cervical sarcoma
Introduction
Introduction to cervical sarcoma Cervical sarcoma is a rare female genital tract tumor with a high degree of malignancy. Cervical sarcoma has low incidence and no specific clinical manifestations. Many patients are undergoing surgery, including cervical myomectomy and postoperative pathology. Only discovered. Cervical enlargement, especially the sudden increase of the cervix, with vaginal bleeding, vaginal discharge increased significantly, should be suspected of cervical sarcoma. basic knowledge The proportion of the disease: the incidence of this disease is extremely low, generally between 0.0001% and 0.0002%. Susceptible people: women Mode of infection: non-infectious Complications: urinary tract infection
Cause
Causes of cervical sarcoma
(1) Causes of the disease
Cervical sarcoma occurs in the cervical muscles and interstitial tissues, and has a high degree of malignancy. It is a mesodermal tumor, which can come from the cervical muscular layer, the endometrial stroma of the cervical canal, connective tissue, epithelium or blood vessels. The mixed tumor of the component is only 1/10 to 1/15 of that compared with the uterine sarcoma. The cause of the disease is not exact and may be related to the following factors:
Oral contraceptive factors (37%):
Long-term oral contraceptives (>15 years), the risk of sarcoma increases, mainly for leiomyosarcoma, long-term use of non-contraceptive estrogen also increases the risk of sarcoma, mainly Müllerian mixed tumors, also reported in the literature There are estrogen and progesterone receptors in leiomyosarcoma, which are estrogen-dependent tumors. The level of estrogen in blood is also higher than that in normal control group.
Obesity factor (25%):
Epidemiological studies have found that women with high body mass index have an increased incidence of sarcomas, including various types of uterine sarcoma, in which estrogen levels are elevated, and there are multiple mechanisms, including androstenedione in peripheral adipose tissue. In the transformation, the increase in non-protein-bound estrogen, estradiol degradation and metabolism.
Other factors (13%):
The incidence of sarcoma in the ethnic black population was higher than that in the control group. Socioeconomic status: leiomyosarcoma is rare in women with higher socioeconomic status. Müllerian mixed tumors are found in women with lower socioeconomic status. Tumor-associated genes: The literature reports that 32% to 56% of cervical sarcomas have mutations in the p53 gene, and 24% to 32% detect mutations in the k-ras gene. Radiotherapy: It has been reported that the cervix is prone to sarcoma several 10 years after local radiotherapy.
(two) pathogenesis
The long-term metastasis of cervical sarcoma is mainly disseminated by blood. The histopathological types of cervical sarcoma include: leiomyosarcoma, embryonal rhabdomyosarcoma, cervical stromal sarcoma, vascular endothelium or cutaneous tumor, lymphoma, unclassified sarcoma, smooth muscle Sarcomas accounted for the majority, followed by liposarcoma and malignant mesodermal mixed tumors belonging to interstitial sarcoma.
Leiomyosarcoma
(1) Origin: smooth muscle fibers that can come from the muscular layer, but also from the original leiomyomas.
(2) Gross shape:
1 Like smooth muscle-like growth, 2/3 between the muscle wall, 1/5 under the mucosa, 1/10 below the subserosal.
2 There is a clear false envelope, but it can also diffuse growth, and there is no boundary with the muscle layer.
3 cut surface is loose and soft, fish-like, most with bleeding and necrosis.
4 sarcoma development can infiltrate into the surrounding muscle layer, even through the serosa and spread to the pelvic cavity.
(3) Organizational form:
1 nuclear fission image > 5/10HP.
2 cell atypia.
3 tumors can infiltrate into the muscle layer, blood vessels, intima and neck.
When some muscle cells in the fibroids are malignant, the fibroids are called fibroids, and the whole fibroids are malignant.
2. Endometrial stromal sarcoma
(1) Origin: The interstitial cells of the endocervix of the cervix occur mostly after menopause, but can occur in the reproductive age and children, accounting for 0.2% of the genital malignant tumors. They are divided into high and low malignant stroma. sarcoma.
(2) Characteristics of endometrium: Low-grade malignant sarcoma can form single or multiple polypoid masses, sometimes filling the entire neck, wide base, infiltrating muscle layer, and highly malignant interstitial sarcoma often forming soft polypoid Or a lobulated mass protruding to the cervical canal, the tumor is 2 to 3 cm in size, infiltrating the muscular layer, blood vessels and serosal surface.
(3) Histomorphological features: low-grade malignant interstitial sarcoma, its proliferating endometrial stromal cells invade the myometrial muscle bundle, mitotic like <3/10HF, highly malignant stromal sarcoma, its histomorphology is often homogeneous , polymorphic, mitotic elephant > 10/10HF, even up to 20 ~ 30 / HF.
