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Endometrial cancer of the uterus: signs, ultrasound diagnosis, prognosis
Last reviewed: 18.10.2021
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Epidemiology
According to statistics, about 4.5% of patients with postmenopausal bleeding are diagnosed with uterine cancer.
Over the last decade, economically developed regions demonstrate a pronounced increase in the incidence of endometrial cancer: this pathology makes up 13% of all oncological processes in women and is found mainly in patients aged 55 to 60 years.
According to world statistics, endometrial cancer has the status of the most common female oncology, ranking sixth among all malignant processes (only breast cancer, cervical cancer, colorectal cancer, and lung and stomach cancer are more common).
Over the past ten years, mortality rates in patients with endometrial cancer have relatively decreased, but at the moment this pathology continues to occupy the 8th place in terms of death rates.
Causes of the endometrial cancer
Endometrial cancer is a neoplasm that is interconnected with the hormonal background of a woman and sensitive to steroid hormone imbalance. Proliferation processes are triggered against the background of regulatory disorders within the hypothalamus-pituitary system: hyperplasia begins in the endometrial layer, which is an ideal basis for the formation of malignant changes.
The causes of such phenomena may be:
- AIDS virus;
- decompensated states (hypertension, diabetes);
- papilloma virus;
- long or chaotic hormonal treatment;
- sexually transmitted infections;
- early sex life, early abortions (frequent abortions);
- lack of order in sexual life;
- the absence of pregnancies throughout the reproductive period;
- frequent disruptions of the monthly cycle, late menopause.
The main factors that influence the level of estrogen in the blood (one of the causes of endometrial cancer) are:
- early menarche, late menopause;
- the absence of pregnancies during the entire reproductive period of a woman’s life;
- improperly chosen means for hormone replacement therapy, chaotic hormonal treatment.
One of the obvious reasons for the emergence of endometrial cancer, experts call various damaging effects on the mucous tissues of the uterus. Such injuries include scars, adhesions, erosion, birth injuries, polypous and condylomatous tumors, leukoplakia, chronic inflammation (for example, endometritis, endocervicitis).
Obesity often leads to the evolution of endometrial cancer. Thus, women, whose weight exceeds the norm by 20 kg, are three times more likely to experience the disease, in contrast to patients with normal weight. If the excess weight is more than 25 kg, then the risk of becoming ill with cancer increases nine times. The essence of this trend is that fat cells produce estrogens, which can be from 15 to 50% of the total amount of estrogen in the body.
Risk factors
What could be a risk factor for a cancer in the uterus?
- Early or late menopause.
- Obesity.
- Long-term use of hormonal drugs (for example, about the impossibility of conception, or for the treatment of other female diseases).
- Unfavorable heredity (someone in the family was sick with malignant diseases of the reproductive organs).
- Earlier onset of sexual activity, promiscuity.
- Frequent genital infections, chronic inflammatory diseases of the reproductive organs.
- Failure of immune protection.
- Alcohol abuse, smoking, other types of addictions that provoke intoxication of the body.
Endometrial cancer in the elderly
Cancer processes in older people have their own characteristics. For example, they are more often found already running malignant forms, the most aggressive morphological types of pathology. In addition, there are violations when performing the prescribed treatment - due to reduced functional reserve of patients.
Most elderly women already have numerous, including chronic diseases, which often require constant medication. Not in all cases, such therapeutic schemes can be combined, without prejudice to the patient's health. Therefore, clinical protocols in the elderly are rarely carried out, given the risks of complications.
The approach in the treatment of endometrial cancer in humans after 70 years should be very gentle: for example, from this age the risk of death increases three times, and by 75 years - almost five times. At the same time, overall and relapse-free survival rates are significantly reduced. In addition, age patients are much more likely to have contraindications for surgery. Therefore, often treatment is directed only to alleviate the condition and prolong the life of the sick person.
