Postmenopausal cervical cancer
Introduction
Introduction to postmenopausal cervical cancer The incidence of gynecological malignancies in women's life is the highest in perimenopause and postmenopausal old age. Cervical cancer is one of the main malignant tumors endangering women's health. At this stage, women's ovarian function gradually declined and eventually failed; The estrogen level decreases, the reproductive organs atrophy and age, and the whole body gradually ages; The decline of immune function, combined with the influence of various carcinogenic factors, increases the incidence of malignant tumors, most of which are cervical cancer. Basic knowledge Prevalence rate: 0.31% Susceptible population: adult women Mode of infection: non infectious Complications: shock anemia
Cause
Etiology of postmenopausal cervical cancer
（1） Pathogenesis
The etiology of cervical cancer has not been fully understood, and its incidence is related to some high-risk factors.
1. Local cervical lesions
Early marriage, early childbearing and prolificacy cause local cervical trauma, cervical erosion, cervical polyps, cervical laceration and cervical precancerous lesions, which are the internal factors leading to the incidence of cervical cancer.
2. Sexual behavior factors
In a sense, cervical cancer can be said to be an infectious disease. Low age of first sexual intercourse, multiple sexual partners, multiple male sexual partners or sexual partners suffering from cervical cancer, frequent sexual life, and lack of attention to sexual hygiene can lead to certain viruses such as human papillomavirus (HPV), herpes virus type II (HSV - II), chlamydia, bacteria, etc. entering the reproductive tract, A man who repeatedly infects the erosive surface of the cervix and causes cervical cancer, and who has penis cancer, prostate cancer, or his ex-wife has cervical cancer, his wife's risk of cervical cancer is several times higher than that of other women.
3. Human papillomavirus (HPV) infection
In recent years, it has been found that HPV infection is the main risk factor for cervical cancer. More than 70 homologous HPVs have been identified, of which more than 20 exist in the genital tract. According to their carcinogenic risk, they can be divided into three groups.
(1) Low or no cancer risk: HPV6, 11, 42.
(2) Moderate risk: HPV31, 33, 35, 51, commonly exists in CIN II and III.
(3) High risk: HPV16, 18, 45, 56, mostly seen in invasive cancer.
4. Other reasons
Smoking, low immune function, economic status, race, geographical environment and other factors are all related to the incidence of cervical cancer.
Therefore, the incidence of cervical cancer may be caused by a combination of multiple factors, rather than a single factor.
（2） Pathogenesis
1. Cervical intraepithelial neoplasia (CIN)
The cervical epithelium is composed of the cervical vaginal squamous epithelium and the cervical tubular columnar epithelium. The junction of the two is located at the outer mouth of the cervix, called the scale column junction, which is the vulnerable part of cervical cancer. The estrogen level of postmenopausal women is low, and the scale column junction can move upward into the cervical canal, which is one of its characteristics. The columnar epithelium covered on the surface of the transitional zone is gradually replaced by metaplastic squamous epithelium, Immature metaplastic squamous epithelium is actively metabolized. Under the stimulation of some substances, such as sperm, semen histone, trichomonas vaginalis, human papillomavirus, etc., poor cell differentiation, disordered arrangement, abnormal nucleus, increased mitosis, and formation of cervical intraepithelial neoplasia may occur.
Cervical intraepithelial neoplasia is a group of precancerous lesions closely related to invasive cancer. It was proposed by Richard in 1967 and has been accepted by many scholars at home and abroad. It includes mild, moderate and severe atypical hyperplasia of the cervix and cervical carcinoma in situ.
(1) Microscopic characteristics of cervical atypical hyperplasia:
① The nuclei are enlarged, hyperchromatic, and vary in size and shape.
② Chromatin is increased and thick.
③ Abnormal nucleoplasm ratio.
④ Increased mitosis.
⑤ The cell polarity was disordered to disappear.
Cervical atypical hyperplasia can be divided into three degrees: mild, moderate and severe.
① Mild atypical hyperplasia: the cells with abnormal hyperplasia are only limited to the lower 1/3 of the epithelial layer.
② Moderate atypical hyperplasia: the cells with abnormal hyperplasia are limited to the lower 2/3 of the epithelial layer.
③ Severe atypical hyperplasia: cells with abnormal hyperplasia occupy more than 2/3 of the epithelial layer or reach the whole layer.
(2) Microscopic features of cervical carcinoma in situ: cancer cells are only confined to the epithelium, the basement membrane is intact, and there is no interstitial infiltration.
① Cells are disordered and nonpolar.
