Endometrial cancer

Introduction to endometrial cancer Endometrial cancer (carcinoma of endometrium), also known as endometrial cancer, refers to the cancer that occurs in the endometrium, the vast majority of which are adenocarcinomas. It is one of the most common malignant tumors in the female genital tract. The high incidence age is 58-61 years old, accounting for 7% of the total number of female cancers, accounting for 20-30% of female genital malignant tumors. In recent years, the incidence rate has increased, and the cervix Compared with cancer, it has become close to or even exceeded. basic knowledge The proportion of illness: 0.03% Susceptible people: women Mode of infection: non-infectious Complications: ovarian tumor dysfunctional uterine bleeding

Endometrial cancer

Anovulatory dysfunctional uterine bleeding (20%):

Such as functional uterine bleeding with anovulatory or luteal dysfunction, long-term menstrual disorders, so that the endometrium continues to be stimulated by estrogen, no progesterone resistance or progesterone deficiency, endometrial lack of periodic changes, and long-term In a proliferative state.

Infertility (12%):

Infertility, especially infertility caused by ovulation without ovulation, the risk of endometrial cancer is significantly increased. In patients with endometrial cancer, about 15% to 20% of patients have a history of infertility, these patients do not ovulate or Less ovulation, resulting in lack or deficiency of progesterone, so that the endometrium is stimulated by estrogen continuously, the placenta produces estrogen and progesterone during pregnancy, causing the corresponding changes in pregnancy of the endometrium; lactation, due to the hypothalamus and pituitary The role of the ovarian function is temporarily in a state of inhibition, so that the endometrium is free from estrogen stimulation, infertility, especially due to infertility caused by anovulation, so that the endometrium is proliferated for a long time.

Obesity (16%):

Excessive obesity can lead to endometrial cancer, and for female friends, excess fat will increase the storage of estrogen and increase the conversion of androstenedione to estrone in plasma. This free increase in active estrone may be a carcinogen of endometrial cancer, or a cancer-promoting factor.

Late menopause (8%):

According to reports, the risk of endometrial cancer in menopausal age >52 years is 1.5 to 2.5 times that of menopause before the age of 45. Late menopause does not ovulate in the next few years, but prolongs the estrogen action time. Late menarche (late menarche) is a protective effect on endometrial cancer, especially for premenopausal women, menarche can reduce the risk of endometrial cancer by 50%, and menarche delay can reduce the stimulation of endometrial persistence of estrogen. effect.

Polycystic ovary syndrome (15%):

About 19% to 25% of patients with endometrial cancer under 40 years of age have polycystic ovary syndrome. Patients with polycystic ovary syndrome have long ovarian follicles but cannot mature to achieve ovulation, making the uterus The membrane is under continuous estrogen stimulation, lack of progesterone regulation and periodic endometrial shedding, leading to hyperplasia of the intima. Patients with polycystic ovary syndrome also have higher levels of androgen, which is about 3 to 4 higher than the average person. Times, and androgen can be converted to estrone, leading to intimal hyperplasia or proliferative disease, which can occur dysplasia or even endometrial cancer, girls with polycystic ovary syndrome, the possibility of endometrial cancer is normal 4 times of menstruation girls of the same age.

Ovarian tumors (13%):

Estrogen-producing ovarian tumors, such as granulosa cell tumors and follicular cell tumors, approximately 25% of pure vesicular cell tumors with endometrial cancer.

Endometrial cancer prevention

Prevention of endometrial cancer is primarily directed to risk factors associated with the disease:

1. Carry out anti-cancer publicity screening, strengthen health medical knowledge, educate women with abnormal menopause bleeding, vaginal discharge, combined with obesity, high blood pressure or diabetes, and be vigilant, timely medical treatment and early diagnosis.

2, treatment of precancerous medical history, the growth of the endometrium is too long, especially in patients with dysplasia, should be actively treated, closely followed, poor efficacy, timely surgical removal of the uterus, if the patient has children, or Those who have no fertility hope or older can directly remove the uterus without conservative treatment.

3, when there are benign gynecological diseases, it is best not to use radiotherapy, so as not to induce tumors.