Pathogenesis
Endometrial cancer belongs to the category of hormone-dependent tumor processes: this is confirmed by a number of scientific experiments and clinical projects, during which it was possible to prove that this disease often develops against the background of other disorders of the endocrine system and metabolism.
Among women who have been diagnosed with cancer in the uterus, there is a fairly large percentage of not having a single child, or even virgins. Often they have fibroids and feminizing tumor processes in the ovaries.
Endometrial cancer is mainly located at the bottom, sometimes in the zone of the isthmus. The tumor can grow outward, inward, or simultaneously in two directions (mixed type). Distribution occurs more often in the lymphatic system, at least - in the bloodstream or implantation method. The implantation pathway is the germination of a tumor with the involvement of the parietal and visceral peritoneum: the appendages are affected, metastasis spreads to the greater omentum (mainly with low differentiation of the neoplasm).
There are several basic stages of the pathogenetic development of endometrial cancer:
- Stage I of functional disorders (lack of ovulation, increased estrogen levels).
- Stage II of the formation of morphological disorders (glandular-cystic hyperplasia, polyposis).
- Stage III of the formation of pretumor morphological disorders (atypical hyperplasia and epithelial dysplasia in the third stage).
- Stage IV - the formation of onconeoplasia (preinvasive cancer tumor → minimal invasion of muscle tissue → an obvious form of endometrial cancer).
- Is endometrial hyperplasia cancer?
Endometrial hyperplasia is a dangerous disease in which the overgrowth of mucous tissue in the uterus. But despite the danger, hyperplasia is not cancer, although it is a favorable process for the development of oncology. Timely removal of the zone with abnormal mucous tissue allows you to stop the development of the disease and thereby prevent the development of the malignant process.
- Is atypical endometrial hyperplasia a cancer?
Atypical or atypical hyperplasia is the most insidious type of this pathology. It is this type that most often goes into a malignant tumor. However, this disease also has a favorable prognosis if timely and competent treatment is prescribed.
- Endometrial hyperplasia goes into cancer?
Indeed, hyperplasia of the endometrial layer has a tendency to malignancy - that is, to cancer degeneration. This is especially true of the atypical type of the disease (this type of malignancy is most often, therefore, often radical methods are used for its treatment - for example, hysterectomy). In other cases, predominantly combined therapy is prescribed, implying both surgery and hormonal treatment.
- Is endometrial adenomatous hyperplasia a cancer?
Adenomatous hyperplasia, also called complex hyperplasia, is characterized by the formation of atypical structural units within the endometrial layer of the uterus. This pathology affects about three out of hundreds of patients - that is, the disease is quite common. However, it does not apply to cancerous processes: endometrial cancer may be a complication of the lack of treatment, or improper treatment of this disease.
Pathogenetic variants of endometrial cancer
Two pathogenetic variants of endometrial cancer have been identified for medical specialists.
The first option is most common: pathology is formed in relatively young patients, as a result of prolonged elevated levels of estrogen in the body and signs of hyperplasia. With this type of disease, patients often have obesity, metabolic disorders, hypertension, and sometimes hormone-secreting ovarian tumors, glandular-cystic hyperplasia of the endometrium or SCSKYA. Such tumors are often highly differentiated, have a relatively favorable prognosis.
The second option is low-grade neoplasms with a less favorable prognosis. This pathology develops in age-related patients: hyperestrogenism is absent, there is atrophy of the endometrial layer.
About 80% of patients with a diagnosis of endometrial cancer have adenocarcinoma. Approximately 5% have a tumor associated with hereditary pathologies - for example, with non-polypous colorectal cancer.
[26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38]
Symptoms of the endometrial cancer
The early stage of endometrial cancer is asymptomatic. The first signs may appear as bloody discharge from the vagina, watery whiter and abdominal tenderness. In this case, the main symptom that is recorded most often is bleeding from the uterus: this symptom is atypical, since it can be observed for most gynecological disorders (for example, for adenomyosis, uterine myoma).
