Cancer of the uterus symptoms
Mar 04, 2018
Cancer of the uterus is the growth of malignant cells in the uterus. Recently, there has been a steady and steady increase in the incidence of cancer of the body of the uterus and ranks second or third among all malignant neoplasms in women, second only to breast and ovarian cancer. Despite the current opinion about the slow growth and spread of cancer of the uterus body, the lethality from this disease remains very significant.
The term uterine cancer is often used in place of the term "endometrial cancer", since the malignant uterine formations most often develop in the endometrium - the tissues lining the uterus. Malignant tumors can also develop in the muscular wall of the uterus( sarcoma of the uterus), although this is relatively rare.
Uterine cancer is the most common cancer of the pelvic female genitalia;it most often affects women in the postmenopausal period, between the ages of 50 and 70 years. Younger women, whose ovaries produce estrogen, but ovulation does not occur, and women with polycystic ovary are also prone to developing uterine cancer. Uterine cancer usually develops and spreads slowly;he is cured at early detection and treatment.
• Cause of cancer of the uterus is unknown.
• Obesity, high blood pressure, diabetes, endometrial hyperplasia, intrauterine polyps, polycystic ovary and late menopause with severe bleeding are associated with an increased risk of uterine cancer.
• Long-term use of estrogen replacement therapy( without gestagen) by women in the post-menopausal period is associated with a higher likelihood of developing uterine cancer.
• Tamoxifen, a drug used in the treatment of breast cancer, increases the risk of uterine cancer.
• Uterine cancer is more common in women who have little or no children;it is less common in those who have used oral contraceptives.
An increase in the detection rate of uterine body cancer is found mainly in countries with a high economic standard of living.
The increase in the incidence of cancer of the body of the uterus is associated with a rise in the material standard of living, a change in the principles of nutrition( increased use of meat and animal fats), widespread uncontrolled use of contraceptives and hormonal medications. Others see the reason for the increase in the overall life expectancy of women.
High incidence rate is observed in risk groups, which include women with concomitant endocrine-metabolic diseases, ovarian dysfunction.
In women of young age, the risk of developing the cancer of the uterus is associated with the previous pathology of the genitals: uterine myoma in 1.6-8%;polyposis of the endometrium - 5.3-25%;dysfunction on the background of polycystic ovary - 25%;various forms of endometrial hyperplasia - 81.3%.
• Bleeding from the vagina after menopause.
• Abundant constants or unusual( watery or with blood) discharge from the vagina.
• Pain in the lower abdomen and weight loss with severe development of the disease.
• The main method of treatment is complete hysterectomy( surgical removal of the uterus).Fallopian tubes, ovaries, the upper vagina and neighboring lymph nodes can also be removed depending on the extent of the spread of cancer.
• Cancer at the earliest stage( non-invasive cancer with normal cells) can be cured with a single hysterectomy, without removing adjacent organs.
• If cancer is thought to have advanced further than the earliest stage, radiation therapy( external and internal irradiation) can be used in addition to surgery;with internal irradiation, small radioactive balls are injected into the tumor or placed next to it for 48-72 hours per session.
• Progestogen can be used to treat uterine cancer;Chemotherapy is ineffective in most cases.
Methods of treatment of uterine body cancer over the past 2 decades have undergone significant changes. This circumstance is largely due to the evolution of views on the biological properties and radiosensitivity of the malignant neoplasms of the uterus body, deepening the understanding of the pathogenesis and the role of the pituitary-hypothalamic system in the development and clinical manifestation of this disease, as well as increasing knowledge of the nature of lymphogenous metastasis of endometrial tumors. It is generally accepted that surgical and combined therapies are leading.
The most significant achievement in the field of surgical treatment of patients with uterine body cancer is the substantiation of differentiated indications for the use of three types of surgical intervention. The use of advanced hysterectomy allowed to improve the 5-year results of treatment of patients with uterine cancer by 12%.Thus, an important role in improving the effectiveness of treatment belongs to the actual surgical component.
The opinions of the clinicians are unanimous in that the priority remains for the combined method of treatment, which provides rather high rates of 5-year survival of patients.
The widespread use of radiation treatment is an objective factor that requires the improvement of existing and the development of new methods of radiation exposure.
Radiation therapy as a component of combined treatment of patients with uterine body cancer. The literature data on the role of the radial component in the combined and complex treatment of patients with uterine body cancer are highly controversial. A number of researchers use preoperative intracavitary gamma-therapy.
In pre-operative irradiation, the following results are expected:
1. To kill or reduce the viability of cancer cells, to ensure the operation under ablast conditions;
2. to reduce the size of the tumor, to provide the possibility of surgical treatment in cases where the local spread of cancer does not allow the operation at the first stage of treatment.
