What Are the Different Endometrial Cancer Stages?

Endometrial cancer is a group of epithelial malignant tumors that occur in the endometrium. It occurs in perimenopausal and postmenopausal women. Endometrial cancer is one of the most common tumors of the female reproductive system, with nearly 200,000 new cases each year, and the third most common gynecological malignancy that causes death (after ovarian and cervical cancer). Its incidence is closely related to lifestyle, and its incidence varies from region to region. Its incidence is second only to breast cancer, lung cancer, and colorectal tumors in North America and Europe, and it ranks first among women's reproductive system cancers. In China, with the development of society and the improvement of economic conditions, the incidence of endometrial cancer has also increased year by year, currently second only to cervical cancer, ranking second in female malignant tumors of the reproductive system.

Basic Information

English name

endometrial carcinoma

Visiting department

Obstetrics and Gynecology, Oncology

Multiple groups

Perimenopausal and postmenopausal women

Common causes

Unclear so far

Common symptoms

Bleeding, vaginal drainage, pain, abdominal mass, etc.

Causes of endometrial cancer

The cause of endometrial cancer is not clear so far. It is generally believed that endometrial cancer can be divided into estrogen-dependent (type I) and non-estrogen-dependent (type II) according to the pathogenesis and biological behavior characteristics. Most of the estrogen-dependent endometrial cancers are endometrioid carcinomas, and a small part of them are mucinous adenocarcinomas. Non-estrogen-dependent endometrial cancers include serous carcinomas and clear cell carcinomas.

Clinical manifestations of endometrial cancer

Symptoms

Very early patients may be asymptomatic and only found by accident during a census or gynecological examination. Once symptoms appear, they usually manifest as:

(1) Bleeding Irregular vaginal bleeding is the main symptom of endometrial cancer, and it is usually a small to moderate amount of bleeding. In young women or perimenopausal women, it is often mistaken for irregular menstruation and ignored. Postmenopausal women often present with persistent or intermittent vaginal bleeding. Some patients show only a small amount of vaginal bloody discharge after menopause. Late-stage patients may have rotten meat-like tissue mixed in the bleeding.

(2) Vaginal drainage Some patients have varying degrees of vaginal drainage. In the early stage, it can show thin white secretions or a small amount of bloody leucorrhea. If there is infection or necrosis of cancerous foci, there may be purulent secretions with odor. Sometimes tissue-like substances can be associated with vaginal drainage.

(3) Pain Cancer foci and the bleeding or infection caused by it can stimulate uterine contraction and cause paroxysmal lower abdominal pain. Postmenopausal women suffer from poor drainage of uterine secretions due to stenosis of the cervical canal, secondary infection leading to empyema, and patients may experience severe lower abdominal pain with fever. Invasion of cancerous tissues through the entire uterine layer at the advanced stage of the tumor, or invasion of parauterine connective tissue, paracervical ligament, bladder, intestine, or infiltration of pelvic wall tissues or nerves can cause persistent, gradually increasing pain, which can be accompanied by lumbosacral Pain or radiation to the ipsilateral lower extremity.

(4) Abdominal masses Early-stage endometrial cancers generally cannot reach the abdominal masses. If endometrial cancer is associated with large uterine fibroids, or if uterine empyema occurs in the late stage, and a large mass is formed in the pelvic cavity (such as when the ovarian metastases), the mass may be touched in the abdomen, which is generally solid and has poor mobility. Sometimes there is tenderness.

(5) Invasion and compression of the iliac vessels at the late stage of other tumors can cause pain in the ipsilateral lower extremity; Infiltration of the lesions and compression of the ureter can cause hydronephrosis in the ipsilateral renal pelvis and ureter, and even cause renal atrophy; continuous bleeding can lead to secondary anemia; long-term tumor consumption can lead to Symptoms of systemic failure such as weight loss, fever, and cachexia.

2. Signs

(1) Systemic manifestations Early patients may be asymptomatic. However, many patients have obesity, hypertension, and / or diabetes at the same time; patients with long-term hemorrhage may have secondary anemia; those with empyema may have fever; patients with advanced disease may touch abdominal masses, edema of the lower limbs, or have cachexia. In advanced patients, metastases such as enlarged or fused lymph nodes can be touched on the clavicle and groin.