In patients of reproductive age, endometrial cancer is most often detected on the background of long-term observation and treatment for dysfunction of the hypothalamus-pituitary system. This is a fairly common diagnostic error in endometrial cancer: doctors are more likely to be mistaken when examining young women, since oncology is mainly suspected in age-related patients.
The basic signs about which women seek medical help are:
- non-cyclical bleeding from the uterus;
- difficulty conceiving;
- impaired ovarian function.
However, bleeding refers to typical symptoms only in the postmenopausal period. At a younger age, this symptom can manifest itself only when a woman is diagnosed with combined endometrial and cervical cancer - that is, at a later stage in the development of the disease.
Discharges in endometrial cancer in the form of massive serous secretion, in the absence of signs of inflammation of the genital organs, are typical of patients in old age. Such secretions are almost always abundant, serous-watery (the so-called leukorrhea).
Soreness of one degree or another is the most late sign of endometrial cancer. Pain is felt mainly in the lower abdomen, or in the lumbosacral area, have incessant nature or arise in the form of short-term contractions. Unfortunately, the overwhelming number of patients come for medical help with a delay, when all the symptoms of the prevalence of the nidus are already present.
Many experts associate endometrial cancer and metabolic syndrome: in patients, an increase in blood pressure, obesity, insulin resistance, and myocardial hypoxia appear. It is worth noting that this syndrome can be both a factor and a consequence of endometrial cancer. Signs of such a violation are fatigue, a state of apathy, irritability, and mood swings in a state of hunger. Symptoms are not typical and require additional diagnostics.
Stages
There are two classification options for endometrial cancer. One of the options was presented by the MA of obstetricians and gynecologists of FIGO. The second option identifies endometrial cancer by tnm, estimating both the size of the formation and the likelihood of damage to the lymphatic system or distant metastases.
According to the first version of the classification, medicine distinguishes between the following stages of the disease:
- Early endometrial cancer is the so-called “zero” stage, at which the development of pathology begins without its spread. This is the most favorable stage, with indicators of complete recovery in the range of 97-100%.
- Stage 1 is divided into several stages:
- Stage 1a is the stage of germination of the process in the tissue, without going beyond the endometrial layer;
- Stage 1c is a similar stage at which a tumor grows into the muscle layer;
- Stage 1c - the germination of the tumor approaches the outer layer of the organ.
- Stage 2 is accompanied by the spread of pathology on the tissue of the uterine cervix:
- Stage 2a - cancer changes affect the cervical glands;
- Stage 2c - stromal structures are affected.
- Stage 3 corresponds to the exit of the malignant process to the limits of the uterine organ, without further spreading of the pelvic area:
- Stage 3a - appendages are affected;
- Stage 3 - the vagina is affected;
- Stage 3c - nearby lymph nodes are affected.
- Stage 4 corresponds to the further spread of the tumor with metastasis:
- Stage 4a - accompanied by lesions of the urinary tract and / or direct intestine;
- Stage 4c - is accompanied by the spread of distant metastases.
Staging tnm implies taking into account three parameters: these are t (tumor size), n (affecting lymph nodes), and m (presence of metastases).
Decryption of parameters is as follows:
- t is precancerous pathology;
- t1a - the neoplasm is localized within the organ and has dimensions of up to 80 mm;
- t1b - the neoplasm is localized within the organ, but its dimensions exceed 80 mm;
- t2 - the pathology has spread to the uterine neck;
- t3 - the tumor has spread beyond the uterus, but has not left the pelvic area;
- t4 - the neoplasm sprouted into the rectum and / or bladder tissue, or left the pelvic area;
- n0 - lymph nodes are not involved in the process;
- n1 - lymph nodes are involved in the process;
- m0 - there are no distant metastases;
- m1 - there is a suspicion of the presence of distant metastases.
Forms
According to the generally accepted classification, such histological forms of endometrial cancer are distinguished:
- Endometrial glandular cancer (adenocarcinoma) is derived from endometrial glandular cells. This is a hormone-dependent process, because the state of the glandular tissues of the endometrium undergoes cyclic changes under the influence of sex hormones - steroids. In turn, adenocarcinoma is subdivided into a highly differentiated, moderately differentiated and low-differentiated tumor.