In some studies, the range of indications for preoperative intra-cavity irradiation is limited to observations in which there is an increase in the uterus or a decrease in the histological differentiation of the tumor, as well as in the II and III stages of the disease. In a number of foreign clinics where preoperative irradiation is used, its proponents point to the following advantages:
1. Preference from radiobiological positions, i.e., the tumor undergoes intact vascularization.
2. Decrease in the transplantability of tumor cells, and, consequently, the danger of their intraoperative dissemination.
3. The risk of development of radiation complications from adjacent organs is decreasing.
There has been a slight but definite improvement in treatment outcomes compared with uterine extirpation without prior gamma therapy. However, in a number of clinics this conclusion was not confirmed. And rightly noted that the radiation exposure is directed only at the primary tumor, which will still be removed. The question regarding lymph nodes remains in this case open. However, it is their removal or irradiation that plays an important role in the treatment of uterine body cancer.
A number of researchers believe that with pre-operative irradiation:
1. the possibilities of individualizing therapeutic tactics are reduced;
2. "morphology" of the tumor is smeared, which makes it difficult to determine the degree of histological differentiation and the depth of infestation;
3. The operation is performed in the worst conditions( in irradiated tissues), which leads to an increase in the frequency of postoperative complications.
In the opinion of other authors, preoperative irradiation of endometrial cancer patients causes excessive standardization of the treatment program, often leading to its aggressiveness, denoted in the English literature as "overtreatment".
There are also known studies in the preoperative period of the course of remote radiation therapy in the conventional fractionation mode with total doses of 30-40 Gy per point B. The main goal of such an impact is the reduction in the possibility of cancer cells spread by irradiating the regional lymphatic apparatus. Some authors consider it necessary to conduct a course of combined radiotherapy before surgical intervention.
The ranges used for preoperative irradiation of doses vary from 30 to 60 Gy with prolonged doses and 20-30 Gy with intensively concentrated courses.
However, in patients after the course of radiation therapy, subsequent histological examination of the removed uterus revealed the remains of tumor cells. For example, cancer cells were found in 67% of patients operated after a preoperative course of radiotherapy, and in highly differentiated adenocarcinomas they were detected in 46%, moderately differentiated - in 80% and in low-grade - in 89%.Many studies indicate that tumor remains were found in 47% of patients operated after the end of radiation therapy.
Thus, the authors' opinions about the possible positive role of preoperative irradiation seem ambiguous. All of the above confirms the need to further improve the radial component of the combined treatment of uterine body cancer.
With combined treatment of patients with uterine body cancer, postoperative irradiation is often used.
For postoperative irradiation seek:
1. To cause the death of cancer cells that have remained undelete during the operation, preventing the development of local relapse;
2. in case of deliberately non-radical intervention, provide suppression of growth of the unremoved part of the tumor;
3. To achieve the death of cancer cells in areas of regional metastasis.
In the case of metastatic lesions of regional lymph nodes, the use of postoperative irradiation is associated with the impossibility of absolutely radical performance of lymphadenectomy and taking into account intraoperative dissemination of cancer cells acquiring high potencies for growth after surgery. The appointment of postoperative remote irradiation in this situation is considered mandatory. However, the possibility of curing regional metastases using existing methods of radiation therapy is questionable. Given, the defeat of regional lymph nodes reduces the five-year survival rate of patients to 20-30%.
Evaluation of the role of "preventive" remote radiation therapy in preventing regional recurrence of cancer is also a difficult task. A picture of the uncertainty of our knowledge about the possible positive role of preventive irradiation of obviously unaffected lymph nodes is emerging. Apparently, despite the ingrained traditions of combined treatment of patients with uterine body cancer, indications for postoperative remote irradiation need a thorough reassessment. This is justified, among other things, by the fact that obesity of II-III degrees often observed in patients with cancer of the body of the uterus creates technological difficulties in the conduct of remote radiation therapy.
Despite the numerous works related to various aspects of combined treatment for patients with uterine cancer, we feel that insufficient attention has been paid to the rationale for the role of radiotherapy. Further prospective studies are needed in this direction. At the same time, it should be noted that when planning such research, complex deontological problems arise. For example, the planned refusal to conduct postoperative remote irradiation in patients with stage III disease, where the risk of recurrence and metastasis is very high.
One of the ways to evaluate the role of postoperative radiotherapy in combined and complex treatment is to compare the effectiveness of treatment in retrospective material depending on a number of prognostic factors characterizing the characteristics of the organism and the tumor. However, this path is not free from shortcomings, since it is difficult to form comparable groups of patients. In addition, in some clinical situations, due to strict regulation of postoperative radiation, for example, with metastatic lesions of regional lymph nodes, it is almost impossible to form a control group.
