CANCER AND SARCOMA OF THE UTERUS.
CANCER OF THE BODY OF THE UTERUS.
Cancer of the body of the uterus is a rare disease in comparison with cancer of the cervix. The older statistics—those of Schroeder—appear to show that the disease begins in the body of the uterus in about 2 per cent. of all cases of cancer of this organ. This percentage, however, is probably too small. Cancer of the body of the uterus is by no means an infrequent disease; it is a disease for which the physician should always be on the watch.
Fig. 125.—Diffuse cancer of the endometrium.]
Cancer of the body of the uterus originates in the epithelial structures of the endometrium. It may first appear on the surface of the endometrium or deeply in the utricular glands.
The gross appearance of the disease varies as does cancer of the cervix or of any other part of the body.
Cancer of the uterus may begin upon the surface of the endometrium as a superficial ulceration, as a uniform swelling of the mucous membrane, as a polypoid or papillary projection, or as a large cauliflower-like mass projecting into the uterine cavity.
When the disease begins in the utricular glands, it may form nodules throughout the body of the uterus. These nodules are of various sizes, from that of a pea to that of a hen’s egg. They grow rapidly. They may be submucous and project into the uterine cavity, or they may project beneath the peritoneal covering, giving the uterus an irregular nodular appearance ([Fig. 126]).
Fig. 126.—Nodular form of cancer of the body of the uterus.
In the later stages of the disease the whole body of the uterus becomes infiltrated. The endometrium is destroyed. The cancerous masses ulcerate and break down. The peritoneal covering is for a certain time a barrier to the extension of the disease. In many cases the whole of the body of the uterus may be infiltrated with cancer, and yet the peritoneum will remain intact. The accompanying illustration ([Fig. 127]) shows this: the infiltration extends to, but does not involve, the peritoneum.
Fig. 127.—Cancer of the body of the uterus: a large single cancerous nodule (c) in the anterior wall has been divided.
Later, however, the peritoneum, the Fallopian tubes, and the ovaries become involved. Intestinal adhesions are formed, and the disease may extend throughout the abdominal cavity. The cervix and the vagina may be attacked by extension from above, though, on the other hand, the disease may progress sufficiently to destroy life, and yet the cervix may remain unaffected.
Metastasis may take place by way of the lymphatics. Extension by metastasis, however, is unusual.
Cancer of the body of the uterus occurs at a somewhat later age than cancer of the cervix. The average age is between fifty and sixty. The disease attacks both the parous and nulliparous woman, the latter perhaps more often than the former.
The causes of cancer of the body of the uterus are unknown. It is probable that the various forms of endometritis, by diminishing the resistance of the endometrium, predispose to the development of cancer. It has been maintained that fibroid tumors of the uterus, as a result of the accompanying alterations in the endometrium, predispose to cancer. Cancer of the endometrium is certainly not infrequently found in uteri containing fibroid tumors.
Fig. 128.—Malignant adenoma of the body of the uterus (Beyea).
Malignant adenoma is a disease of the utricular glands which has been classed by some writers as a distinct disease, by others as a form of carcinoma. In it the gland-spaces are much enlarged, irregular, and joined to other gland-spaces. The columnar epithelial cells often fill the whole of the gland-space ([Fig. 128]) The cells, however, never infiltrate the interstitial tissue, as in cancer. The muscular wall of the uterus appears to be destroyed by atrophy or by fatty degeneration.
The disease is malignant, it extends to the neighboring structures, and it destroys life. It presents, in the later stages, all the gross appearances and phenomena of cancer.
The symptoms of cancer of the fundus are hemorrhage, leucorrheal discharge, and pain.
Fig. 129.—Advanced malignant adenoma of the body of the uterus. A fibroid tumor (F) is in the fundus.
In women before the time of the menopause the hemorrhage may appear as a menorrhagia or a metrorrhagia, as an increase of the normal menstrual bleeding, or as a bleeding occurring at some other time than the normal menstrual period. Such irregular bleeding may be caused by any unusual effort.
After the menopause the hemorrhage may appear as a return of menstruation, occurring with more or less periodicity, and, as in cancer of the cervix, often contemplated with satisfaction by the woman. It may appear as a slight occasional discharge of blood, as a bloody streak in the leucorrheal discharge, as a spot upon the clothing, or as continuous hemorrhage. In the late stages of the disease there is a continuous discharge of blood.
The leucorrheal discharge at first resembles that of a non-malignant endometritis. It often begins as a gradual increase of a leucorrhea which the woman may have had for several years. It may be streaked with blood. In the early stages there is nothing at all characteristic about the discharge; later, however, it usually becomes very offensive, on account of the breaking down of necrotic tissue. It becomes more purulent in character, and brown in color from the presence of blood. In some cases of cancer of the fundus, however, the leucorrheal discharge remains light-colored and practically odorless throughout the whole course of the disease. It is sometimes thin and watery and exceedingly profuse, saturating many napkins during the day.
The pain of cancer of the fundus is not a marked symptom. It may be absent even though the whole body of the uterus be involved by the disease. When the peritoneum is affected, and extension takes place to other pelvic structures, the pain is much more pronounced. In other cases the pain may be present in the early stages, before the disease has extended beyond the endometrium.
The pain may be referred to the region of the uterus, to the back, or sometimes to parts of the pelvis remote from the uterus, as the crest of the ilium.
Bimanual examination shows a patulous external os, cervical canal, and internal os. As has already been said, this patulous condition is characteristic of gross disease of the endometrium.
The body of the uterus is usually somewhat enlarged, tender on pressure between the vaginal finger and the abdominal hand, and, in the late stages of the nodular form of cancer, irregular in outline.
The causes of death in cancer of the fundus uteri are the same as those that have already been considered in cancer of the cervix. Extension to abdominal organs is, however, more frequent in cancer of the fundus.
Diagnosis.—It is of the greatest importance to make an early diagnosis of cancer of the fundus uteri, because, of all parts of the body that may be attacked by malignant disease, the fundus uteri offers the best prospect of cure by operation. In the early stages the disease can easily be completely removed.
Hemorrhage from the uterus is the universal symptom, and should never be disregarded. The various manifestations of hemorrhage in cancer of the fundus should always be borne in mind, and should always prompt a thorough investigation.
Leucorrheal discharge occurring at or after the menopause, in a woman previously free from such discharge, should also excite suspicion.
If a careful examination of the cervix fails to reveal any cause for the hemorrhage or the discharge, the interior of the uterus should be thoroughly examined by the curette.
A patulous cervical canal and internal os are good indications that there is some gross disease of the endometrium. In cancer of the fundus the cervical canal and the internal os are usually sufficiently open to permit thorough curetting without further dilatation.
The Sims sharp curette may be used with safety if ordinary care be observed. If the woman is nervous, an anesthetic should be administered, though in most cases diagnostic curetting gives but little pain and may be performed without ether.
The operator should not be content with the removal of a few strips or portions of the endometrium. He should remember that in the early stages the disease may be confined to a small area, and, unless the whole interior of the uterus is gone over, this area may be missed by the curette, and only healthy endometrium may be removed for examination. Such thorough curetting is of especial importance in case the tissue removed should at first present no suspicious features upon gross examination. All portions of the endometrium should be saved and preserved as directed in cancer of the cervix.
The tissue should be submitted for examination to a person trained in gynecological pathology. The recognition of the early stages of cancer of the endometrium, and especially of malignant adenoma, requires the training of the expert. If a positive diagnosis cannot be given from the microscopic examination, the case should be carefully watched, and if the symptoms continue, subsequent curetting and microscopic examination should be made.
The treatment of cancer of the fundus is immediate complete hysterectomy, with removal of the tubes and ovaries. Cancer has recurred in an ovary after removal of the uterus. The hysterectomy may be performed by the vaginal, the abdominal, or the combined method.
The ultimate results of hysterectomy for cancer of the body of the uterus are exceedingly good. Statistics show about 75 per cent. of permanent cures. Recurrence may be considered exceptional. In this respect they are in marked contrast to the results after operation for cancer of the cervix.
SARCOMA OF THE UTERUS.
Sarcoma of the uterus is a very rare disease. There have been but few properly authenticated cases of this disease reported in medical literature. All cases of this disease should be put on record.
There are two varieties of sarcoma of the uterus: diffuse sarcoma of the mucous membrane, and sarcoma of the uterine parenchyma.
In diffuse sarcoma of the mucous membrane the endometrium is infiltrated by round or spindle cells. Soft projections or tumors, which may be villous, lobulated, or polypoid in shape, are formed upon the mucous membrane.
The polypoid sarcoma may present at the cervix uteri. The disease extends to the muscular coat of the uterus.
Fig. 130.—Diffuse sarcoma of the mucous membrane of the uterus.
In the later stages ulceration and disintegration of tissue occur.
The cervix is not involved by the disease.
The symptoms of this form of sarcoma resemble those of cancer of the fundus. There are hemorrhage, discharge, and pain.
The discharge is serous, and is less fetid than in cancer, as ulceration takes place later in the course of the disease.
The cervical canal is patulous, and in the polypoid form the tumor may be felt projecting into the cavity of the uterus or protruding from the external os.
The fundus uteri is enlarged and is tender upon pressure. A positive diagnosis can be made only by microscopic examination of curetted or excised tissue.
Sarcoma of the uterine parenchyma, or fibro-sarcoma, or recurrent fibroid, begins in the muscular coat of the uterus. It appears as nodules of various size, which may be interstitial or confined to the muscular coat, submucous or projecting beneath the mucous membrane, or subperitoneal, projecting beneath the peritoneal coat. On section these nodules are pale in appearance and soft in consistency. They are rarely found in the cervix. The submucous form of nodule may become polypoid, project into the cavity of the uterus, and with comparative frequency produce inversion of the uterus.
The nodules of sarcoma differ from those of benign fibroid tumors in the fact that they have no capsule. They cannot be enucleated, but are intimately connected with the surrounding uterine tissue. Metastatic nodules occur in the vagina, the peritoneum, and in other parts of the body.
In the later stages of the disease the nodules disintegrate and break down.
It is probable that fibro-sarcoma usually, if not always, originates in a benign fibroid tumor. In the early stage of the disease the microscopic appearances of fibroid tumor are present, and the transition from the benign to the malignant growth may be studied.
Symptoms.—The symptoms of this form of sarcoma resemble at first those of fibroid tumor; they are—hemorrhage in the form of menorrhagia; a serous, non-odorous discharge; and a moderate degree of pain.
Later, when ulceration and disintegration take place, the hemorrhage becomes more profuse and continuous. The discharge becomes fetid, and contains broken-down sarcomatous tissue. The pain becomes more severe. The uterus is enlarged, and the nodular outline may be determined by palpation.
Before metastasis has taken place the differential diagnosis between sarcoma and benign fibroid tumor can be made only by microscopic examination of the discharge or of curetted or excised portions of tissue. The duration of sarcoma of the uterus is about three years.
Sarcoma may occur at almost any age. Hysterectomy has been performed for this disease in a girl of thirteen. Several cases have been reported under twenty years of age. The most usual period is about the time of the menopause, in the decade from forty to fifty.
The treatment of sarcoma of the uterus is immediate complete hysterectomy. If in the early stage a positive diagnosis cannot be made between benign fibroid and sarcoma, the woman should not be exposed to the dangers of waiting, but the uterus should be immediately removed.
Chorio-epithelioma or syncytioma malignum is a rare and peculiar malignant growth of the uterus which occurs after pregnancy. It originates at the placental site from the epithelial cells covering the chorionic villi. It occurs during the course or after the termination of a uterine or tubal pregnancy. In typical cases the disease immediately follows labor at term, abortion, or a destroyed extra-uterine pregnancy. It may, however, remain latent for weeks or months.
The tumor may be a nodular or pedunculated outgrowth attached to the uterine wall; a fungoid growth from the endometrium; or an intramural growth covered with endometrium. The tumor varies in size from that of a cherry-stone to a mass several inches in diameter. It is composed of soft fragile spongy tissue, light or dark red in color, infiltrated with blood, and containing circumscribed hemorrhages. Histologically the tumor consists of many types of cells irregularly placed; syncytial tissue, cells derived from Langhans’ layer, and sometimes chorionic connective tissue. There are numerous cavities containing blood and connective tissue.
Metastatic growths have a similar structure. Metastasis takes place through the vascular system and may reach distant organs—the lungs, liver, and spleen.
Symptoms.—There is no characteristic symptom of chorio-epithelioma. The chief symptom is irregular or continuous hemorrhage from the uterus following a labor, an abortion, or an extra-uterine pregnancy. The body of the uterus is enlarged, and the cervical canal dilated as in cancer and sarcoma. A positive diagnosis can be made only by microscopic examination of tissue removed by the curet.
Treatment.—As the disease is exceedingly malignant and of rapid growth, immediate hysterectomy is indicated.