or sarcoma allows you to detect a dense, enlarged uterus, the presence of infiltrates in the parametria.
For the early diagnosis of cervical cancer, a smear examination for oncocytology, an extended colposcopy, and a targeted biopsy of the cervix are of great importance. Ultrasound of the pelvic organs helps to identify precancerous processes and the initial stages of cancer of the uterine body in a timely manner. To confirm the diagnosis of endometrial cancer, an aspiration biopsy, a hysteroscopy with SDC and a histological examination of the scrape are performed.
To determine the stage of a malignant tumor of the uterus and detect distant metastases, additional diagnostics may be required (chest X-ray, cystoscopy, rectoromanoscopy, pelvic MRI, etc.). Differential diagnosis is carried out with tuberculosis and syphilitic ulcers of the cervix, hyperplastic transformation of the endometrium, submucous uterine myoma, chorioncarcinoma.
Therapeutic tactics in relation to uterine cancer are chosen taking into account a variety of criteria: localization, stage, histological form of the tumor, age of the patient, etc. Depending on the listed components, surgical intervention, radiation therapy, chemotherapy, hormone therapy, as well as combined treatment can be used.
In preinvasive cervical cancer, the volume of intervention may be limited by conization of the cervix. In women of reproductive age, the uterus is removed without appendages, in patients older than 50 years, a pangisterectomy is performed. With stage I cervical cancer, the surgical stage is usually supplemented with postoperative radiation therapy, with stage II cervical cancer – with pre- and postoperative irradiation. In the later stages, only external and intracavitary radiation therapy, symptomatic treatment is used.
The main scope of surgical treatment of uterine body cancer is hysterectomy with adnexectomy, which is supplemented with lymphadenectomy if necessary. Radiation treatment is also used in the pre- and postoperative period. If progesterone receptors are detected in the affected tumor, hormone therapy with progestogens is prescribed. Chemotherapy is used for the spread of a malignant tumor of the uterus beyond the pelvic region, but its effectiveness is very limited.
Prevention of uterine cancer consists in the timely detection and treatment of precancerous conditions, systematic passage of preventive examinations with a Pap test, prevention of STDs. It is important to monitor weight, blood pressure, glycemic level, treat extragenital pathology, get rid of bad habits. Preventive vaccination against highly oncogenic HPV strains is proposed in the future to protect teenage girls from cervical cancer.