In real clinical practice, the question of the appointment of postoperative radiotherapy is solved precisely on the basis of an evaluation of a set of prognostic criteria. The most important of them, characterizing the features of local-regional spread of the tumor, include the histological structure( degree of differentiation), the depth of infestation in the myometrium, the stage of the disease, involvement of regional lymph nodes in the process, and cytological studies of abdominal washings. The consideration of prognostic factors allows us to logically justify the need for postoperative radiotherapy. However, we must state that the traditional application of more aggressive treatment programs in patients with a complex of unfavorable prognostic indicators does not always lead to success of treatment: the influence of signs characterizing the characteristics of the tumor, as it negates the effect of treatment factors. The refusal to conduct postoperative remote irradiation in patients with favorable prognostic indicators is possible without sacrificing survival.
As can be seen from the literature, the question of the role and indications for postoperative irradiation remains controversial. Correct analysis of the values of postoperative radiation therapy and specification of indications for its implementation is possible only as a result of further prospective studies, as well as in the multivariate analysis of the retrospective material, taking into account the complex and ambiguous influence of various prognostic factors.
Radiation therapy as an independent method for treating patients with uterine body cancer. Radiation treatment is used as a radical method of treating patients with localized uterine body cancer and otosematicheskimi contraindications to surgery, as well as in inoperable tumors in prevalence. However, it should be recognized that the results of radiation treatment are much inferior to the combined indicators.
The results of radical radiation therapy are very ambiguous, constituting in the patients with cancer of the body of the uterus of the first clinical stage by FIGO 57.1- 85.7%;II - 53.1-76.5%;III - 37.5-44.5%;IV - 24.9%.
In connection with the rather low results of treatment, it is of undoubted interest to consider the structure of failure of radiation therapy. To this end, we analyzed summary data on 880 patients with uterine cancer.
Relapses in the irradiation zone developed in 23.8% of patients, distant metastases - in 15.2%.Analysis of Table 5 allows to come to the conclusion that the main specific gravity in the structure of failures is occupied by relapses in the area of the primary tumor and zones of regional metastasis. This circumstance indicates that one of the real ways to improve the effectiveness of radiation treatment of uterine body cancer is to improve intracavitary methods of irradiation on the basis of widespread use of modern radiotherapy equipment.
Intracavitary radiotherapy. The implementation of intracavitary radiation is associated with certain difficulties. This is due to the relatively low radiosensitivity of the tumor and the need to use high doses of ionizing radiation in connection with this.
A similar problem is complicated by the fact that bringing fairly high doses to the primary focus is limited to the tolerance of surrounding healthy tissues or organs.
The value of the dose value is widely discussed in the specialist literature. In a number of works this circumstance was proved with great conviction. In particular, the idea of the ineffectiveness of radiation therapy in case of insufficient dose has already affected in those years when radiation technology did not provide the necessary levels of doses both in the most affected organ and in the parietal regions of the pelvis. The results of treatment depend on the magnitude of the total focal dose. And the most optimal level is a dose of the order of 50-70 Gy, created at the level of serous cover of the uterus. In general, most authors believe that the therapeutic effect is directly dependent on the magnitude of the dose. However, the issue of the required dose loads remains unresolved.
The principal task of intracavitary irradiation is the creation of a uniform dose distribution throughout the entire volume of the affected organ. For this purpose, various options for placing radioactive sources in the uterine cavity were proposed.
The method of linear placement of sources is the oldest and simplest, which has not lost its value even now. The method consists in introducing several linear sources into the uterus cavity to the bottom, placed in special metal or rubber radiophors. The choice of the number of drugs is determined by the length of the uterine cavity, under which the active length of all sources is selected. The implementation of these treatment programs involves 4-5 irradiation sessions lasting 24-48 hours with total doses of 60-80 Gy being applied to the primary tumor. However, this method, as evidenced by numerous publications, does not provide one of the basic principles of intracavitary irradiation - the uniformity of the distribution of radiation energy in a tumor. This explains the rather modest results of the cure using this method. It is believed that in these cases, the required dose is not achieved in the region of the bottom and tube corners of the uterus).The described technique can be used only in patients with normal uterine cavity length and tumor localization in the lower segment or cervical canal.
In order to eliminate the mentioned deficiency, E-and Y-shaped applicators have been proposed. This arrangement of sources creates a fairly uniform dose field in all parts of the uterus. However, their placement in the uterine cavity was not always possible due to the fact that the cavity is often strongly deformed due to the growth of the tumor.
The most successful solution for optimal source placement, which significantly improved the results of 5-year cures, was the "tight filling method" proposed by J. Heyman in 1930.The method consists in that 10-20 special ampoules containing 8 mn Ra are introduced into the uterine cavity, depending on its volume. In order to standardize the exposure conditions, the author suggested introducing the same number of drugs as possible, and to achieve the effect, the filled ampoules with Ra should be inserted into additional filters of different diameters, the number and size of which are dependent on the volume of the uterine cavity. The round shape of the radiation sources and their autonomy in relation to each other provide sufficient mobility and adaptability in general to the shape of the uterine cavity. This technique ensures a homogeneous effect of radiation on the primary tumor. The incidence of 5-year survival was 69.9% compared to 45% in the group of patients treated with linear applicators.
Despite the great advantages of the method of tight filling, in principle it remained a laborious process, since it was necessary to inject each source separately into the uterine cavity. In 1952, the technique developed earlier was substantially modified. Sources specially designed for intra-uterine placement have been proposed. The preparations were in the form of a ball from 3 to 6 mm in diameter with holes in the center. This design simplified the technique of intrauterine placement of sources, since it became possible to collect the necessary number of active drugs in combination with inactive ones on a single strand and conduct them simultaneously into the uterine cavity through a special tube inserted through the cervical canal.
Intracavitary irradiation sessions are conducted once a week and last for 45 hours, during which the focal dose reaches 15-20 Gy. For 4-5 applications, the dose is 80-100 Gy. The effectiveness of such a method of intracavitary irradiation is noted in the works of many authors.
Analysis of published studies aims at the fact that the J. Heyman method allows to obtain the optimal distribution in the primary tumor and provides an increase in the efficiency of radiation therapy by an average of 20-30% compared to the use of linear drugs.
However, radiation therapy using spherical sources is associated with certain difficulties. Among the main of them are issues of dosimetry, which are still far from perfect. In connection with this, so far in many publications, doses given through intracavitary irradiation are indicated in milligram equivalents per hour, rather than in units of absorbed doses. There are technical difficulties in the introduction of sources, proper placement and fixation of drugs relative to the tumor, the likelihood of their displacement during treatment and, as a consequence, the inability to create a dosing field with constant parameters, as well as the complexity of providing a system of reliable protection of personnel at various stages of work.
Currently, one of the main methods of intracavitary gamma therapy is the "afterloading" method using high activity sources based on radionuclides 60 Co;127 Cs;192 lr. The use of special equipment for intracavitary irradiation of the uterine body cancer, which provides automatic supply and extraction of sources, is radically new in radiation therapy. The possibility of directional fixation of radiation sources contributes to the formation of strictly localized dose fields in the primary tumor with constant parameters, which creates real conditions for dosimetric monitoring. In addition, reducing the duration of irradiation sessions, the possibility of adequate analgesia, as well as reducing the radiation hazard for medical personnel are the undeniable advantages of this method.
Studies of recent years reflect the widespread use of sources of high activity in radiation treatment of patients with uterine body cancer. Intracavitary irradiation was carried out using single focal doses of 10 Gy 1 time per week. In the intervals between intracavitary irradiation sessions, mobile or static remote irradiation of regional metastasis routes was performed. The total focal doses from combined radiotherapy amounted to 70-75 Gy at point A and 70-75 Gy at point A, and 40-45 Gy at point B.At the same time, the 3-year survival rate was 80%.
A series of works has appeared, in which promising immediate results of treatment of patients with uterine body cancer have been obtained with the help. It should be emphasized that the domestic experience of using sources of high activity is small, requires the accumulation and generalization of clinical data, and the improvement of methodical techniques. In addition, there are many unresolved issues related to the amount of absorbed dose, the required number of fractions and the time of irradiation.
Of particular interest is the study of dosimetric support for intracavitary gamma therapy using high activity sources. Creating an effective dose field, especially with an enlarged uterine cavity, is quite a challenge. In order to improve the spatial distribution of the dose and taking into account the constructive limitations of the AGAT-B and AGAT-VZ apparatus, VA Titova( 1981-1983), a method of multi-position intracavitary irradiation was developed that allows achieving the necessary increase in the activity of radiation exposure in the upper parts of the uterus. In most patients with cancer of the uterus body, three main positions of the endostat can be realized: a straight line and two lateral ones. Poliposition irradiation, as it seems to us, has certain advantages over the use of a three-channel endostat. Among these advantages is primarily the possibility of simultaneous administration of several sources to the endostat located in a lateral position along the uterine wall. The introduction of one endostat requires a smaller expansion of the cervical canal and therefore less traumatic.
Use for intracavitary treatment of a new domestic apparatus AGAT-VU expands the possibilities of the radiation method, ensures the formation of an effective dose field with practically no physiological limitations. The first experience of clinical use of a universal apparatus in the treatment of 70 patients with uterine cancer is encouraging. However, the numerous unresolved clinical and dosimetric questions, the absence of significant groups of long-tracked patients require further scientific research.