4, strict control of the use of estrogen indications, menopausal women using estrogen for replacement therapy, should be used under the guidance of a doctor, while the application of progesterone to regularly transform the endometrium.

5, for people with high risk factors should be closely followed or monitored: endometrial cancer patients should be closely followed up after treatment, to seek early detection of recurrence, about 75% to 95% of recurrence is within 2 to 3 years after surgery Routine follow-up should include detailed medical history (including any new symptoms), pelvic examination, vaginal cytology smear, X-ray chest radiograph, serum CA125 test and blood routine, blood chemistry test, etc., if necessary, CT and MRI Generally, every 3 months after 2 to 3 years of follow-up, 3 months after every 3 months, 5 years after 1 year, 95% of recurrence cases can be clinically examined, vaginal cytology smear examination And serum CA125 examination found.

Endometrial cancer complications Complications ovarian tumor dysfunctional uterine bleeding

Often combined with polycystic ovary syndrome, functional uterine bleeding, uterine fibroids and ovarian tumors that secrete estrogen, etc., combined with severe infection, acute abdomen.

Endometrial cancer symptoms Common symptoms Menstrual cycle changes lower abdominal pain vaginal discharge is black watery menstrual volume more vaginal bleeding lower abdominal pain endometrial proliferative lesions lumbosacral pain uterine empyema cachexia

Symptom

Very early no obvious symptoms, vaginal bleeding, vaginal discharge, pain and so on.

(1) vaginal bleeding: mainly manifested as vaginal bleeding after menopause, the amount is generally not much, not yet menopause can be manifested as increased menstruation, menstrual prolongation or menstrual disorders.

(2) vaginal discharge: mostly bloody liquid or serous secretions, combined with infection, there is pus and bloody discharge, malodor, due to abnormal vaginal discharge patients accounted for about 25%.

(3) lower abdominal pain and other: if the cancer involves the internal cervix, it can cause uterine empyema, abdominal pain and sputum pain, late infiltration of surrounding tissue or compression nerve can cause lower abdomen and lumbosacral pain, late There are symptoms such as anemia, weight loss and cachexia.

2. Signs

Early endometrial cancer gynecological examination can be found without abnormalities, the uterus can be significantly enlarged in the late stage, there may be obvious tenderness when combined with uterine empyema, occasional cancer tissue prolapse in the cervical canal, easy to hemorrhage, and the surrounding tissue of the tumor infiltrating At the time, the uterus is fixed or paralyzed and irregular nodules.

According to the above symptoms, and then carry out auxiliary examination, whether it is more endometrial cancer can be diagnosed, so women should always pay attention to their changes in menstruation, pay attention to the vaginal discharge traits; once symptoms appear, go to the hospital early.

Endometrial cancer examination

Cytological examination

The positive rate of cervical smears, posterior vaginal smear and cervical smear for cytological examination to diagnose endometrial cancer is not high, 50%, 65% and 75%, respectively, resulting in cervical stenosis in elderly women Endometrial exfoliated cells are more difficult to exclude the cervix, and easy to dissolve and degeneration. In recent years, there have been new advances in cytological methods, such as endometrial irrigation, nylon mesh intima scraping and uterine cavity suction smear method, etc. The rate can reach 90%, but the operation is more complicated, and the positive only has the effect of screening and examination, and can not be used as a basis for diagnosis. Therefore, the application value of clinical examination is limited.