3. Malignant Müllerian mixed tumors: including carcinosarcoma and malignant mesodermal mixed tumors.
(1) Gross morphology: The tumor grows in the endometrium, which is common in the posterior lip of the cervix. It is a polypoid protruding into the neck tube. It can be multiple, lobulated, and can protrude to the cervix.
(2) Tissue morphology: There are two components of cancer and sarcoma. The cancer component is often endometrioid adenocarcinoma (90%), or it can be translucent cell type, mucous goblet cell type, and in a few cases it can be squamous cell carcinoma.
Clinical staging: The clinical stage of cervical cancer has a history of more than 70 years. After several revisions, it has been gradually improved. At the beginning, the tumor was infiltrated into the basin wall, that is, the "frozen pelvis" was classified as stage IV, and in 1937, the stage was revised to be III. In the 1950 revision of the staging, it was decided to invade the uterus body as a standard for staging (the original staging was invaded as stage II); the staging criteria of 1961 clarified that stage 0 cancer was carcinoma in situ, intraepithelial cancer, and It is pointed out that the stage 0 cancer case is not included in any treatment statistics. In 1970 and 1985, the concept of occult cancer (OCC) was added, and in the third stage, hydronephrosis or renal inactivity was added. Later, stage 0 and stage IV were added. The standard was explained. At the FIGO meeting held in Santiago (Chile) in 2003, the phase I standard was revised. The revised clinical stage standard for cervical cancer is the current international standard for staging. The content is as follows:
Stage 0: carcinoma in situ, intraepithelial neoplasia (this case is not included in any treatment statistics).
Stage I: The lesion is limited to the cervix (whether the palace is affected or not).
Stage Ia: Invasive cancer identified only under the microscope, lesions visible to the naked eye, even superficial infiltration, is stage Ib; interstitial infiltration depth <5mm, width <7mm (infiltration depth from tumor site epithelium or gland) The basement membrane is <5 mm down, and the infiltration of the vein or lymphatic zone does not change the stage.
Stage Ia1: interstitial infiltration depth <3mm, width <7mm.
Stage Ia2: The interstitial infiltration depth is 3 to 5 mm and the width is <7 mm.
Stage Ib: Clinical examination of lesions with limited cervical or preclinical lesions greater than stage Ia.
Stage Ib1: clinically visible lesions <4 cm in diameter.
Stage Ib2: clinically visible lesions > 4 cm in diameter.
Stage II: The lesion is beyond the cervix, but not to the pelvic wall. The vaginal infiltration does not reach the lower third of the vagina.
Stage IIa: no obvious parametrial infiltration.
Stage IIb: There is obvious parametrial infiltration.
Stage III: The lesion infiltrates into the pelvic wall. There is no gap between the tumor and the pelvic wall during rectal examination; the cancer involves the lower third of the vagina; there is no other reason for hydronephrosis or no function of the kidney.
Stage IIIa: The lesion did not reach the pelvic wall, but it involved the lower third of the vagina.
Stage IIIb: The lesion has reached the pelvic wall or has hydronephrosis or no function of the kidney.
Stage IV: The lesion has exceeded the true pelvis or clinically infiltrated bladder or rectal mucosa.
Stage IVa: The lesion spreads to adjacent organs.
Stage IVb: The lesion is transferred to a distant organ.
(3) Notes on staging:
Stage 10 includes atypical cells in the entire epithelium, but no interstitial infiltrates.
The 2Ia (Ia1 and Ia2) phase diagnosis must be determined based on observations under the microscope.
The diagnosis of stage 3III should be infiltration of the paraventricular wall, no gap between the tumor and the pelvic wall, and the thickening of the nodular shape can be determined.
4 Even if it is determined to be stage I or II according to other tests, if there is a ureteral stenosis and hydronephrosis or no kidney function, it should be classified as stage III.
5 Bladder edema can not be classified as stage IV, cysts and sulcus are seen in cystoscopy, and when the bulge or rectum can be confirmed by vaginal or rectal examination, the bulge or sulcus and tumor fixation should be considered as submucosal invasion. When the bladder irrigation fluid has malignant cells, it should be confirmed by pathological examination of the living tissue in the bladder wall.
Prevention
Cervical sarcoma prevention
Due to the high malignancy and non-specific clinical manifestations of cervical sarcoma, the cause should be prevented. Regular examinations should be carried out for women, especially those with high incidence, in order to achieve early diagnosis, early treatment and follow-up work.