Possibilities, limits and limitations of remote irradiation of patients with uterine body cancer. The necessary component for the implementation of radiotherapy is remote therapy. Taking into account the progress of radiotherapy, the methodology of distance therapy has undergone some changes. Traditional variants provide for irradiation from two counter fields of sizes 15-16x15-20 cm2 with a splitting block or a four-field irradiation technique with single fractions 1.8-2 Gy to total doses of 40-50 Gy.
It is carried out with the help of splitting blocks shielding the area of the bladder and rectum, up to the total absorbed doses in the lateral parts of the pelvis 40-50 Gy. Static irradiation through opposing fields with the formation of a maximum dose in the area of subcutaneous fat has its limitations associated with the impossibility of summing up the necessary absorbed doses, especially in women with severe obesity. The implementation of these programs often leads to the development of radiation complications from adjacent organs of the uterus, especially in elderly patients with reduced tolerance to radiation exposure.
In the past decade in the domestic and foreign practice for the treatment of gynecologic cancer, bremsstrahlung and electron radiation of linear accelerators and betatrons with an energy of 6-45 MeV are widely used. Irradiation is performed in a static mode through 2 opposing fields or with the help of matrix formation fields in strict dependence on the individual topographic features of the irradiated region. At the same time, high-energy radiation, which has a pronounced penetrating power and small dispersion outside the useful beam, is considered preferable in patients with a hypersthenic constitution.
The use of high-energy radiation in the multifraction mode is also considered promising. The method allows to expand clinical indications for remote radiation therapy in patients with locally advanced tumors and a significant violation of fat metabolism, and to reduce the frequency and severity of radiation reactions from adjacent organs due to a uniform dose distribution in the tumor, reducing single and integral absorbed doses in normalorgans and tissues.
One of the most promising ways to increase the effectiveness of radiation therapy for patients with uterine body cancer is the use of mobile methods of remote irradiation, allowing to concentrate the maximum dose at a given depth with a sharp decrease in it in all directions outside the tumor focus.
It should be noted that the issue of the need for remote radiation therapy in patients with uterine cancer remains controversial. Most authors consider it necessary to supplement the intracavitary irradiation with a remote one, justifying this by improving the results of treatment of patients.
In addition, when planning and implementing remote irradiation, it is necessary to take into account the individual characteristics of patients with uterine body cancer( old age, the presence of concomitant endocrine and metabolic pathologies, cardiovascular diseases, and a decrease in tolerance of surrounding tissues and organs).Thus, the methodology of remote irradiation needs careful correction.
Hormonal therapy in radiation treatment of patients with uterine body cancer. Speaking about the effectiveness of combined and radiation treatment of uterine body cancer, it should not be forgotten that this tumor is hormone-dependent. Most specialists therefore consider it expedient to use the term "complex treatment".
Over the past decade, hormone therapy has been used successfully in combination with surgery, radiotherapy, and as an independent method for common forms of the disease.
It has been found that synthetic progestogens cause a decrease in proliferative activity and destruction of the endometrial tumor, and can also inhibit the development of hidden tumor metastases outside the surgical and radiation exposure region.
The experience of clinical observations allows us to treat adjuvant hormone therapy not as a "complementary effect," but as a methodpathogenetic therapy, contributing in a situation of adequate conduct significantly improve the results of surgical and combinedThere is a fairly large number of publications that testify to the effectiveness of using progestogens in the combined treatment of
.In the study, VA Titova and co-authors.(1988) reported the use of hormones in combined radiation therapy in patients with inoperable forms of the tumor. It is important to point out the authors for the radio-modifying effect of progestins, which undoubtedly should serve as an incentive for further research.
The use of adjuvant hormone therapy leads to remission in 30-35% of cases, including using progesterone - 56%;MAP - 35-37% and the defense industry - 18-33%.
Certain successes of hormone therapy for uterine body cancer are due to the use of compounds of an antiestrogen nature, synthesized on the basis of the stilbene molecule( enclomifene, kpomifene citrate, tamoxifen napoxyl), along with progestogens. The clinical efficacy of the combination of tamoxifen and progesterone was predicted by S. Sekiya and H. Tokamizawa( 1976), who showed their synergistic effects on adenocarcinoma cells in vitro. A feature of tamoxifen is the preservation in it, along with anti-estrogenic, and some of the extrogenic properties. The most important is its ability to enhance the synthesis of progesterone receptors and to exert a specific estrogenic effect on certain target tissues of the reproductive system.
The tumor regression effect was observed 5 times more often with highly differentiated tumors than with adenocarcinomas with a reduced degree of maturity. This is due to the presence of a clear relationship between cell differentiation and the content of receptors in the tumor.
It will be added to the site that prolonged use of hormones does not cause significant side effects and even can increase the activity of liver enzymes, leading to better overall health, appetite and weight gain.