- Endometrial hyperplastic cancer is a cancer process triggered by hyperplastic modifications of the endometrial layer. Hyperplasia is considered the most likely basis for the development of malignant tumors.
- Endometrial mucinous cancer: this type includes tumors that show signs of mucinous differentiation, but do not have specific characteristics of adenocarcinoma. The tumor is represented by cellular structures consisting of intracytoplasmic mucin. This type is found in 1-9% of all glandular forms of uterine cancer.
- Serous endometrial cancer belongs to a large group of epithelial tumors. The process develops from modified or transformed epithelial tissues. The disease is dangerous because it has a particularly hidden aggressive course and is detected by chance.
This is what German oncologists say about serous endometrial cancer of the uterus: "Recent studies have shown that women carrying the BRCA1 genetic mutation are more likely to develop serous aggressive cancer: they are recommended to remove the uterus together with the appendages as soon as possible after the mutation is detected." It was found that in four out of five cases, serous cancer developed in patients with the genetic mutation BRCA1.
- Endometrial squamous cell carcinoma is a neoplasia formed from flat epithelial structures that have become atypical. Most often, such cancer is caused by the human papillomavirus, but can also be provoked by the herpes simplex virus, cytomegalovirus, etc.
- Undifferentiated endometrial cancer is a variant of the tumor, the nature of which can only be assumed, mainly due to the underdevelopment of the cells and the absence of signs of belonging to any type of tissue. Such cells are simply called "cancer cells." Undifferentiated cancer is one of the most malignant neoplasms and has the worst prognosis.
Complications and consequences
Endometrial cancer is in itself a complex and dangerous disease, but it can also cause a lot of additional complications and problems. The neoplasm can squeeze other tissues and organs, there may be difficulties with urination, develop hydronephrosis, purulent infection of the urinary tract.
Not less often there is bleeding from the genital tract, which, if delayed treatment to the doctor can lead to death.
When the pathology is neglected, fistulas can form - peculiar pathological holes in the walls of the intestine, bladder, vagina. Such a complication also often causes the death of the patient.
Relapse is considered theoretically possible, so for a long time after the initial treatment, the patient is under observation. Urgent medical intervention requires the following conditions:
- bleeding (uterine or rectal);
- a sharp appearance of edema of the lower extremities, ascites;
- the appearance of pain in the abdomen;
- the appearance of shortness of breath, spontaneous cough;
- loss of appetite, drastic weight loss.
Metastases, metastasis pathways
The main route of spread of metastases is lymphogenous, through the lymphatic system. Metastasis is predominantly defined in the para-aortic and iliac lymph nodes.
Metastases are a kind of “pieces” of a tumor, having a similar structure and properties. Why do they appear and separate from the main tumor lesion?
Since the neoplasm - endometrial cancer - is rapidly increasing and developing, it gradually loses the ability to "feed up" all its elements. As a result, some structural parts are separated and transferred with lymph or blood to different parts of the body, where they take root and begin to exist independently, as a separate tumor (now a daughter one).
Most often, metastases "settle" in the nearby lymph nodes, however, they can spread further - to the lungs, liver, bones, etc. If single "screenings" can still be traced and destroyed, then it is almost impossible to identify multiple metastases: in this case you have to resort to supporting treatment with chemotherapy drugs to prolong the life of the patient.
Diagnostics of the endometrial cancer
The diagnosis of endometrial cancer is established after receiving the results of a study conducted by a gynecologist, followed by consultation with a specialist in the field of oncology. Sometimes it may be important the so-called "second opinion" is to obtain advice from an outside specialist (for example, a parallel treatment to another clinic with subsequent comparison of the results). This is done in order to eliminate possible errors in diagnosis, because cancer is quite a serious and complex disease.
