postmenopausal cervical cancer
Introduction
Introduction to postmenopausal cervical cancer Women have the highest incidence of gynecologic malignancies in menopause and postmenopausal age in their lifetime. Cervical cancer is one of the major malignant tumors that endanger the health of women. At this stage, women's ovarian function gradually declines, eventually failing; estrogen levels are reduced, reproductive organs are atrophied and aging, and the whole body is gradually aging; immune function is reduced, and the effects of carcinogenic factors increase the incidence of malignant tumors. The most common of these is cervical cancer. basic knowledge The proportion of illness: 0.31% Susceptible people: adult women Mode of infection: non-infectious Complications: shock anemia
Cause
Causes of postmenopausal cervical cancer
(1) Causes of the disease
The etiology of cervical cancer has not yet been fully understood, and its incidence is related to some high-risk factors.
Cervical local lesion
Early marriage, early childbirth, prolific cervical trauma, cervical erosion, cervical polyps, cervical laceration and cervical precancerous lesions are the intrinsic factors leading to the incidence of cervical cancer.
2. Sexual behavior factors
Cervical cancer can be said to be an infectious disease in a certain sense. The first sexual intercourse is low, there are multiple sexual partners, male sexual partners have multiple or sexual partners with cervical cancer, frequent sexual life, sexual health, etc. , can cause certain viruses such as human papillomavirus (HPV), herpesvirus type II (HSV-II) and chlamydia, bacteria, etc. into the reproductive tract, repeated infection in the cervical erosion surface induced cervical cancer, suffering from penile cancer, A man with prostate cancer or a former wife who has had cervical cancer has a higher risk of cervical cancer than his wife.
3. Human papillomavirus (HPV) infection
In recent years, HPV infection has been found to be a major risk factor for cervical cancer. More than 70 homologous HPV have been identified, of which more than 20 are present in the human reproductive tract and can be divided into three groups according to their carcinogenic risk.
(1) The risk of cancer is small or absent: HPV 6, 11, 42 type.
(2) Moderate risk: HPV 31, 33, 35, 51 type, commonly found in CINII, III.
(3) High risk: HPV16, 18, 45, 56 type, more common in invasive cancer.
4. Other reasons
Smoking, low immune function, economic status, ethnicity, geographical environment and other factors have a certain relationship with the incidence of cervical cancer.
Therefore, the incidence of cervical cancer may be caused by a combination of factors, rather than the role of a single factor.
(two) pathogenesis
1. Cervical intraepithelial neoplasia (CIN)
The cervical epithelium is composed of the squamous epithelium of the cervicovaginal region and the columnar epithelium of the cervical canal. The junction between the two is the outer part of the cervix. It is called the scale-column junction, which is the prone site of cervical cancer. The postmenopausal women have low estrogen levels and scales. The junction can be moved up into the cervical canal. It is a feature. The columnar epithelium covered by the transition zone is gradually replaced by the metaplastic squamous epithelium. The immature metaplastic squamous epithelium is active in metabolism, in some substances such as sperm and semen. Under the stimulation of histones, Trichomonas vaginalis, human papillomavirus, etc., cell differentiation may occur, disordered arrangement, abnormal nuclear nucleus, increased mitosis, and cervical intraepithelial neoplasia.
Cervical intraepithelial neoplasia is a collective term for precancerous lesions closely related to invasive cancer. It was proposed by Richart in 1967 and has been accepted by many domestic and foreign scholars. It includes mild, moderate, and severe dysplasia of the cervix. And cervical cancer in situ.
(1) Features of cervical atypical hyperplasia:
1 The nucleus is enlarged, deeply stained, and the size and shape are different.
2 chromatin increased, coarse.
3 The proportion of nucleoplasm is abnormal.
4 nuclear division increased.
5 cells are disordered to disappear.
Cervical atypical hyperplasia can be divided into light, medium and heavy three degrees.
1 mild atypical hyperplasia: abnormally proliferating cells are limited to the lower third of the epithelial layer.
2 Moderate atypical hyperplasia: Cells with abnormal proliferation are limited to the lower 2/3 of the epithelial layer.
3 severe atypical hyperplasia: abnormally proliferating cells occupy more than 2/3 of the epithelial layer or reach the full layer.
(2) Characteristics of cervical carcinoma in situ: The cancer cells are confined to the epithelium, the basement membrane is intact, and there is no interstitial infiltration.
1 cells are disordered and non-polar.
2 The cell nucleus is large and the proportion of nucleoplasm is increased.
3 The shape is large and the dyeing depth is different.
4 abnormal mitotic figures, can be found in all layers of the epithelium.
(3) CIN classification: CIN can be divided into 3 levels:
CINI grade, equivalent to very mild and mild atypical hyperplasia.
CINII level, equivalent to moderate atypical hyperplasia.
CIN grade III, equivalent to severe atypical hyperplasia and carcinoma in situ.
2. Cervical invasive cancer
Cervical cancer mostly occurs in the transitional zone between the squamous epithelium and the columnar epithelium. Because the transition zone of the elderly moves up into the cervical canal, most of the cancer in the elderly is located in the cervical canal. The main pathological type of cervical invasive carcinoma is squamous cell carcinoma. , adenocarcinoma and undifferentiated cancer.
(1) Cervical squamous cell carcinoma: the most common, accounting for about 70%.
1 histological morphology: divided into 3 levels according to the degree of differentiation.
A. Squamous cell carcinoma grade I (highly differentiated squamous cell carcinoma), large cells, with obvious keratinized bead formation, showing cell bridges, tumor cells are less atypia and less nuclear division.
B. Squamous cell carcinoma grade II (medium differentiated squamous cell carcinoma), large cells, with small or no horny beads, cell bridge is not obvious, cell atypia is obvious, and nuclear division is more common.
C. Squamous cell carcinoma grade III (low-differentiated squamous cell carcinoma), large or small cells, hornless bead formation, cell-free bridge, cell atypia and nuclear division are common.
2 general morphology: according to the growth pattern of the tumor is divided into 4 types.
A. erosive type: the tumor is not visible to the naked eye, and the surface is smashed.
B. Nodular type: The tumor forms a mass-like nodule from the external cervix to the surface of the cervix, which is an exogenous tumor.
C. Cauliflower type: Tumor growth is like a cauliflower from the cervix to the vagina, and is an exogenous tumor.
D. Ulcer type: The tumor grows erosively from the cervix to the uterine cavity, forming ulcers and cavities, and is an endogenous tumor.
(2) Cervical adenocarcinoma: 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, cervix Adenocarcinoma, etc., adenocarcinoma occurs more in the neck tube, tumor cells have glandular epithelial cell characteristics, forming a glandular structure, infiltrating the stroma.
Cervical adenocarcinoma comes from the cervical canal and infiltrates the neck wall. It can have a variety of general forms, which can grow inward. The neck can be enlarged to make the whole cervix enlargement into a "barrel-shaped cervix", which is hard and has a smooth surface or mild erosion. The external growth can be polypoid, nodular, papillary or sputum-like; nearly 15% of patients have no visible lesions.
Prevention
Postmenopausal cervical cancer prevention
Cervical cancer should be followed up regularly after the treatment, the first follow-up 1 month after the end of treatment, and then every 2 to 3 months, once every 3 to 6 months after the second year of treatment, At least once a year, check at the time of follow-up, in addition to clinical examination, chest X-ray, blood routine, B-ultrasound and cytology.
Complication
Postmenopausal cervical cancer complications Complications, shock anemia
Late cervical cancer compression ureteral obstruction caused by ureteral hydronephrosis and hydronephrosis, eventually leading to renal failure; long-term repeated bleeding based on another major bleeding leading to hemorrhagic shock; anemia, secondary infection, pain and chronic consumption leading to cachexia and death.
Symptom
Postmenopausal cervical cancer symptoms Common symptoms of vaginal discharge increased vaginal bleeding kidney no function cachexia urinary vesicular edema lower abdominal pain hydronephrosis vaginal discharge blood
Symptom
Early cervical cancer may have no clinical symptoms. However, although some patients have obvious clinical symptoms such as increased vaginal discharge and vaginal bleeding, the clinical stage may still be early lesions. The clinical symptoms of patients in the early stage of the disease are the main treatment for patients with cervical cancer. The reason is also one of the important reasons for the good treatment of cervical cancer. The common clinical symptoms of cervical cancer have no obvious specificity.
(1) increased vaginal discharge: 80% to 90% of cervical cancer patients have varying degrees of vaginal discharge symptoms, leucorrhea traits similar to general inflammation, with tumor progression necrosis and secondary infection, may appear malodorous pus and leucorrhea.
(2) vaginal bleeding: 80% to 85% of patients with vaginal bleeding symptoms, can be manifested as contact, menstrual period, postmenopausal or irregular vaginal bleeding, young women with contact vaginal bleeding or vaginal bleeding after menopause It is a clinical symptom that deserves special attention. The amount of bleeding in vaginal bleeding is related to the early and late stages of the disease, and is also related to the type of tumor growth. Large cauliflower-like exogenous tumors and ulcerated cavities are prone to vaginal bleeding.
(3) Other symptoms: tumor infiltration can occur in lower abdomen pain, lumbosacral pain, lower abdomen and bowel movements, blood in the stool, difficulty in defecation, frequent urination, hematuria, lower extremity edema, etc., patients with advanced disease will also have anemia, weight loss and other cachexia symptom.
2. Signs
The essential examination method for gynecological examination, the local observation of the local tumor of the cervix can be expressed as erosion, cauliflower-like, ulcer-like or nodular new organism, the original shape of the cervix disappears, and the gynecological examination is not only the type and size of the naked eye of the local tumor of the cervix, but also Should also check the extent of tumor invasion of the vagina and para-uterus to determine the clinical stage, in addition to understand the degree of vaginal dilatation, uterus, accessories, rectum, etc., during gynecological examination, pay attention to avoid vaginal and finger palpation and bruise the tumor tissue The major bleeding caused by the physical examination should pay attention to the inguinal and supraclavicular lymph nodes, whether there is any pain in the kidney area, no swelling in the lower limbs.
Clinical Staging Method: The clinical staging of cervical cancer is currently based on the latest international clinical staging method of FIGO (1995).
Staging considerations:
Stage 10 includes atypical cells in the entire epithelium but no interstitial infiltration.
Stage 2Ia should include minimal interstitial infiltration and measurable microcarcinoma; both Ia1 and Ia2 are diagnosed under the microscope and are not visible to the naked eye.
3 cervical cancer involving the uterus does not affect the prognosis, so it is not considered when staging.
4 check the thickening of the parametrial tissue is not necessarily caused by cancerous infiltration, can be seen in inflammatory thickening; only the paranoid tissue nodular thickening, poor elasticity, hard tough pelvic wall can be diagnosed as stage IIb, up to The pelvic wall was diagnosed as stage IIIb.
5 When the hydronephrosis or renal non-function caused by cancerous ureteral stricture, regardless of whether other tests are only stage I or II, it should be designated as stage III.
6 Only bladder edema can not be classified as stage IV and stage III, must have malignant cells in the bladder irrigation solution or pathologically confirmed submucosal infiltration, can be diagnosed as stage IV.
Examine
Examination of postmenopausal cervical cancer
1. Tumor marker detection: 70% of patients with elevated serum squamous cell carcinoma antigen (SCC) and carcinoembryonic antigen (CEA) values, the level of which is related to tumor size and stage, dynamic determination of its concentration can help monitor the condition.
2. Vaginal exfoliated cell examination (cervical scraping test) Most patients with early cervical cancer have no symptoms. It is difficult to identify the presence or absence of tumor by visual observation during clinical examination. Cervical exfoliated cell examination is easy to obtain, which is the most effective examination for early cervical cancer. Methods, when married women, gynecological examinations or population anti-cancer census, should be routinely used for this examination, as a method of screening for cervical cancer, it is necessary to pay attention to the squamous-columnar epithelial junction where cervical cancer is good, in order to improve diagnosis. The accuracy rate, because the elderly women scale-colum epithelial junction moved up the neck tube, so in addition to scraping cells in the cervix at the time of taking the material, pay special attention to the material from the cervical canal.
The reporting method of cytology is mostly based on the five-level classification of Pap, the grade I is normal, the grade II inflammation is caused, the grade III is suspicious, the grade IV is suspicious, the grade V is positive, and the cervical smear is cytologically graded. Above, repeat smear or colposcopy, Pap test III, IV, V grade should be performed under the colposcopy or iodine test cervical biopsy.
In recent years, new progress has been made in the technology of cytological examination at home and abroad.
(1) Liquid-based thin layer cytology or flake preparation cytology (TCT): The exfoliated cells of the external cervical and cervical canal were collected by a special plastic scraper and a neck tube brush, and the collected cells were washed into cells. In the special vial of the preservation solution, the mucus, blood and inflammatory cells in the specimen are separated by programmed treatment, and the epithelial cells are left and filtered to form a thin layer smear, which is examined under a microscope, because the cells to be examined are concentrated, the background Clear, better screening of abnormal cells.
(2) Computer-assisted cytology (CCT): Screening using the Auto Pap 300 QC system or Pap Net system is a method of introducing computer readings to improve diagnostic accuracy, improve efficiency, and reduce workload.
(3) Improvement of the cytological examination report method: For a long time, most of the domestic and international Pap categorization methods have been used as the reporting method of cytological examination. With the progress of cytopathology, it is gradually felt that the Pap grading method can not adapt to the disease. The clinical requirements for diagnosis, in 1988, WHO proposed the application of a descriptive reporting system. In the same year, American pathologists proposed the Bethesda System Reporting Method (TBS) to gradually replace the Pap 5 classification, which emphasizes the quality of smear. Descriptive diagnosis and clinical and cellular pathology communicate with each other, and TBS has been adopted in China.
The main findings of TBS were: low-grade squamous intraepithelial lesion (LSIL), highly squamous intraepithelial lesion (HSIL), atypical squamous cells (ASCUS) with undiagnosed significance, and atypical glandular cells with undiagnosed significance ( AGCUS).
3. Iodine test
The iodine solution with a concentration of 2% was applied to the cervix and vaginal mucosa to observe the coloration. The squamous epithelium of the normal cervix was rich in glycogen, which was easily stained brown by iodine solution, which was positive without staining. Determine the biopsy site.
4. Colposcopy
All vaginal exfoliative cytology examinations of Papillary II or higher, clinical suspicious symptoms and signs, such as contact bleeding, cervical moderate or severe erosion, or erosion of long-term treatment should be performed colposcopy to observe the presence of atypical epithelium on the surface of the cervix or The purpose of early canceration is to select the biopsy site and improve the diagnostic accuracy.
5. Cervical and cervical biopsy
It is the most reliable and indispensable method for the diagnosis of cervical cancer and its precancerous lesions. The biopsy should be taken at the 3,6,9,12 o'clock junction of the cervical squamous-column junction, or observed by colposcopy or iodine test. The suspicious part is taken from a certain depth. The tissue to be taken must have both epithelial tissue and interstitial tissue. It should be noted that even if the local lesion is very similar to a cancerous tumor, a cervical biopsy should be performed to confirm the diagnosis, because some Benign lesions such as chronic cervicitis, cervical tuberculosis and other appearances are very similar to tumors. It is difficult to identify by the naked eye only. It must be confirmed by biopsy. If there is no tumor on the surface of the cervix, the cervical scraper is grade III or above. A small curette scrapes the tissue inside the cervical canal for pathology.
6. Cervical conization
When the cervical smear is positive for multiple examinations, and the cervical biopsy is negative; or the biopsy is carcinoma in situ, but can not rule out invasive cancer, cervical conization can be performed, and the cut cervical tissue is divided into 12 pieces, each piece is made 2~3 A biopsy is performed to confirm the diagnosis.
After the diagnosis of cervical cancer, chest X-ray, cystoscopy, proctoscopy, pyelography, lymphography, CT scan or MRI are performed according to the patient's condition to assist in determining the clinical stage.
Diagnosis
Diagnostic diagnosis of postmenopausal cervical cancer
Cervical cancer, after typical symptoms and signs, is generally invasive cancer, the diagnosis is more difficult, biopsy can confirm the diagnosis, early cervical cancer is often asymptomatic, physical signs are not obvious, the diagnosis often depends on some comprehensive auxiliary examination method.
Because cervical cancer has no specific clinical symptoms, it should be distinguished from benign lesions such as infectious vaginitis, senile vaginitis, cervical erosion, cervical polyps, uterine submucosal fibroids, cervical submucosal fibroids, and cervical tuberculosis. These lesions can be characterized by irregular vaginal bleeding and cervical erosion or new organisms. The primary method for initial differential diagnosis is cervical exfoliative cytology, and a reliable method for differential diagnosis is biopsy of cervical neoplasms, colposcopy, etc. The auxiliary inspection method can improve the accuracy of the biopsy site.