2. Histopathological examination

Endometrial histopathology is the basis for the diagnosis of endometrial cancer. It is also the only way to understand the pathological type and the degree of cell differentiation. The use of tissue specimens is an important issue affecting the accuracy of histopathological examination. Commonly used endometrial specimens are taken: 1 endometrial biopsy; 2 cervical canal scraping; 3 segmental scraping, with segmental scraping as the most common and valuable method, after disinfection and palatation, first use the small cervical curette to scrape the cervical canal to take the cervical canal tissue The probe is used to detect the depth of the uterine cavity. Finally, the uterine cavity is fully scraped. All the tissues of the cervical canal and the uterine cavity should be fixed and then sent to histopathological examination. The advantage of segmental diagnosis is that the uterus can be identified. Endometrial cancer and cervical ductal adenocarcinoma can also determine whether endometrial cancer affects the cervical canal, assist clinical stage (I, II), and provide a basis for the development of treatment plans, clinicians should pay attention to strict follow the surgical procedures, Avoid leakage and mixing in the cervical canal and uterine cavity scraping. In assisting staging, it is difficult to diagnose endometrial cancer in the diagnosis of cervical cancer. Obstetrics and Gynecologist The level and experience of the clinical examination will affect the accuracy of the segmental diagnosis to a certain extent. Some domestic scholars have reported that 69 cases of endometrial cancer segmental diagnostic pathology specimens are compared with the pathology of postoperative hysterectomy specimens, and the diagnosis of cervical sinus is false positive. The rate was 34.5%, the false negative rate was 12.68% (total error rate was 47.2%). For patients with obvious lesions in the uterine cavity, uterine biopsy (sucking) and cervical canal scraping were the easiest, and the clinic was feasible.

Film degree exam

Hysteroscopy

At present, hysteroscopy has been widely used in the diagnosis of endometrial lesions. Domestic fiberoptic hysteroscopy is the most widely used. About 20% of patients with post-menopausal vaginal bleeding are endometrial cancer, which can be directly observed by hysteroscopy. Cervical canal and uterine cavity, finding lesions and taking biopsy accurately can improve the rate of biopsy diagnosis, avoid routine diagnosis and diagnosis, and provide information on the extent of the lesion, whether the cervical canal is involved or not, and assist in the correct clinical staging before surgery. Hysteroscopy should be injected into the uterus, which may flow into the pelvic cavity through the fallopian tube, causing the spread of cancer cells and affecting the prognosis. This should be noted.

2. Cystoscopy, proctoscopy

It is important to have any tumor invasion, but it should be confirmed by biopsy to confirm the diagnosis of bladder or rectum.

3. Lymphangiography

Computed tomography (CT) and magnetic resonance imaging (MRI) lymphatic metastasis is the main dissemination pathway for endometrial cancer. The literature reports that the lymph node metastasis rate of stage I endometrial cancer is 10.6%, and that of stage II is 36.5%. Preoperative examination predicts the presence or absence of lymph node metastasis, but the operation is more complicated, the puncture is difficult, and it is difficult to promote and apply clinically. Since the application of FIG0 new surgery-pathological staging in 1989, the lymph node is determined by surgical pathological examination, which can accurately determine Prognosis, the range of lymphography has been smaller than before. CT, MRI, etc. are mainly used to understand the uterine cavity, cervical lesions, depth of myometrial invasion, lymph node growth (2cm or more), etc., due to its high cost, not yet routine For examination and use, MRI is currently considered to provide mesenteric infiltration of the myometrium and the presence or absence of metastasis of the retroperitoneal lymph nodes, which can be used to guide treatment (FIGO, 2003).

4.B type ultrasound examination

In recent years, B-mode ultrasonography has developed rapidly, especially transvaginal ultrasound examination (TVB), which has been used in the diagnosis of endometrial lesions. Vaginal B-ultrasound examination Can understand the size of the uterus, the shape of the uterus, the presence or absence of sputum in the uterine cavity, the thickness of the endometrium, the presence or absence of infiltration and depth of the muscle layer (Sahakian, 1991), for clinical diagnosis and pathological sampling (uterine biopsy, or diagnostic scraping) Provide reference, after the uterine bleeding in women after the uterus, according to the results of transvaginal B-ultrasound examination to choose further diagnosis.

According to domestic and foreign scholars, the average thickness of atrophic endometrium in postmenopausal women is 3.4mm ± 1.2mm, and endometrial cancer is 18.2mm ± 6.2mm, and it is considered that patients with postmenopausal bleeding undergo endoscopic examination by transvaginal B-ultrasound. If the thickness is less than 5mm, no diagnostic curettage can be performed. If the B-ultrasound is used to determine the local small sputum, a hysteroscopic biopsy can be used. If there are a large number of neoplasms in the uterine cavity, the endometrial boundary is unclear, incomplete, or muscular. For obvious thinning or deformation, simple endometrial biopsy is appropriate.