The doctor may initiate such laboratory tests:
- general blood and urine tests;
- blood biochemistry;
- coagulogram;
- blood test for tumor markers - specific protein substances whose content increases if the body has a tumor process.
- An analysis of genetics in endometrial cancer (more precisely, in case of suspected disease) is carried out:
- patients with HPV;
- patients with burdened heredity, whose relatives suffered from endometrial cancer;
- patients taking hormonal drugs.
Mutations are being studied in several gene groups, which allows to determine the individual degree of risk of endometrial cancer. In turn, this will help the doctor orient himself in determining the future tactics of treatment and preventive measures.
Instrumental diagnostics, in the first place, includes a smear on oncological cytology. This type of research allows to determine the early precancerous signs of the disease: this method is available, it can be used several times throughout the diagnostic course.
The standard instrumental approach involves a two-handed vaginal examination using mirrors, as well as a similar rectal examination.
If necessary, appoint aspiration endometrial biopsy. The endometrial tissue is aspirated with a brown syringe. This method is effective in 90% of cases.
Ultrasound examination of the pelvis helps to examine the changes that have occurred in the adjacent tissues and organs.
Important ultrasound signs are detected when measuring Meho (median echo of the uterus):
- in patients of reproductive age, the Meho value is not more than 12 mm;
- in postmenopausal patients, this value should not be more than 4 mm;
- an increase in anteroposterior size above standard values may be regarded as a likely sign of the development of a malignant process.
- Endometrial thickness in endometrial cancer is treated as follows:
- if the value of the middle echo is more than 12 mm, then an aspiration biopsy of the endometrium is performed;
- if the Meho value is less than 12 mm, then a hysteroscopy is performed with a targeted endometrial biopsy;
- if the value is less than 4 mm, then set the observation of the dynamics of the process.
As a rule, the main role in the diagnosis of endometrial cancer is played by histology, which provides an opportunity to determine the type of morphological disorders. Young patients belonging to any of the risk groups are advised to undergo cervicogisteroscopy. This diagnostic method allows to estimate the distribution and depth of the neoplastic reaction, as well as to conduct targeted biopsy of the modified tissue.
To determine the extent of damage to the lymph nodes and adjacent tissues, x-ray diagnostics are prescribed: ileocawaragraphy, irrigology, rectoromanoscopy, pyelography, lymphography, cystoscopy.
In addition, it is recommended to conduct magnetic resonance studies of the thoracic and abdominal organs, as well as computerized skeletal tomography. Endometrial cancer on MRI is determined by the presence of lymph nodes.
Differential diagnosis
Differential diagnosis is quite complicated and is usually carried out taking into account all the diseases of the genital sphere, which are accompanied by similar symptoms. We are talking about cervical cancer, dysfunctional states, fibromyoma, chorionepithelioma, ovarian cancer, etc. Many of these pathologies can occur independently or be combined with endometrial cancer.
Endometrial hyperplasia, like endometrial cancer, have one common symptom - postmenopausal bleeding. Therefore, it is very important to identify these pathologies in a timely manner: first of all, the help of an ultrasound method is necessary.
Endometriosis is usually diagnosed by the laparoscopic method: the symptoms are often mild, but it is not possible to differentiate only on the basis of the clinical picture.
Uterine fibroids are often combined with endometrial cancer, so it is practically important to separate and identify these pathologies. The patient diagnosed with myoma is carried out both by probing and by complete cyto-examination (or fractional curettage) with further histological evaluation of the scraping. If there is an accelerated growth of certain areas of the neoplasm, and the patient's condition is rapidly deteriorating, then uterine sarcoma can be suspected.
If cervical cancer and endometrial cancer are differentiated , the patient’s age criteria, as well as functional and somatic characteristics (overweight, concomitant diseases), information obtained during an external examination (absence of atrophic genitalia) and a bimanual study, are necessarily taken into account. For specification or a refutation of the alleged diagnosis do full cytoexamination with the analysis of an endometrial scraping.