(2) Gynecological examination Early patients often have no obvious abnormalities. The cervix often does not have any special changes. If the cancerous focus is shed, sometimes the cancerous tissue may come out of the cervix. The uterus can be normal or older than the corresponding age, and when the fibroids or empyema are present, the uterus can be enlarged. The uterus can be immobilized during late uterine metastases. The ovaries can be enlarged when there are ovarian metastases or ovarian tumors that secrete estrogen.

Endometrial cancer examination

1.B-ultrasound

B-ultrasound can understand the size of the uterus, the thickness of the endometrium, the presence or absence of echogenicity or intrauterine neoplasms, the presence or absence of myometrial infiltration, and the degree of diagnosis. The diagnostic compliance rate is over 80%. Because there are many obese patients with endometrial cancer, transvaginal ultrasound has advantages over transabdominal ultrasound. Because the B-ultrasound is convenient and non-invasive, it has become the most routine test for the diagnosis of endometrial cancer, and it is also a preliminary screening method.

2. Segmented curettage

It is the most commonly used and most valuable method for the diagnosis of endometrial cancer. Not only can it be clear whether it is cancer, endometrial cancer involves cervical canal, but it can also distinguish endometrial cancer and cervical adenocarcinoma, so as to guide clinical treatment. For patients with massive perimenopausal vaginal bleeding or continuous bleeding, segmented diagnosis and curettage can also stop bleeding. The specimens for segmented diagnosis and scraping need to be marked and sent for pathological examination in order to confirm or exclude endometrial cancer.

3. Hysteroscopy

Under hysteroscopy, you can directly observe the presence of cancerous lesions in the uterine cavity and cervical canal, the location, size, and extent of the lesions, and whether the cervical canal is involved. Biopsy of suspected lesions under direct vision can help find smaller Or earlier lesions reduce the rate of missed diagnosis of endometrial cancer. The accuracy of biopsy under hysteroscopy is close to 100%. Hysteroscopy and segmental diagnosis and curettage have complications such as bleeding, infection, uterine perforation, cervical laceration, and comprehensive flow of people. Hysteroscopy is still at risk of water poisoning. Whether hysteroscopy can lead to the spread of endometrial cancer is controversial. Most studies currently believe that hysteroscopy will not affect the prognosis of endometrial cancer.

4. Cytological examination

Endometrial specimens can be obtained by uterine cavity brushes, uterine cavity suction smears, and other methods to diagnose endometrial cancer, but the positive rate is low, and routine application is not recommended.

5. Magnetic resonance imaging (MRI)

MRI can clearly show the size and extent of lesions, endometrial invasion, and metastasis of pelvic and para-aortic lymph nodes in endometrial cancer, so as to estimate the tumor stage more accurately. The resolution of CT for soft tissue is slightly lower than that of MRI. Therefore, in conditional hospitals, there are many evaluators before applying MRI.

6. Tumor marker CA125

In patients with early endometrial cancer, generally there is no elevation, and those with extrauterine metastasis, CA125 can be significantly increased, and can be used as a tumor marker for this patient to detect disease progression and treatment effect.

Endometrial cancer diagnosis

Based on the patient's medical history, symptoms, and signs, clinicians are often prompted to be vigilant about endometrial cancer. The diagnosis of endometrial cancer is based on histopathological examination.

1. Medical history and clinical manifestations

For patients with postmenopausal vaginal bleeding, perimenopausal abnormal bleeding or drainage, endometrial cancer and cervical cancer must be excluded before they can be treated as benign diseases. Special attention should be paid to patients with the following high-risk factors: those with high-risk factors for endometrial cancer, such as patients with hypertension, diabetes, obesity, polycystic ovary syndrome, infertility, and delayed menopause; have long-term applications People with a history of estrogen, tamoxifen, or other estrogen-increased diseases; people with a family history of breast cancer and endometrial cancer.

2. Related inspections

Combined with B-ultrasound, hysteroscopy, cytology, and MRI to assist diagnosis.