As can be seen, the possibility of increasing the effectiveness of treatment of patients with uterine body cancer with the help of hormone therapy is of exceptional interest. At the same time, a small number of such works hinder the elucidation of the role of hormonal effects in complex therapy. This served as an incentive for our research.
Electroacceptor compounds as modifiers of radiation exposure. One of the promising ways to improve the effectiveness of radiation treatment of malignant neoplasms is the use of radio-modifying drugs that selectively increase the sensitivity to irradiation of hypoxic cells.
Experimental data show that the radiosensitivity of the hypoxic fraction of cells is 3 times less than normal oxygenated.
To overcome the radio-resistance of the hypoxic subpopulation of cells, a number of methods and means have been proposed. Among them, the most promising was the use of electron-withdrawing compounds( EAS), which for many years are widely studied in the experiment and clinic. Abroad, I-II phases of clinical trials of EAS were conducted. These studies relate mainly to misonidazole. In the former USSR, in the framework of the All-Union program "Modifier" metronidazole( M3) was most often used.
As a result of the studies it is clearly shown that EAS can be successfully applied in three main directions:
1. as radiosensitizers of hypoxic cells of tumors containing hypoxic cells;
2. as chemosensitizers, which increase the effectiveness of action on tumors of certain chemotherapeutic drugs;
3. as compounds that, without irradiation and without chemotherapy, have cytotoxicity, causing cell death by themselves.
Radiobiological experiments indicate that the sensitizing effect of EAS is directly proportional to the concentration of the drug in the tumor and has a threshold effect, ie, it appears at concentrations not lower than 120-150 μg per 1 g of tumor tissue.
It is noted that uterine cancer often occurs on the basis of postnatal neck rupture, which in turn leads to a reversal of the mucous membrane of the cervical canal and the formation of superficial sores, the so-called erosions of the cervix. These latter can turn into cancer, especially under the influence of prolonged exposure to uterine secretions( whites), so often observed in female diseases. Consequently, the chronic inflammation of the uterus and ovaries plays an important role in the origin of cervical cancer, especially if accompanied by abundant purulent leucorrhoea. It is important and non-observance of hygiene of sexual life and a number of other factors contributing to the emergence of gynecological diseases( abortions).
The disease is dangerous, because the initial signs of it are often escaping from women who are not attentive to their health. Therefore, every woman, especially giving birth, must closely monitor the state of her sexual sphere.
The most frequent and early sign of cervical cancer is spotting from the vagina. These are not those periodic periodic hemorrhoids, which are familiar to every woman, starting and ending on certain dates;it is mostly insignificant, hardly noticeable admixture of blood to the usual vaginal mucus, appearing just outside the menstrual period, after sexual intercourse, douching, lifting of gravity, etc., or in women who no longer have menstruation, in the menopause, sometimes without anyA subtle cause. Cancer of the body of the uterus reveals itself the appearance of persistent, supra-purulent or watery discharge with putrefactive odor, sometimes only seeming causeless, severe bleeding. In many cases, these initial signs elude attention or are not given due importance. There are also forms of uterine cancer, which in the early stages do not give any symptoms at all.
If a woman observes the appearance of one of the listed signs - unusual blood or foul-smelling leucorrhoea, she should immediately consult a gynecologist and find out.- whether they are signs of beginning uterine cancer, remembering that in the early period the cancer of the uterus is cured reliably, and if you lose a favorable time, then the cure becomes very doubtful, and the disease carries with it heavy suffering.
Cancer of the uterus, especially cervical cancer, is easily recognized by gynecological examination with the help of mirrors, and not only by a routine manual examination, in which minor but important for the diagnosis signs can be missed. In the early stages of tumor development, especially if it is invisible during examination, microscopic examination of swabs from vaginal secretions can help in order to detect cancer cells in them.
In unclear cases, error-free recognition can be established by microscopic examination of a small piece of a tumor extracted by a special instrument( biopsy).If you suspect a cancer of the uterus, you have to resort to a test scraping of the uterine cavity for the same purposes. With these simple and painless interventions, it is possible to confidently bet or deny the diagnosis of uterine cancer.
Cervical cancer is an ulcerated surface on the surface that appears on the lower part of the uterus facing the vagina. At the very beginning, the tumor does not cause any unpleasant sensations and can be detected only during medical examination. With an increase in its volume, loose tumor tissue easily tears when straining, straining, or intercourse. This results in insignificant bleeding, staining the usual vaginal discharge and leaving pinkish-red spots on the underwear. This sign is usually considered the first symptom of uterine cancer, but it does not occur in all cases and is not always early.