② The nucleus is large, and the proportion of nucleoplasm increases.
③ The heteromorphism is large and the dyeing depth is different.
④ There are many abnormal mitotic figures, which can be found in all epithelial layers.
(3) CIN classification: CIN can be divided into three levels:
CIN grade I, equivalent to very mild and mild atypical hyperplasia.
CIN grade II, equivalent to moderate atypical hyperplasia.
CIN grade III, equivalent to severe atypical hyperplasia and carcinoma in situ.
2. Cervical invasive carcinoma
Cervical cancer mostly occurs in the transitional zone at the junction of squamous epithelium and columnar epithelium. Because the transitional zone of the elderly moves up into the cervical canal, most of the elderly cancer is located in the cervical canal. The main pathological types of invasive cervical cancer are squamous cell carcinoma, adenocarcinoma and undifferentiated cancer.
(1) Cervical squamous cell carcinoma: the most common, accounting for about 70%.
① Histological morphology: according to the degree of differentiation, it can be divided into three grades.
A. Squamous cell carcinoma grade I (well differentiated squamous cell carcinoma), large cell, with obvious formation of keratinized beads, visible cell bridge, less atypia of tumor cells, and less mitosis.
B. Grade II squamous cell carcinoma (moderately differentiated squamous cell carcinoma), large cell, with few or no keratinized beads, no obvious cell bridge, obvious cell atypia, and more mitosis.
C. Squamous cell carcinoma grade III (poorly differentiated squamous cell carcinoma), large or small cells, no keratinized bead formation, no cell bridge, cell atypia and mitosis are common.
② General shape: according to the growth mode of the tumor, it can be divided into 4 types.
A. Erosive type: no tumor can be seen with naked eyes, and the surface is erosive.
B. Nodular type: the tumor forms lumpy nodules from the outer mouth of the cervix to the surface of the cervix, which is an exogenous tumor.
C. Cauliflower type: the tumor grows like cauliflower from the cervix to the vagina, which is an exogenous tumor.
D. Ulcerative type: the tumor grows erosively from the cervix to the uterine cavity, forming ulcers and cavities, which is an endogenous tumor.
(2) Cervical adenocarcinoma: it has an upward trend in recent years, accounting for about 20%, including cervical mucinous adenocarcinoma, endometrioid adenocarcinoma, clear cell carcinoma, cervical serous papillary adenocarcinoma, undifferentiated adenocarcinoma, cervical adenosquamous carcinoma, etc. Adenocarcinoma mostly occurs in the cervical canal, and tumor cells have the characteristics of glandular epithelial cells, form glandular structures, and infiltrate the stroma.
Cervical adenocarcinoma comes from the cervical canal and infiltrates the cervical canal wall. It can have a variety of general shapes and can grow inward. The cervical canal expands to enlarge the entire cervix and presents a "barrel shaped cervix", which is hard and smooth or slightly erosive; Outward growers may be polypoid, nodular, papillary or mushroom like masses; Nearly 15% of patients had no lesions visible to the naked eye.
Prevention
Prevention of cervical cancer after menopause
After the treatment of cervical cancer, strict regular follow-up should be carried out. The first follow-up should be carried out one month after the treatment, and the follow-up should be carried out every 2 to 3 months later. The follow-up should be carried out every 3 to 6 months in the second year after the treatment, and at least once a year later. In addition to clinical examination, chest films, blood routine, B ultrasound and cytology should also be carried out during the follow-up.
Complication
Postmenopausal cervical cancer complications complication Shock anemia
Late cervical cancer compresses ureteral obstruction, causing hydroureter and hydronephrosis, which ultimately leads to renal failure; Hemorrhagic shock is caused by massive bleeding on the basis of long-term repeated bleeding; Anemia, secondary infection, pain and chronic consumption lead to cachexia and death.
Symptom
Postmenopausal cervical cancer symptoms common symptom Increased leucorrhea, vaginal bleeding, renal nonfunctional cachexia, frequent vesicular edema Lower abdominal pain, hydronephrosis, leucorrhea and hematochezia
1. Symptoms
Early cervical cancer may not have any clinical symptoms. However, although some patients have obvious clinical symptoms such as leukorrhea and vaginal bleeding, the clinical stage may still be early lesions. The clinical symptoms of patients at the early stage of lesions are the main reason for timely treatment of cervical cancer patients, and also one of the important reasons for good treatment effect of cervical cancer, The common clinical symptoms of cervical cancer have no obvious specificity.
