postmenopausal endometrial cancer
Introduction
Introduction to postmenopausal endometrial cancer Endometrial cancer, also known as endometrial cancer, refers to a malignant tumor that originates in the endometrium, the vast majority of which are adenocarcinomas. In postmenopausal women, ovarian function declines and eventually fails. As estrogen levels gradually decrease, immune function declines, and the incidence of endometrial cancer increases. Mainly manifested as menstrual disorders, such as increased menstrual flow, prolonged menstruation, inter-menstrual bleeding or irregular bleeding. basic knowledge The proportion of illness: 0.014% Susceptible population: menopausal women Mode of infection: non-infectious Complications: bloating, ascites, anemia
Cause
Causes of postmenopausal endometrial cancer
Disease factors (32%):
With anovulatory dysfunctional uterine bleeding, polycystic ovary syndrome, functional ovarian tumor, long-term single estrogen after menopause, no progesterone resistance or progesterone deficiency, endometrial lack of periodic changes, and long-term proliferative state related. Endometrial simple hyperplasia is too long, about 1% develop endometrial cancer; complex hyperplasia is about 3%; dysplasia is about 29% to develop endometrial cancer.
Physical factors (10%):
Endometrial cancer is prone to obesity, hypertension, and diabetes. Generally, obesity-hypertension-diabetes is called triad of endometrial cancer. Unmarried and infertile are also risk factors for endometrial cancer. According to reports, the risk of endometrial cancer in menopausal age >52 years is 1.5 to 2.5 times that of menopausal age <45 years old.
Genetic factors (10%):
Family history of ovarian cancer, colon cancer or breast cancer is more likely to have endometrial cancer than a family history.
Pathogenesis
The occurrence of endometrial cancer is the same as that of cervical cancer. It also follows the evolution from benign hyperplasia to carcinogenesis. The development of endometrial cancer is: normal hyperplasia of endometrium cystic hyperplasia adenomatoid hyperplasia dysplasia And carcinoma in situinvasive carcinoma, simple endometrial hyperplasia is the mildest intimal hyperplasia; cystic hyperplasia is the early stage of cancer development, only 1.5% can develop into cancer; endometrial intraepithelial neoplasia Lesions (EIN) include uterine adenoma hyperplasia with atypical dysplasia and endometrial carcinoma in situ, also known as precancerous lesions of endometrial cancer. Endometrial intraepithelial neoplasia can be reversed to normal. Membrane can also develop into cancer. Because of the slow development of endometrial cancer, 20% to 40 patients with endometrial cancer are still limited to the endometrium at the time of diagnosis.
General form
Visual observation of endometrial cancer can be divided into two types:
(1) diffuse type: most or all of the endometrium is invaded by cancerous tissue. The cancerous lesion often grows from the endometrial surface and protrudes into the uterine cavity. It is filled with uterine cavity and even out of the uterus. The cancer tissue is gray or light. Yellow, the surface is bleeding, necrosis, sometimes forming ulcers, when the cancer tissue blocks the cervical canal can cause uterine empyema.
(2) Localized type: The cancerous lesion is confined to the uterine cavity. It is more common in the bottom of the palace or at the corner of the uterus. It is polypoid or cauliflower-like. It has ulcers on the surface and is prone to hemorrhage. Localized cancerous foci are easy to invade the muscular layer, sometimes the lesion is small. But it has infiltrated the deep muscle layer.
2. Histological form
There are many types of endometrial cancer. According to the structure of the cancer and the degree of nuclear atypia, the pathology can be divided into 3 levels, grade I (highly differentiated); grade II (moderately differentiated); grade III (lowly differentiated). .
(1) Endometrioid adenocarcinoma: 80% to 90%, endometrial gland hyperplasia, epithelial stratification, and the formation of a mesh-like structure, cancer cells are distinct, nuclear large, irregular, deep-stained, The mitotic division is active, the adenocarcinoma with poor differentiation is less, and the glandular structure disappears into a solid region.
(2) Adenocarcinoma with squamous epithelial differentiation: Adenocarcinoma tissue contains squamous epithelial components. If adenocarcinoma contains benign squamous epithelium, it is called squamous adenocarcinoma. If adenocarcinoma contains malignant squamous epithelium, it is called Squamous cell carcinoma.
(3) Clear cell carcinoma: The cancer cells are solid flaky, glandular or papillary, and the cancer cells are rich in cytoplasm, transparent, central in nuclear nucleus, or composed of spike-like cells, with high degree of malignancy and easy early metastasis.
(4) serous adenocarcinoma: complex papillary structure, fissure-like glands, large nuclear atypia, high degree of malignancy, easy to extensively involve the muscular layer, vasculature, or peritoneal dissemination.
(5) Undifferentiated carcinoma: Rarely, cancer cells have neither glandular differentiation nor squamous epithelial differentiation.
3. Transfer route
Most endometrial cancers grow slowly, limited to the endometrium or uterine cavity for a long time, some special pathological types of endometrial cancer, such as serous papillary adenocarcinoma, squamous cell carcinoma, clear cell carcinoma and poorly differentiated cancer can develop Soon, there will be metastasis in a short period of time. The main route of metastasis is direct spread, lymphatic metastasis, and blood transfer may occur in the late stage.
(1) direct spread: the lesion grows along the endometrium, and can be extended to the fallopian tube through the uterine horn; downward can involve the cervical canal and continue to spread to the vagina. If the cancer tissue infiltrates into the muscle wall, it can reach the uterine serosa layer and extend to Tubal ovary, and can be widely planted in the pelvic peritoneum, uterine rectal lacuna and greater omentum.
(2) Lymphatic metastasis: the main metastasis pathway of endometrial cancer. When the cancer infiltrates into the deep muscle layer or spreads into the cervical canal, or the cancer tissue is poorly differentiated, lymphatic metastasis is prone to occur. The metastasis pathway is related to the growth site of the cancerous foci. The tumor at the bottom of the uterus is along the upper lymphatic network of the broad ligament, through the pelvic funnel ligament to the ovary, up to the para-aortic lymph node; the uterine horn cancer along the round ligament to the inguinal lymph node; the lower uterus and the cervical canal and cervical cancer Lymphatic metastasis pathways are the same, can be to the parauterine, intraorbital, sputum total lymph nodes; posterior uterine cancer can be along the palpebral ligament to rectal lymph nodes; anterior wall cancer can spread to the bladder lymph nodes, endometrial cancer can also be lymphatic The tube is retrogradely drained to the front wall of the vagina.
(3) Hematogenous metastasis: The advanced stage can be transferred to various organs of the body by blood, and the common parts are lung, liver and bone.
Prevention
Postmenopausal endometrial cancer prevention
1. Regular anti-cancer examination.
2. For menopausal menstrual disorders and irregular vaginal bleeding after menopause, timely diagnosis of curettage, except for malignant tumors and then symptomatic treatment.
3. For high-risk patients should pay attention to timely inspection.
4. Correctly guide the use of hormone replacement therapy, taking estrogen at the same time, should also take progesterone for not less than 10 days a month to protect the endometrium, prevent hyperplasia, use HRT should be regular gynecological examination, family history, breast hyperplasia Or use the endometrial hyperplasia with caution.
5. Because long-term high-dose tamoxifen (tamoxifen) can cause endometrial hyperplasia, and even have the possibility of endometrial cancer, patients taking tamoxifen (tamoxifen) after breast cancer surgery should be regular. Gynecological examination, and should be B-ultrasound, to understand the thickness of the endometrium, such as the endometrium > 5mm, or irregular vaginal bleeding, should be promptly diagnosed curettage.
Complication
Postmenopausal endometrial cancer complications Complications, abdominal distension, ascites anemia
Can be combined with systemic symptoms of abdominal cavity can have abdominal mass, abdominal distension, ascites, advanced can cause anemia, weight loss, cachexia and systemic failure.
Symptom
Postmenopausal endometrial cancer symptoms Common symptoms of uterine empyema, cachexia, abdominal pain, secondary infection, postmenopausal bleeding, menopausal, purulent discharge, vaginal bleeding, uterine bleeding
Abnormal uterine bleeding
Is the most common symptoms of endometrial cancer, the incidence of which accounts for 88% to 96%, postmenopausal bleeding is characterized by bloody secretions or irregular vaginal bleeding, the amount is small, major bleeding is rare, premenopausal often misdiagnosed as dysfunctional uterus Bleeding, manifested as prolonged menstruation, increased menstrual flow or intermittent bleeding.
2. Vaginal drainage
Mostly the result of tumor exudation or secondary infection, it can be bloody liquid, serous secretion or purulent secretion, accompanied by malodor, when the neck tube is blocked, it can cause uterine empyema, abnormal vaginal secretions often increase Simultaneously with uterine bleeding.
3. Pain
Most of the advanced cancer infiltrates the surrounding tissue or oppresses the nerve and causes lower abdominal pain, low back pain, and can be radiated to the legs. When the uterine cavity is empy, there may also be lower abdominal pain.
4. Other
Patients with advanced disease often have anemia, weight loss, and cachexia.
5. Clinical staging
The clinical staging established by the International Maternity Alliance in 1971 was used, and the surgical-pathological staging established in 1988 was used for the surgical treatment.
Irregular vaginal bleeding in women of high childbearing age, especially postmenopausal vaginal bleeding, combined with the above clinical features and laboratory, auxiliary examination can be diagnosed, the diagnosis needs to rely on pathological examination.
Examine
Postmenopausal endometrial cancer examination
Cytological examination
Some authors report that about 60% of patients undergoing cervical sinus and posterior sacral smears are positive. If benign endometrial cells are found in menopausal or postmenopausal women with cervical or vaginal smears, it is predicted to be 2% to 6 % of latent endometrial cancer, therefore should be vigilant and further examination, but endometrial cells are not easy to fall off, once they fall off, they often have degenerative changes, difficult to identify, so can only play a role in auxiliary diagnosis, uterine cavity Smear examination of eluate and aspirate can increase the positive rate, and experienced cytologists can check the positive rate of endometrial cells by 90% to 95%, but negative can not exclude endometrial cancer, and can not carry out cell grading. Finally, a partial diagnosis is needed.
Endometrial cancer with ascites, stage I without myometrial invasion sometimes found cancer cells in ascites, Marris reported 3 cases of endometrial cancer with ascites, age 70 years, no vaginal bleeding, preoperative diagnosis of ovary Cancer, endometrial cancer did not invade the muscular layer, protruding to the uterine cavity, these 3 patients are elderly patients, the fallopian tube is extremely atrophy, more conducive to reflux, Creasman also mentioned that 8% of patients without myometrial invasion pelvic wash The effluent cells were positive.
2. Endometrial examination
Segmental curettage, which is necessary for the diagnosis of endometrial cancer, in order to find out whether the lesion involves the neck, the curettage should be obtained from the neck and uterine cavity respectively, the depth of the neck should be based on the size of the uterus and the length of the neck Estimate, first cure the neck tube, and then measure the depth of the uterine cavity, in order to determine the clinical period, and then the curettage of the palace and the bottom of the palace, especially pay attention to scraping the intima of the uterus double angle, be careful to segment the curettage, scrape out If the endometrial tissue is a crisp gray-white bean dregs-like tissue, it should be considered as cancer tissue. At this time, it should stop scraping again, so as to avoid the uterus perforation and cause tumor cells, blood and bacteria contaminate the abdominal cavity, and finally send the scraped tissue separately. Pathological examination, endometrial histological examination is the final basis for diagnosis, and its positive rate is 90%.
Endometrial biopsy: can be used for outpatient examination, using the Novak curette to scrape the intima on the wall of the uterine cavity, the positive rate is 80% to 90%, but negative can not exclude endometrial cancer, because sometimes too little tissue is obtained Can not meet the diagnostic requirements, still need to segment the curettage.
3. Tumor marker examination
(1)CAl9-9: It is present in a variety of digestive tract adenocarcinomas. The uterus and fallopian tubes derived from Mullerian tube also synthesize CA19-9 antigen. Scharl et al reported that endometrial adenocarcinoma CAl9-9 57/70 is positive and normal. The endometrium is only 3/26 positive, so it can be a marker of endometrial cancer.
(2) Determination of DNA content of cancer cells: New-bury's research results show that DNA ploidy is related to the tissue grade of endometrial cancer. The higher the tissue grade, the higher the DNA magnification. According to Izumis, the detection of endometrial cancer In 68 cases, 50% were aneuploid, aneuploidy with poor cell differentiation accounted for 77.8%, and highly differentiated aneuploidy accounted for only 33.5%. The DNA index was negatively correlated with tumor differentiation.
Ieda M studies have shown that DNA ploidy is associated with myometrial invasion and staging, deep myometrial invasion and III and IV DNA aneuploidy rates are higher than those without myometrial invasion and stage I, DNA aneuploidy patients The survival rate was significantly lower than that of diploids. The 5-year survival rates were 65.9% and 87.6%, respectively, suggesting that DNA ploidy is an important prognostic factor.
(3) Changes of SPF in the periodic phase of endometrial cancer cells: SPF is an important indicator reflecting cell proliferation activity. SPF is related to myometrial invasion and staging. With the increase of myometrial invasion depth and staging, SPF is significantly increased. Gao, Fribery et al reported that the higher the SPF value, the worse the prognosis and the higher the mortality rate. Xue Fengxia et al reported that the 5-year survival rate of SPF <17% was 79.1%, and that of >17% was 50.4%.
(4) Determination of serum CA125 value: Duk data for the determination of serum CA125 in 110 patients with endometrial cancer found:
1CA125 is present in all endometrial cancer tissues, especially adenocarcinoma;
2 The endometrial cancer CA125 increased by 25%, and its incidence increased with clinical stage, 13% in stage I, 86% in stage IV, vascular infiltration in stage I and II, and increased in vitro expansion. When I and II are found to have elevated CA125, attention should be paid to re-scheduling the clinical period;
The level of 3CA125 varies with the clinical course of the disease, and CA125 is elevated before tumor development and recurrence, especially when there is a tumor in the abdominal cavity;
4I, stage II patients with CA125 increased before treatment, and finally almost died of endometrial cancer, therefore, the determination of CA125 before treatment is valuable for estimating the prognosis.
(5) QVX1 is a high molecular weight mucoid-like glycoprotein. XU Fengji uses two-factor radioimmunoassay to measure OVX1 levels in serum of 45 patients with endometrial cancer in different stages, and to measure serum CA125 levels in patients. The OVX1 value in normal human serum was (2.23±2.48) U/ml, and the value below 2U/ml was the boundary value. The result was that the OVX1 in the serum of the four patients was greater than 7.2 U/ml, and the positive rate of OVX1 was higher than the corresponding period. The other CA125 positive rate was significantly higher, and OVX1 was associated with the stage and tissue grade of early endometrial cancer. The positive rate of OVX1 in the serum of IA, IB, and IC patients increased sequentially. The worse the tissue grade, the OVX1 was positive. The higher the rate, the higher the positive rate of OVX1 in stage I endometrial cancer is 64%, the sensitivity is higher than CA125. Because there is no cross relationship between OVX1 and CA125, OVX1 and CA125 can be combined to detect endometrial cancer. Therefore, the authors believe that OVX1 can be used as a tumor marker for early endometrial cancer, and can be combined with other more sensitive markers to conduct a general survey of endometrial cancer at high risk.
4. Hysteroscopy
Hysteroscopy can directly look at the shape, location and extent of intrauterine lesions, locate biopsy of the lesion or locate the scraping tissue, which is meaningful for the discovery of small endometrial cancer. Therefore, hysteroscopy is an early diagnosis. A reliable method for membrane cancer, at the same time, hysteroscopy can also observe the presence or absence of infiltration of the cervical canal.
Endometrial cancer has the following morphology under hysteroscopy:
1 polyp type, the surface is grayish white rough and uneven polypoid protruding tissue, and has varicose veins;
2 nodular type, showing a large rough protrusion with a curved blood vessel on the surface;
3 papillary type, obvious nodular protrusions are dendritic, grape-like or velvet-like;
4 ulcer type, the surface of the depression has purulent infection, dirty, crisp.
Regarding the question of whether hysteroscopy can cause cancer cell migration, it is still inconclusive. It is generally believed that the microscopic examination leads to the migration of cancer cells and the skill level of the operator, the operation time, the type of the media and the injection rate and the palace. The intracavity pressure is related. If CO2 is used as the expansion medium, the flow rate is small (30-40 ml/min), the uterine pressure is low (6.67-8.0 kPa), and the operation time is within 5 min. Will be smaller.
Hysteroscopy should avoid acute pelvic inflammatory disease, and if you have heart, lung disease or physical weakness, you should consider other safer diagnostic methods.
5. Microscopic hysteroscopy The cervical canal Goldbery believes that the segmental curettage is blind operation, the length of the cervix is unknown, and the biopsy can only be taken casually, so the accuracy of the diagnosis is not high, and the microscopic hysteroscopy is to determine whether the cervical canal is Being affected has great advantages:
1 can directly look at the neck tube, such as the appearance of blood vessels, nipple structure and uterine wall structure;
2 does not need to expand the cervix and the uterine cavity;
3 pairs of cervical mucosal epithelial damage is minimal;
4 can accurately measure the length of the neck tube;
5 easy to take specimens of lesions;
8 can be done in the clinic.
6.B type ultrasound examination
In recent years, the application of vaginal probes can be used to observe the thickness of the endometrium, the depth of myometrial invasion and the degree of cervical involvement, which can assist clinical staging. The study by Granberg S et al suggests that endometrial thickness 5mm is a benign postmenopausal Endometrium, >9mm may be endometrial cancer, the average thickness of endometrial cancer in patients with endometrial cancer is 17.7mm, therefore, the use of vaginal B ultrasound is a simple method for diagnosing endometrial cancer, its specificity is 96 %, the sensitivity is 100%, in addition to observing the thickness of the endometrium, the depth of myometrial invasion can also be observed.
Schoenfeld used the ratio of the anteroposterior diameter of the tumor on the sagittal plane of the uterus to the total width of the intima as a standard for predicting the presence or absence of deep cancer infiltration. The value >30% had deep cancer infiltration, which was accurate compared with the pathological specimen. The rate is 84%, the sensitivity is 100%, and the specificity is 80%, so that a more accurate clinical stage can be obtained for proper treatment during surgery.
Kurjiak reported that changes in blood flow signals were measured by vaginal blood flow Doppler to identify benign and malignant lesions of the endometrium. Monitoring of 308 patients with various uterine diseases found that the resistance coefficient (RI) of endometrial cancer was 0.34±0.05, RI>0.5 of normal or benign disease patients, the accuracy rate was 92.3%, and the endometrial abnormal blood flow map RI<0.4, RI 0.4-0.5 should be suspicious patients.
7. Lymphangiography
For lymph node metastasis before surgery, according to its lymphatic drainage and metastasis process, cancer cells can directly reach the anterior and aortic lymph nodes, and can also transfer to the inguinal lymph nodes along the round ligament. If the tumor has invaded the cervical canal, its metastasis The route is the same as the primary cervical cancer, the spread of lymph nodes to the axillary lymph nodes, and the diagnostic value of lymphography for endometrial cancer. According to Musumeci et al., of the 300 recurrences, 61 were positive for lymphangiography and 47.5%, and no signs of recurrence were positive. The rate is only 7.7%, and the predictive value of angiography for prognosis can also be seen.
8.CT and magnetic resonance (MRI)
Mainly used to observe the uterine cavity, cervical lesions, especially the depth of myometrial invasion and lymphatic metastasis, but the lymph nodes less than 2cm in diameter are difficult to confirm.
Diagnosis
Diagnosis and diagnosis of postmenopausal endometrial cancer
Peri-menopausal functional uterine bleeding
Mainly manifested as menstrual disorders, such as increased menstrual flow, prolonged menstruation, inter-menstrual bleeding or irregular bleeding, gynecological examination without abnormal findings, the disease and endometrial cancer symptoms and signs similar, should be divided into sections, After the endometrial cancer is excluded, the corresponding treatment is given.
2. Senile vaginitis
Senile vaginitis can be manifested as bloody vaginal discharge, which needs to be differentiated from endometrial cancer. The former is vaginal wall hyperemia or submucosal scattered at the bleeding point; the latter vaginal wall is normal, drainage is from the cervical canal, and older women should pay attention to the coexistence of two conditions. may.
3. Uterine submucosal fibroids or endometrial polyps
The performance is more menorrhagia and prolonged menstruation, you can choose B-mode ultrasound, hysteroscopy and segmental diagnosis.
4. Senile endometritis with uterine empyema
The performance of vaginal discharge increased, serous, purulent or pus and blood, the uterus is normal or large and softened, and the expansion of the cervical canal can be clearly diagnosed.
5. Cervical cancer, uterine sarcoma and fallopian tube cancer
There are increased vaginal discharge, or irregular bleeding, cervical cancer due to the cancer is located in the cervical canal, the cervix becomes thick and hard into a barrel, uterine sarcoma can have uterus enlargement, soft, fallopian tube cancer with vaginal discharge, vagina Bleeding, lower abdominal pain is the main symptom, there may be accessory mass, segmental diagnosis and B-mode ultrasound can help differential diagnosis.