The tumor left untreated spreads in breadth and depth, comparatively soon( in a few months) passes to neighboring tissues, destroying the cervix and penetrating into the perio-vascular space. The putrefactive disintegration of the tumor and the permanent hemorrhages lead to the appearance of purulent-bloody leucorrhoea, and simultaneously the arising inflammatory process and compression of the surrounding nerves cause pain in the lower abdomen and in the sacrum.
Thus, these signs indicate already developed cancer. Contrary to popular belief, very many of these patients for a long time retain a blossoming appearance, which only emphasizes the insidiousness of this disease and lulls the vigilance of both the patients themselves and their loved ones.
Treatment of uterine cancer is a very grateful task. If 50 years ago, only surgical treatment was possible, at the present time X-rays and radium are widely used in this disease. In no other field of practical oncology, radiotherapy methods are not applied with such brilliant success as in uterine cancer. However, here, as with all other cancers, the main position retains its full force - the earlier treatment is initiated, the better the results can be, the more persistent recoveries are achieved.
• Case history and examination by a gynecologist.
• Diagnosis of uterine cancer requires an endometrial tissue or curettage biopsy to obtain a tissue sample.
• Ultrasonic examination of pelvic organs can be done to detect tumors.
• Smears( which are taken during pelvic examination) show the presence of malignant cells in the cervix, but the smear is not reliable for detecting endometrial cancer.
Modern methods of diagnosis of uterine body cancer. A number of new aspects of the diagnosis of uterine cancer have been identified. Among them, the concept of a two-stage examination system deserves attention, in which the first stage is the primary detection, screening of patients from healthy, while in the second stage, advanced diagnostic methods are used.
The possibility of a radical cure for all patients with stage I cancer of the uterus body confirms the advisability of developing and introducing methods of mass screening for the prevention and early detection of the disease.
Due to the high informativeness and simplicity at the first stage( primary detection), a cytological examination of aspirate from the uterine cavity is applied. The diagnostic accuracy of the cytological method is quite high, making, according to the data of a number of authors, 93.7-94.2%.Improvement of the methods of obtaining the material makes it possible to increase its diagnostic value to 100%.
When suspected of atypical hyperplasia or endometrial cancer, diagnostic scraping of the uterine cavity is made, clarifying the features of the histostructure and the degree of differentiation of the tumor.
Morphological study is also conducted to study the criteria for stromal invasion, which contributes to the individualization of therapeutic tactics. Most authors agree that a decrease in the degree of histological differentiation and an increase in the depth of infestation correlates with an unfavorable prognosis. Cytomorphologic indices are also widely used to assess changes occurring in a tumor under the influence of radiation and hormone therapy.
The morphological method itself is applicable to the assessment of the effectiveness of radiation treatment 9-12 months after its termination. However, due to obliteration of the cervical canal, which is observed in 18.4% of cases, the risk of uterine perforation is rather high( 5.3%).In this connection, a number of authors consider the cytological method more expedient.
In the past decade, there has been a great interest in morphometry, useful in studying the qualitative characteristics of the elements that make up the tumor( stroma and parenchyma ratio, perimeter and gland dimensions, cell size and diameter, nuclei).
Thus, a dynamic cytomorphological study of the tumor allows us to assess the degree of its regression in the course of specific therapy.
One of the most informative methods is hysterocervicalcography. The significance of this method lies in the need to establish the characteristics of the tumor - its location and the extent of the lesion. According to the data, the coincidence of the topical diagnosis, established with hysterography with the results of the study of the operating macro preparation, was noted in 96.2% of cases. The high informativeness of the method makes it possible to use it for assessing the condition of the cervical canal, which is of particular importance for choosing a rational method of treatment.
Hysterocervicalography is used to refine some topographic and anatomical data. In particular, it is possible to judge the position of the uterus in the small pelvis along the contours of the contrasted cavity. Hysterocervicography, performed in two mutually perpendicular projections, quite accurately determines the position of the uterus in relation to the bones of the pelvis. In the opinion of a number of authors, hysterocervicalography also provides information on the volume of the uterine cavity. These data serve as the main criteria for the selection of optimal irradiation conditions.
In addition, when performing radiation or hormonal treatment of uterine body cancer, this method allows to evaluate the dynamics of tumor regression during therapy and clarifies the clinical situation after its completion. A comparison of the hysterography data with the results of a targeted biopsy can serve as an objective criterion for completing the course of radiation treatment.
Ultrasonography is widely used to detect pelvic tumors.
With the help of ultrasound it is possible to determine the external dimensions of the uterus and the size of its cavity, to clarify the presence of cancer related pathology( myoma, ovarian cysts), which is especially important for planning radiation therapy and individualizing the calculations of absorbed doses from intracavitary irradiation. At the same time, the diagnostic value of echography reaches 70%.