Hormone-producing ovarian cancer can occur simultaneously with carcinoma, or represent a separate pathology with signs typical of endometrial cancer. When advanced stages of ovarian cancer, when a malignant lesion spreads to the endometrium, characteristic acyclic bleeding can occur. In this situation, a bimanual examination and cytomorphological information are required.
Polycystic ovary syndrome (PCOS, PCOS) is rarely suspected simultaneously with endometrial cancer: the disease is differentiated primarily from thyroid disease, hyperprolactinemia, congenital dysfunction of the adrenal cortex. However, in some cases, the combined development of pathology is possible. Conduct laboratory studies of hormonal levels, which allows to ascertain the origin of the problem.
An endometrial polyp, unlike a cancer, is easily diagnosed: it is detected during an ultrasound scan (with repeated testing after menstruation). With special need prescribe aspiration biopsy.
Who to contact?
Prevention
Unfortunately, there are no such preventive measures that would give a 100% guarantee that endometrial cancer will never appear. But still we must not forget about a number of factors that can become trigger mechanisms in the development of oncology. So, you should monitor your weight, not to take uncontrolled hormones, systematically - at least once a year - visit the gynecologist's office.
If there are any problems in the form of genital diseases, they should be treated promptly.
For any suspicious signs that are associated with the reproductive system, you need to consult a doctor: even minor bleeding from the genital tract can be a precursor of the tumor process. And this must not be forgotten.
In addition, it is important to eat properly, include fiber and healthy foods in the diet, and eliminate bad habits.
And another important point is sexual health. Prevention of sexually transmitted diseases, the presence of a stable healthy partner is the key to the health of the female reproductive organs.
Forecast
The basic factor that determines the quality of the prognosis for endometrial cancer is the stage at which pathology is detected. An aggravation of the malignant process is observed in approximately one in four patients diagnosed with the early stage of the disease. There are a number of adverse factors that worsen the prognosis of a cancer:
- age of the patient is over sixty years old;
- adverse histological variation with a low degree of differentiation of the tumor process;
- deep malignant lesion of the muscular layer of the uterus (more than 50% of myometrium);
- transition of the malignant process to the cervix;
- cancer embolism of the vascular lumen of the blood or lymph circulation system;
- spread to the peritoneum;
- significant malignant lesion;
- a small amount of progesterone and estrogen receptors in the tumor focus;
- the presence of cancer structures in the material of the abdominal cavity;
- change in the karyotype of the neoplasm;
- oncogenic expression.
How many endometrial cancer patients live? Survival, chances of life in endometrial cancer depends on the extent and differentiation of the cancer process.
After the operation, the 5-year survival rate may be from 5 to 85%, depending on what stage the pathology was. Patients with cancer stages I and II have the best prognosis. Thus, the survival rates over the five-year period in patients with stage I are within 85-90%, and in patients with stage II - within 70-75%. Patients with a diagnosed third stage of endometrial cancer survive in about 30% of cases, and in the fourth stage, the five-year survival rate is only 5%.
If the disease recurs, then most often it occurs during the first three years after the end of therapy. Relapse problems can be detected (by frequency of detection):
- in the tissues of the vagina;
- in the pelvic lymphatic system;
- on the periphery (at a distance from the main focus).
The 10-year survival for endometrial cancer ranges from 3.2 to 71.5%: the best indicators are found in patients with tumors that have progesterone receptors.
[76], [77], [78], [79], [80], [81], [82], [83]
Endometrial cancer patient forums
Endometrial cancer is a complex and serious illness, and sometimes it is difficult for a woman to cope with her own thoughts and fears on her own. Therefore, often come to the aid of forums that have the opportunity to communicate with people who are faced with a similar problem. Each patient can share his story, provide new information, or clarify for himself some aspects related to the disease. Here, not only the sick, but also the doctors are sharing their comments: it all translates into tremendous support for the sick, and even for the stimulation of healing. Among patients with diagnosed endometrial cancer, the most popular forums are: