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.
[Illustration: 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).
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.