The diagnostic capabilities of computed tomography are well known. This is a highly informative method that provides the physician with the necessary volume of diagnostic and topometric information, and allows research in all patients without physiological limitations. Many note that the diagnostic accuracy of computer tomography significantly exceeds methods such as phlebography, lymphography, cystoscopy, errors in the detection of relapses at which reach 20-25%.Computer tomography has a high resolution to divide tissues according to their density. This is especially important for imaging the target tumor from surrounding healthy organs and tissues in order to correct the dose distribution.
In case of uterine body cancer, computed tomography provides information on organ syntopy in the areas most difficult for clinical and radiologic examination, for obesity and allows to clarify the individual characteristics of the position of the bulky organs - the uterus, rectum, bladder. This is of fundamental importance in the individual planning of intracavitary and remote irradiation. The diagnostic value of tomography is 81%;at a lesion of lymphonoduses - 47%.
To determine the regions of regional metastasis, radiopaque lymphography is used. The role of direct lymphography in the diagnosis of metastases of uterine body cancer is well known).Its diagnostic accuracy is estimated at 85%.
The frequency of detection of metastases in the lymph nodes of the pelvis, according to the lymphography, with cancer of the body of the uterus of the I stage is 8-12.5%, stage II - 22-27.2%, stage III - 52.5-57.1% and stage IV - 67%
.Moreover, the frequency of involvement of lymphocytes clearly correlates with the degree of differentiation of the tumor. Thus, with cancer of the uterine body of the 1st stage, the incidence of lymph node involvement with highly differentiated adenocarcinoma reaches 1.5-3.1%;moderately differentiated 4-10% and low-grade - 28-36%.The metastatic lesion of the pelvic lymph nodes with all forms of differentiation does not exceed 6-10.6%.
Highly differentiated tumors localized in the upper regions of the uterine cavity metastasize to the lymph nodes of the pelvis in less than 5% of cases. In these situations, according to several authors, there is no need for the use of lymphography. If a diffuse or more total lesion of the uterus is detected during hysterocervicography, and if the histological examination reduces the differentiation of the tumor, then the use of lymphography is desirable. In these cases, the combined use of hysterocervicalography and lymphography makes it possible to compile a holistic view of the features of the primary tumor and the anatomical zone of its lymphogenous metastasis.
Often, the elderly patients, the presence of severe concomitant pathology, endocrine-metabolic disorders are an obstacle to the use of direct lymphography. In the evaluation of the prevalence of the tumor process, as well as the radical nature of lymphadenectomy, the method of indirect radioisotope lymphography is increasingly being used. It is shown that the accuracy of isotope and direct lymphography is comparable and is estimated by the index of 0.82;"Sensitivity" from positive data is somewhat lower for the isotopic method - 0.76 and 0.84, respectively;"Specificity" for negative data is 0.84 and 0.81, respectively, which allows us to consider these methods as mutually complementary.
This, however, does not reduce the self-significant high importance of isotope lymphography in uterine cancer, when direct contrasting of the lymphatic system is contraindicated.
Lymphographic examination information is used to plan remote radiation therapy, specifying the height of the areas to be irradiated.
Comprehensive examination of patients with uterine body cancer includes obtaining information on the status of adjacent organs( cystoscopy, sigmoidoscopy), urinary tract status( chromoscystoscopy, excretory urography, radioisotope renography), as well as liver functional status( hepatoscintigraphy and echographic examination).
Thus, with the use of a complex of clinical, radiographic and radionuclide methods of research, the necessary amount of information on the extent of local and regional cancer can be obtained. This information, characterizing the tumor process and the general condition of the patient, is the basis for planning treatment tactics. It determines the positive attitude towards the surgical treatment of the cancer of the uterus body or justifies the rejection of it, indicates the advisability of radiation treatment or determines the indications for the implementation of its individual components - intracavitary or remote.
At the same time, analysis of the literature data allows us to recognize that the existing numerous diagnostic techniques ensure the receipt of a single indicator, rather than objective information in general. In addition, many methodological questions on the examination of patients with uterine cancer have not been resolved, which makes it impossible to design individual treatment programs.
Thus, the improvement of diagnostic methods based on the systematization of information about the topic of the tumor and the functional indices of the patient's body is clearly necessary.
• For women at high risk of disease( who do not have ovulation), cancer can be prevented through cycles of use of progestational drugs.
• Regular pelvic examinations during and after menopause can help in the early detection and treatment of any abnormality.
• Estrogen replacement therapy for postmenopausal women who did not have a hysterectomy should be accompanied by the use of progestational agents. If this is not the case, an annual biopsy of the endometrial tissue of the endometrium is necessary.
• Call your gynecologist if you experience severe bleeding from the vagina or if you experience bleeding from the vagina between menstruation or after menopause.