A large number of clinical studies in the past 10 years have shown that the idea that endometrial cancer is simple and easy to treat is wrong. If compared with staging, endometrial cancer is as difficult to treat as ovarian cancer, and gynecologic oncologist is also needed. Rigorous and standardized treatment, high-risk groups such as Lynch II syndrome patients with hysteroscopy or biopsy is helpful for early diagnosis, there is no effective screening method, Karlsson et al (1995) reported 1168 women with transvaginal B type Ultrasound examination compared with the results of diagnosis and endometrial biopsy, endometrial thickness with a thickness of 5mm as a threshold, its vaginal prediction is 96%, positive predictive value of 87%, sensitivity of 100%, and the advantages of non-invasive, simple, has widely used.

Diagnosis and diagnosis of endometrial cancer

Endometrial cancer diagnosis steps

1. Pay attention to the factors related to the pathogenesis of endometrial cancer. Collection of history of family cancer, long history of endometrial hyperplasia, persistent ovulation in young women (infertility and polycystic ovary syndrome), ovarian stroma Tumors (granulosa cell carcinoma and ovarian granulosa cell tumor), topical estrogen or long-term hormone replacement therapy, and those with long-term application of tamoxifen after breast cancer surgery should be highly alert to the presence or absence of endometrial cancer. Check, should be comprehensively collected for medical history, such as diabetes, high blood pressure and other medical history.

2. According to the medical history, clinical examination, pathological examination and various auxiliary examination results to determine the diagnosis and clinical stage.

3. According to the results of pathological examination, combined with other auxiliary examinations to make preoperative clinical staging diagnosis (according to FIGO standard), pathological diagnosis of cervical sputum scraping (diagnosis).

Differential diagnosis

First, postmenopausal bleeding

First of all, we should be alert to whether it is a malignant tumor. Although the proportion of malignant tumors in postmenopausal bleeding has decreased greatly with the progress of the times, such as Knitis reported that the malignant diseases in postmenopausal vaginal bleeding accounted for 60-80% in the 1940s. ~40%, in the 1980s, fell to 6-7%, domestic Su Yingkuan and other reports, in the 1960s, malignant diseases accounted for 76.2%, endometrial cancer accounted for 12.9% of malignant diseases. In the late 1980s, malignant diseases accounted for 22.7%, while the intima Cancer accounted for 45.5% of malignant cases, cervical cancer accounted for 43.6%, Zheng Ying et al reported that malignant diseases accounted for 24.9% (benignity accounted for 73.3%), ranking second in postmenopausal bleeding, from menopause years, menopause for 5 years accounted for 14 %, menopause 5 to 15 years accounted for 68.3%, it can be seen that in the progress of malignant tumors, endometrial cancer has an increasing trend, Huang Hefeng reported even more than cervical cancer, postmenopausal bleeding and cancer is not necessarily In proportion, the amount of bleeding may be small, the number of bleeding is not much, and the cancer lesion may have been more obvious, so gynecological examination should be done carefully to find out whether there are abnormalities in the vagina, cervix, uterus, and attachments, as there may be two Above illness There are simultaneous changes, such as the presence of senile vaginitis and endometrial cancer, so you must not neglect further examination because a lesion has been found. In addition to cytological examination, segmental diagnosis is an indispensable examination step because Diagnostic curettage of endometrial cancer diagnosis rate of up to 95%, domestic Cheng Weiya reported that 448 cases of postmenopausal uterine bleeding in the 10 years of diagnosis of the endometrium, including endometrial cancer accounted for 11.4% (51 cases), Luo Qidong and other reports It is 8.7%, and the literature reports that it ranges from 1.7 to 46.6%, generally below 15%.

Second, dysfunctional uterine bleeding

Menopausal disorders often occur in menopause, especially those with frequent uterine bleeding. Regardless of whether the size of the uterus is normal or not, it is necessary to first diagnose and cure the disease. The endometrial cancer may be born in the growing period or even in the early stage of fertility. Shandong Province The hospital has not been a patient with endometrial cancer, only 26 years old, more than 3 years after menstruation, according to functional uterine bleeding treatment is invalid, the final diagnosis confirmed endometrial cancer, so young women uterine irregular bleeding treatment 2 ~ Those who have been ineffective for 3 months should also be diagnosed and diagnosed.

Third, endometrial dysplasia

More common in women of childbearing age, endometrial atypical hyperplasia is severe in tissue morphology, sometimes difficult to distinguish with well-differentiated adenocarcinoma, usually endometrial atypical hyperplasia, pathologically can be characterized as focal, squamous normal Epithelial, cell differentiation is better, or squamous epithelial metaplasia, pigmentation, lotus flower color, no necrotic infiltration, and the endometrial adenocarcinoma has large nuclear cancer cells, increased chromatin, deep staining, and poor cell differentiation. More mitotic division, less cytoplasm, frequent necrosis and infiltration, and differentiation with well-differentiated early endometrial adenocarcinoma:

1 dysplasia often has a complete surface epithelium, while adenocarcinoma does not, so if you see a more complete or flattened surface epithelium can rule out endometrial adenocarcinoma, in addition, endometrial adenocarcinoma often has necrotic bleeding;

2 drug treatment response is different, atypical hyperplasia, the dose is small, that is, the effect is slow, long-lasting, once the drug is discontinued, it may recur quickly;

3 Age: Younger people consider dysplasia more, and challengers consider the possibility of endometrial adenocarcinoma.

Fourth, uterine submucosal osteoma or endometrial polyps

More manifestations of menorrhagia or prolonged menstruation, or bleeding may be accompanied by vaginal discharge or bloody secretions, clinical manifestations and endometrial cancer are very similar, but through the uterine cavity, segmental curettage, uterine lipiodol angiography, or uterine cavity A microscopic examination can make a differential diagnosis.

Fifth, cervical cancer

Like endometrial cancer, it also shows irregular vaginal bleeding and increased drainage. For example, if the pathological examination is squamous cell carcinoma, it is considered to be derived from the cervix. If it is an adenocarcinoma, it will be difficult to identify its source. If it can find mucus glands, then the original It is more likely to be caused by the neck tube. Okudaira et al. pointed out that the positive expression rate of carcinoembryonic antigen (CEA) is high in invasive cervical adenocarcinoma tissues. Therefore, CEA immunostaining is helpful for cervical glands. Identification of cancer and endometrium.

Six, primary fallopian tube cancer

Vaginal drainage, vaginal bleeding and lower abdominal pain, vaginal smears may find cancer cells and similar to endometrial cancer, while fallopian tube cancer endometrial biopsy is negative, parametrial sputum and tumor, different from endometrial cancer, such as A small but palpable patient can be diagnosed by laparoscopy.

Seven, senile endometritis with uterine empyema

Often manifested as vaginal discharge of pus, bloody or pus and bloody discharge, the uterus increased and softened, through B examination and then dilated uterine cancer tissue, only inflammatory infiltrating tissue, uterine empyema often with cervical cancer or uterus Endometrial cancer coexists and must be noted when identifying.

Eight, senile vaginitis

Mainly manifested as bloody vaginal discharge, visible vaginal mucosa thinning, congestion or bleeding, increased secretions, etc., after treatment can be improved, if necessary, can be used for anti-inflammatory treatment before diagnosis of curettage to exclude endometrial cancer .

Nine, uterine submucosal fibroids or endometrial polyps

There are menorrhagia or prolonged symptoms, feasible B-mode ultrasound, hysteroscopy and segmental diagnosis of the diagnosis.

Postmenopausal and perimenopausal vaginal bleeding is the most common symptom of endometrial cancer, so endometrial cancer should be differentiated from various diseases that cause vaginal bleeding. Gynecological examination should exclude vulva, vagina, cervical hemorrhage and infection caused by injury. Bleeding and drainage should pay attention to the size, shape, activity, soft and hard texture of the uterus, whether there is any change in the softness or hardness of the uterine cervix and the parametrial tissue. There should be a careful and comprehensive examination of the attachments without any masses and thickening.

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