(1) Leucorrhea increase: 80%~90% of cervical cancer patients have different degrees of leukorrhea increase symptoms. The characteristics of leukorrhea are similar to general inflammation. With tumor progression, necrosis, shedding and secondary infection, foul smelling abscessed leukorrhea may appear.
(2) Vaginal bleeding: 80%~85% of patients have vaginal bleeding symptoms, which can be manifested as contact, menstrual period, postmenopausal or irregular vaginal bleeding. Contact vaginal bleeding or postmenopausal vaginal bleeding in young women are clinical symptoms that deserve special attention. The amount of vaginal bleeding is related to the early or late stage of the disease, and also to the type of tumor growth, Huge cauliflower like exogenous tumors and ulcerative cavity tumors are prone to vaginal bleeding.
(3) Other symptoms: tumor infiltration may cause lower abdominal pain, lumbosacral pain, lower abdominal and defecation sagging sensation, blood in stool, difficulty in defecation, frequency of urination, hematuria, lower limb edema and other symptoms. In the late stage, patients may also have cachectic symptoms such as anemia and weight loss.
2. Physical signs
It is an indispensable examination method for gynecological examination. Local tumors of the cervix can be manifested as erosion, cauliflower, ulcer or nodular neoplasms in the naked eye, and the original shape of the cervix disappears. In addition to understanding the naked eye type and size of local tumors of the cervix, gynecological examination should also check the scope of the tumor invading the vagina and the uterus, in order to determine the clinical stage, in addition to understanding the vaginal dilatation, uterus, Attachments, rectum, etc. During gynecological examination, attention should be paid to avoid massive bleeding caused by tumor tissue bruised by the vaginal speculum and finger palpation. During physical examination, attention should be paid to whether there is swelling in the inguinal and supraclavicular lymph nodes, whether there is percussion pain in the renal region, and whether there is edema in the lower limbs.
Clinical staging: The latest international clinical staging method revised by FIGO (1995) is currently used for the clinical staging of cervical cancer.
Staging precautions:
① Stage 0 included atypical cells in all epithelial layers, but no interstitial infiltration.
② Stage Ia should include minimal interstitial infiltration and measurable microcarcinoma; Ia1 and Ia2 are microscopic diagnosis, not visible to the naked eye.
③ Cervical cancer involving the uterine body does not affect the prognosis, so it will not be considered in staging.
④ Parauterine tissue thickening may not be caused by cancerous infiltration, but can be seen in inflammatory thickening; Only those with nodular thickening of parauterine tissue, poor elasticity, and hardness and toughness not reaching the pelvic wall can be diagnosed as stage IIb, and those reaching the pelvic wall can be diagnosed as stage IIIb.
⑤ When hydronephrosis or renal failure occurs due to cancerous ureteral stricture, whether other examinations are only stage I or stage II, they should be classified as stage III.
⑥ Only bladder vesicular edema can not be classified as stage IV but as stage III. It can be diagnosed as stage IV only if there are malignant cells in the bladder flushing fluid or pathological evidence of submucosal infiltration of the bladder.
Examine
Examination of postmenopausal cervical cancer
1. Detection of tumor markers: The serum levels of squamous cell carcinoma antigen (SCC) and carcinoembryonic antigen (CEA) in 70% of patients increased, and their levels were related to the size and stage of the tumor. Dynamic measurement of their concentrations could help monitor the condition.
2. Vaginal exfoliated cell examination (cervical scraping examination) Most patients with early cervical cancer have no symptoms, and it is difficult to identify whether there is a tumor with naked eyes during clinical examination. Cervical exfoliated cell examination is easy to obtain materials, and it is the most effective examination method to find early cervical cancer. This examination should be routinely performed for married women, gynecological examination or population cancer prevention census, As a screening method for cervical cancer, attention should be paid to taking samples at the squamous columnar junction where cervical cancer is prone to improve the accuracy of diagnosis. Because the squamous columnar junction of elderly women moves upward into the cervical canal, in addition to scraping cells from the cervical vagina, special attention should be paid to taking samples from the cervical canal.
The reporting method of cytological examination at home and abroad mostly adopts the Pap's 5-level classification. Level I is normal, Level II is caused by inflammation, Level III is suspicious, Level IV is suspicious positive, Level V is positive. When the cytological examination of cervical scraping is above Level II, smear or colposcopy should be repeated. Pap's Level III, IV, and V should be performed with colposcopy or iodine test for cervical biopsy.
In recent years, the technology of cytological examination has made new progress at home and abroad.
(1) Liquid based thin-layer cytology or thin slice preparation cytology (TCT): the exfoliated cells from the outer mouth of the cervix and the cervical canal were collected with a special plastic scraper and cervical brush, and the collected cells were washed into a special vial with cell preservation solution. After programmed treatment, the mucus, blood and inflammatory cells in the sample were separated, and the epithelial cells were left and filtered into thin layer smears, When examined under the microscope, because the cells to be examined are concentrated and the background is clear, abnormal cells can be better screened.
(2) Computer assisted cytology (CCT): Auto Pap 300 QC system or Pap Net system is used for screening, which is a method of introducing computer to read films. It can improve diagnostic accuracy, efficiency and workload.
(3) Improvement of cytological examination report method: For a long time, the Babbitt's five classification method has been used as the report method of cytological examination at home and abroad. With the progress of cytopathology, it is gradually felt that the Babbitt's classification method can no longer meet the clinical requirements of disease diagnosis. In 1988, WHO proposed the application of descriptive reporting system, In the same year, American pathologists put forward the Bethesda systematic reporting system (TBS) to gradually replace the Pap's 5-level classification. This method mainly emphasizes the quality of smears, descriptive diagnosis, and the communication between clinical and cytopathology. China has now begun to use TBS.
The main report results of TBS are: low squamous intraepithelial lesion (LSIL), high squamous intraepithelial lesion (HSIL), atypical squamous cells without definite diagnostic significance (ASCUS), atypical glandular cells without definite diagnostic significance (AGCUS).
3. Iodine test
Apply 2% iodine solution to the cervical and vaginal mucosa, and observe its staining. The normal cervical and vaginal squamous epithelium is rich in glycogen, which is easy to be stained brown by iodine solution. If it is not stained, it is positive, which can help determine the biopsy site.
4. Colposcopy
Vaginal exfoliation cytology examination should be performed on those who are above Pap Ⅱ and have clinical suspicious symptoms and signs, such as contact bleeding, moderate or severe cervical erosion, or erosion that has not been cured for a long time. Colposcopy should be performed to observe whether there is abnormal epithelium or early canceration on the surface of the cervix. The purpose is to select the biopsy site and improve the diagnostic accuracy.
5. Biopsy of cervix and cervical canal
It is the most reliable and indispensable method for the diagnosis of cervical cancer and its precancerous lesions. The samples should be taken at 3, 6, 9, and 12 points of the cervical scale column junction. Four points of biopsy should be taken, or the samples should be taken from the suspicious parts observed by colposcopy or iodine test. The samples should have a certain depth. The tissues should have both epithelial and interstitial tissue. It should be noted that even if the local lesions are very similar to cancer, Cervical biopsy should also be performed to confirm the diagnosis, because some benign lesions such as chronic cervicitis, cervical tuberculosis, etc. are very similar to tumors in appearance, which is difficult to identify with the naked eye, and must be confirmed by living tissue examination. If no tumor is found on the surface of the cervix, and the cervical scraping blade is Grade III or above, the tissue in the cervical tube needs to be scraped with a small curette and sent to pathology.
6. Cervical conization
When cervical scraping is positive for many times, cervical biopsy is negative; Or the biopsy is in situ cancer, but it cannot be ruled out that cervical conization can be performed when invasive cancer occurs. The cut cervical tissue is divided into 12 pieces, and each piece is examined with 2-3 slices to confirm the diagnosis.
After the diagnosis of cervical cancer, chest film, cystoscopy, rectal endoscopy, pyelography, lymphography, CT scanning or MRI examination shall be carried out according to the patient's condition to help determine the clinical stage.
Diagnosis
Diagnosis and differential diagnosis of postmenopausal cervical cancer
After the typical symptoms and signs of cervical cancer appear, it is generally an invasive cancer, and the diagnosis is not difficult. Biopathological examination can confirm the diagnosis. Early cervical cancer is often asymptomatic, and the signs are not obvious. The diagnosis often depends on some comprehensive auxiliary examination methods.
Since cervical cancer has no specific clinical symptoms, it should be differentiated from infectious vaginitis, senile vaginitis, cervical erosion, cervical polyps, submucous myoma of the uterine cavity, submucous myoma of the uterine cavity, cervical tuberculosis and other benign lesions, which can all be manifested as irregular vaginal bleeding, cervical erosion or new organisms, The main examination method for preliminary differential diagnosis is cervical exfoliative cytology, and the reliable method for differential diagnosis is cervical neobiology biopsy, colposcopy and other auxiliary examination methods can improve the accuracy of biopsy site.