Differential diagnosis of endometrial cancer

The most common symptoms of endometrial cancer are postmenopausal bleeding or perimenopausal bleeding, so it needs to be distinguished from other diseases that cause vaginal bleeding:

Dysfunctional uterine bleeding

Perimenopausal dysfunction is characterized by prolonged menstrual periods, increased menstrual flow, or irregular vaginal bleeding, which is the same as the symptoms of endometrial cancer. Therefore, for these patients, segmented diagnosis and curettage should be performed even if the gynecological examination is not positive Examination and exclusion of endometrial cancer can be treated symptomatically. Young women with irregular vaginal bleeding, especially those with infertility, thin menstruation or polycystic ovary syndrome, should also be cautious, such as B-ultrasound thickening or uneven echo, should also be segmented Scraping excludes endometrial cancer or precancerous lesions.

Senile vaginitis

Common in postmenopausal women with bloody vaginal discharge. On examination, the vaginal mucosa atrophied and became thin, congested, with bleeding points, and inflammatory secretions, which could be improved after symptomatic treatment. For such patients, B-mode ultrasound must be performed to exclude endometrial lesions and cervical cytology to exclude cervical lesions before treatment as senile vaginitis.

3. Senile endometritis with pyogenic empyema

Often manifested as vaginal discharge of pus, bloody or purulent drainage, patients may have fever, uterine enlargement and softening, tenderness. There was pus outflow after dilation of the cervix, and only inflammatory infiltrated tissues were seen in the staged diagnosis and curettage. For elderly women, pus in the uterine cavity often coexists with cervical canal cancer or endometrial cancer. Care must be taken during identification.

4. Endometrial polyps or submucosal uterine fibroids

Showed as menstruation or prolonged menstruation, or bleeding accompanied by vaginal drainage or bloody secretions, the clinical manifestations are very similar to endometrial cancer. B-ultrasound, hysteroscopy and polyp or fibroid resection are available for diagnosis and treatment.

5. Cervical canal cancer, uterine sarcoma, and fallopian tube cancer

Like endometrial cancer, it also shows irregular vaginal bleeding and drainage. Adenocarcinoma of the cervix can be thickened and hardened like a barrel, and can be diagnosed by staged diagnosis and curettage, pathological examination and immunohistochemistry. Uterine sarcoma has a short-term enlargement of the uterus, which becomes soft, and the body touches the uterine mass. Color Doppler ultrasound can help diagnosis. The main symptoms of fallopian tube cancer are paroxysmal vaginal drainage, vaginal bleeding, and abdominal pain. Physical examination can touch the mass of the accessory area. Ultrasonography or laparoscopy can help confirm the diagnosis.

Endometrial cancer treatment

The treatment principles of endometrial cancer should be based on the patient's age, physical condition, lesion range, and histological type to select an appropriate treatment. Because the vast majority of endometrial cancers are adenocarcinomas, they are not very sensitive to radiation therapy, so the treatment is mainly surgery, and other comprehensive treatments such as radiotherapy and chemotherapy are still available. Early patients are mainly surgery, and adjuvant treatment is selected according to the results of surgical-pathological staging and high risk factors for recurrence; advanced patients are treated with a combination of surgery, radiotherapy and chemotherapy.

Surgery

Surgery is the main treatment for endometrial cancer. For early patients, the purpose of surgery is surgical-pathological staging, accurately determining the extent of the lesion and its prognosis, and removing the diseased uterus and possible metastatic lesions to determine the choice of postoperative adjuvant treatment. Surgical procedures generally include peritoneal lavage fluid examination, extrafascial hysterectomy, bilateral ovarian and fallopian tube resection, pelvic lymph node dissection + paraabdominal lymphadenectomy. For patients in the low-risk group (stage Ia, G1-2), whether lymph node dissection is required is still controversial. Proponents believe that the pathological type and degree of differentiation may be inconsistent before and after surgery, and that intraoperative freezing judges muscle layer infiltration There may be errors; opponents believe that early cancer lymph node metastasis rate is low, and no lymph node dissection can avoid more surgical complications. Surgery can be done with laparoscopy or laparoscopy. For stage II patients, the procedure should be a modified extensive hysterectomy (type II of cervical cancer hysterectomy), and pelvic lymph nodes and para-aortic lymph node dissection should be performed. Radiotherapy was selected according to recurrence factors after surgery. Stage III or IV should also shrink tumors as much as possible to create conditions for postoperative radiotherapy and chemotherapy. A considerable part of patients with early endometrial cancer can be cured only by standardized surgery, but for patients with high risk factors for recurrence through surgical-pathological staging or advanced stage patients, certain adjuvant treatment is required after surgery. Because endometrial cancer patients are often older and have more comorbidities, such as hypertension, diabetes, obesity, and other cardiovascular and cerebrovascular diseases, it is necessary to evaluate the physical tolerance of individual patients in detail and give individualized treatment. .

2. Radiotherapy

It is one of the effective methods to treat endometrial cancer. Radiotherapy alone is only suitable for elderly and frail patients with severe medical complications who cannot tolerate surgery or contraindications to surgery, and those who are not suitable for surgery above stage III, including intracavitary and extracorporeal irradiation. Preoperative radiotherapy is rarely used, but for vaginal bleeding, patients with poor general conditions, many comorbidities, and intolerable surgery in the short term can be treated with radiotherapy to stop bleeding and control disease progression. After the patient's general condition improves, a total uterus + double appendectomy can be performed. Preoperative radiotherapy is mainly intracavitary radiotherapy. Postoperative adjuvant radiotherapy is more commonly used in clinical practice, and indications for postoperative radiotherapy: lymph node metastasis or suspicious lymph node metastasis during surgical exploration; myometrial infiltration greater than 1/2 or G2, G3; special histological types, such as serous cancer, transparent Cell carcinoma, etc .; residual cancer of vaginal margin. The first three cases mentioned above are given total pelvic irradiation, and the last case requires intracavitary radiotherapy. At present, radiotherapy is often combined with chemosensitization, also known as chemoradiotherapy.

3. chemotherapy

Chemotherapy is rarely used alone for the treatment of endometrial cancer. It is mostly used for special types of endometrial cancer, such as serous, clear cell carcinoma, etc .; or recurrence cases; or postoperative patients with high risk factors for recurrence, such as G3 , ER / PR negative. The main drugs used in chemotherapy are platinum, paclitaxel and doxorubicin, such as doxorubicin. At present, combined chemotherapy is often used, and chemotherapy schemes include AP, TP, and TAP.

4. Hormone therapy

Indications: Patients with advanced or relapse; fertility-preserving endometrial cancer patients; conservative surgery combined with high-dose progesterone to preserve ovarian function; postoperative adjuvant treatment for patients with high risk factors. Contraindications: liver and kidney dysfunction; severe heart dysfunction; history of thrombosis; patients with diabetes; mental depression; patients allergic to progestin; meningioma patients. At present, there is no accepted progesterone treatment plan, and it is generally advisable to use large-dose progestins alone, such as medroxyprogesterone acetate, megestrol acetate, 17-hydroxyprogesterone, and 18-methyl norethisterone. It is generally believed that the application time should not be less than 1 to 2 years. Large-dose progesterone is effective in immunohistochemical progesterone receptor-positive patients with pathological specimens, with an effective rate of 80% for those who retain fertility, and a total response rate of 15% to 25% for patients with advanced or relapsed treatment. For patients with progesterone receptor negative, tamoxifen can be added to reverse the receptor negative situation and improve the treatment effect. Common side effects of progestin drugs are mild sodium and sodium retention and gastrointestinal reactions. Others may include hypertension, acne, and breast pain.

5. Chinese medicine treatment

After surgery and radiotherapy and chemotherapy, patients can be treated with traditional Chinese medicine and traditional Chinese medicine to strengthen the body and improve the body's immunity.

Endometrial cancer prevention

1. The cause of factor endometrial cancer is not clear, and its occurrence cannot be prevented at present. Therefore, the focus should be on early detection and early treatment. For postmenopausal bleeding and menopausal menstrual disorders, care should be taken to rule out the possibility of endometrial cancer. For young women who have failed to treat menstrual disorders, B-ultrasound and endometrial examination should be done in time. Attach importance to precancerous lesions of endometrial cancer. For patients with proven precancerous lesions such as endometrial hyperplasia, total hysterectomy should be performed according to the patient's condition. Those who have fertility requirements should be given high-dose progestin therapy and monitored in time Condition changes.

2. Strictly grasp the indications of hormone replacement therapy and use it reasonably. It should be used with caution for menopausal and postmenopausal women. For women with a uterus, progestogen should be used to protect the endometrium while monitoring estrogen.

3. Change living habits, control diet, strengthen exercise, and reduce the incidence of endometrial cancer by controlling the occurrence of "rich diseases" such as high blood pressure, diabetes, and obesity.