Complication
Cervical sarcoma complications Complications, urinary tract infections
The occurrence of cervical sarcoma as a malignant tumor is mainly related to the site of tumor invasion. Local metastasis causes adhesion of surrounding tissues, resulting in vaginal bleeding, lower abdomen or pelvic pain, abnormal secretion of vaginal discharge, and tissue excretion. Transfer to the bladder urinary system, causing hematuria, urinary tract infection, and even leading to abnormal renal function, distant metastasis, can cause liver metastases, causing liver function damage, ascites; late bloody ascites, and related distant metastatic signs and symptoms , the appearance of dyscrasia.
Symptom
Symptoms of cervical sarcoma Common symptoms Increased vaginal discharge Increased cervix enlargement urgency and re-congestion Vaginal irregular bleeding purulent secretion abnormal uterine bleeding urgency acute abdominal pain frequent urination
Symptom
(1) abnormal vaginal bleeding: the main performance, premenopausal patients with more menstruation, menstrual extension, irregular vaginal bleeding; postmenopausal patients with postmenopausal vaginal bleeding, the incidence rate of 45.1% to 70%.
(2) Abdominal pain: It is also one of the common symptoms. Because sarcoma develops rapidly and grows rapidly, patients often have abdominal distention and pain.
(3) increased vaginal secretions: can be serous, bloody, if combined infection, may be purulent or stench.
(4) compression symptoms: When the mass enlarges the bladder or rectum, it can be expressed as frequent urination, urgency and urinary retention, difficulty in stool and heavy in the rush.
(5) Other symptoms: such as metastatic symptoms.
2. Signs
(1) The cervix is obviously enlarged, and it can be nodular and soft.
(2) If the sarcoma is removed from the uterine cavity and the cervix, the examination may reveal a purple-red mass, surface congestion, and may have purulent secretions when infected.
Examine
Examination of cervical sarcoma
Secretory examination, tumor marker examination.
1. Color pulse Doppler ultrasonography: Cervical sarcoma can be characterized by uterine artery filling, and new blood vessels are formed around the tumor and in the central region, diastolic blood flow occurs, and uterine artery blood flow increases, on Doppler ultrasound. It exhibits high diastolic blood flow and low impedance, and its average RI is significantly lower than that of fibroids.
2. Colposcopy, hysteroscopy.
3. Diagnostic curettage: Diagnosis is a method for early diagnosis of uterine sarcoma, but it should be noted that patients with positive tissue biopsy can be diagnosed. The negative results can not rule out the diagnosis. Diagnostic curettage has little diagnostic value for uterine leiomyosarcoma, positive rate Low, reported in the literature is 10% ~ 8.2%, the diagnosis of scraping in the diagnosis of endometrial stromal sarcoma and malignant mullerian mixed tumors have a high positive rate, the positive rate reported in the literature is 100% and 66.7%, respectively, due to These two sarcoma lesions are located in the endometrial stroma. Because malignant mesodermal mixed tumors have multiple components of cancer and sarcoma, and due to the limitations of diagnosis and microscopy, sometimes it is difficult to diagnose before surgery, often misdiagnosed as cervical gland. Cancer, so suspicious cases can be repeated.
Diagnosis
Diagnosis and diagnosis of cervical sarcoma
In addition to medical history and physical signs, the diagnosis mainly depends on the naked eye of the operation and depends on the frozen section examination. If the mass of the naked eye is fish-like, the tissue is brittle, accompanied by hemorrhagic necrosis, a frozen section should be sent to confirm the diagnosis.
Differential diagnosis
1. The clinical manifestations of cervical cancer and cervical sarcoma are similar to those of cervical cancer. Cervical rupture and necrosis are easy to be confused with advanced ulcerated cervical cancer. It needs to be diagnosed by cervical biopsy and should be distinguished from cervical adenocarcinoma.
2. When the grape-like appearance of cervical polyps and grape sarcoma is not obvious, it is easy to be mistaken for cervical polyps. Cervical polyps are mostly small, reddish, with pedicles, and need to be diagnosed by cervical biopsy.
3. Cervical malignant melanoma, clinical symptoms are similar, the appearance of non-pigmented melanoma is not easy to distinguish from cervical sarcoma, melanoma is characterized by rapid growth, extensive metastasis, cervix is uneven, prominent plaque or ulcer lumps, and finally A biopsy is required to differentiate from cervical cancer or cervical sarcoma.
It also needs to be differentiated from cervical fibroids, endometrial cancer, and other gynecological diseases that cause vaginal bleeding or uterine enlargement.
