Can endometrial cancer be cured without surgery

Uterine cancer

Overview

This article looks at uterine cancer, its risk factors, treatment options, and the chance of a cure. Benign growths of the uterine lining are also discussed. Various surgical techniques such as scraping and laparoscopy are explained.

What is Uterine Cancer?

Uterine cancer is a malignant disease of the lining (endometrium) of the uterus (uterus).

How common is uterine cancer?

It is the most common carcinoma of the female genital organs in developed countries. The incidence of uterine cancer has increased over the past 30 years. Around 24/100 000 women per year develop uterine cancer in Germany. Most women with the disease are over 50 years old, only 15% of all women with uterine cancer are younger than 50 years. The frequency peak is around the age of 70. 80% of all women with uterine cancer are after the menopause (postmenopause).

What are the risk factors for uterine cancer?

The most important risk factor is the continuous, constant stimulation of the uterine lining by hormones (estrogens). Overweight menopausal women who were not pregnant and who entered the menopause (last menstrual period) after the age of 52 are particularly at risk. Women with colon cancer also have a five-fold increased risk of developing endometrial cancer. Overweight women who have had breast or ovarian cancer in their families are also at increased risk.

How can you prevent uterine cancer?

The lining of the uterus often forms benign growths, so-called polyps. Cancer precursors and ultimately cancer can develop from such mucosal growths. Tissue growths (hyperplasias) and polyps are diagnosed by the ultrasound examination and by means of scraping (see below). Benign changes can be treated with hormone preparations or by surgical obliteration of the entire uterine lining. If the disease persists or recurs, patients who are going through menopause or have already passed it are advised to have their uterus removed.

In rare cases, uterine cancer can also occur in patients who have been treated with the hormone preparation tamoxifen for breast cancer. If tamoxifen is taken, an annual abdominal examination including ultrasound should be performed and any vaginal bleeding outside of menstruation should be clarified.

How can the disease be diagnosed?

The most common first symptom is vaginal bleeding in postmenopause (after menopause). Such bleeding should therefore always be clarified. 18% of this bleeding is caused by uterine cancer, 32% by benign mucosal growths and 5% by cervical cancer. After examination, an inconspicuous mucous membrane is found in 45% of the bleeding. Intermenstrual bleeding, discharge, difficulty or pain when urinating and pain in the pelvic area can also be other signs of uterine cancer.

During the gynecological check-up, a smear is taken from the area of ​​the cervix and examined for cells that are suspected of being cancerous. The smear shows tumors in only about 50% of patients with uterine cancer.

What happens with a scraping (Abrasio)?

The reflection and scraping of the uterus provides clarity about the nature of the changes inside the uterus. This is a short operation that involves scraping the cervix and then expanding it so that instruments can be used to get into the uterine cavity. First, the uterine cavity is inspected from the inside with an optic (hysteroscope). A spoon-like instrument (curette) is used to scrape tissue from the surface of the inside of the uterus. The removed material is then examined in the tissue (histology, cytology).

How is the extent of the disease classified?

In order to plan treatment, the doctor must know the stage of the disease. The following stages are differentiated in uterine cancer, using the classification according to FIGO (Fed. Int. Gynecol. Oncol.) Or TNM:

Stage I:

Stage II:

Stage III:

Stage IV:

Relapse:

In uterine cancer there are basically four different ways of expansion:

  • direct ingrowth into the neighboring organs,
  • Sowing through the fallopian tubes into the abdominal cavity,
  • Spread through the lymphatic system and
  • Dispersion via the bloodstream.

How can uterine cancer be diagnosed?

The gynecological examination by the gynecologist includes the vaginal examination, palpation, ultrasound examination and scraping with a subsequent tissue examination.

How can the disease be treated?

There are 4 different ways to treat uterine cancer.

  • Surgery (surgical removal of the tumor)
  • Radiation therapy (high-energy rays kill cancer cells and shrink tumors)
  • Chemotherapy (in this case drugs are used - partly via an infusion - to kill the cancer cells)
  • Hormone therapy (female hormones are used to kill cancer cells)

The most common therapy for uterine cancer is surgery.

1. Surgery: abdominal incision or laparoscopy for uterine cancer?

Approximately ¾ of all women with uterine cancer are diagnosed at stage I. More than 90% of all those affected can be treated primarily surgically. The uterus, fallopian tubes and ovaries are removed and, depending on the staging, the lymph nodes (lymph nodes are small, bean-shaped structures that occur all over the body. They produce and store immune cells that fight infections). The operation can be done either through an incision in the abdomen (open laparotomy) or through a minimally invasive procedure, the laparoscopy (laparoscopy) with removal of the uterus through the vagina. During the laparoscopy, an endoscope and the instruments, which are only 5 - 10 mm wide, are pushed into the abdominal cavity through several small accesses. The laparoscopy is gentler on the patient and is associated with less pain and less blood loss.

2. Radiation for uterine cancer

The radiation uses X-rays, which kill the cancer cells and shrink the tumors. In external radiation therapy (teletherapy), also known as percutaneous radiation, the rays come from a machine outside the body. On the way to the target tissue, the radiation has to pass through other, healthy tissue and can possibly damage this (side effects). Internal radiation therapy (afterloading therapy) involves introducing radioactive material (radioisotopes) through small plastic tubes into the area where cancer cells are found. This method has the advantage that the radiation remains limited to the area that one wishes to irradiate. The irradiation can be done alone or before or after an operation, depending on the extent of the disease. Both procedures (internal and external radiation therapy) can also be used together.

In terms of side effects (radiogenic side effects), a distinction must be made between acute and chronic side effects.

With radiation therapy alone, acute radiation side effects are particularly evident in the vagina, intestines and bladder. Skin reactions are unlikely, as is a change in the blood count. The side effects of radiation appear on the vagina in the form of reddening or inflammation. Radiogenic changes in the bladder in the form of painful urination, bladder spasms or an hourly urge to urinate at night and / or bloody urine or urinary retention, possibly combined with painful bladder spasms, are observed. Radiogenic side effects are exacerbated by additional bacterial infections. In the intestinal area, there may be pain when defecating, mucus secretions or pain or even blood secretions, rarely diarrhea.

In terms of chronic side effects, fistulas and constrictions (stenoses) are the most serious forms. Chronic bladder and bowel infections can occur. In the area of ​​the vagina, shortenings and adhesions and impairments during sexual intercourse (cohabitation) are to be expected. Severe side effects that require surgery or long-term treatment occur in 0.7% - 8%.

3. Chemotherapy for uterine cancer

Chemotherapy uses drugs to kill cancer cells. Chemotherapy can be taken in pill form or given directly into the body as an infusion through a vein. The drugs enter the bloodstream, work throughout the body and can also destroy cancer cells outside the abdomen. However, it cannot be prevented that some of the healthy cells also die.

The side effects vary depending on the drug. Hair loss, nausea, vomiting, skin problems, sensory disorders in the hands and feet, and a reduction in blood cells can occur.

4. Hormone therapy for uterine cancer

Hormone therapy is the use of hormones to kill cancer cells. Hormones are usually taken in pill form. Some forms of cancer are particularly sensitive to hormones. This is determined during the histological examination. Medroxyprogesterone acetate (MPA) or megestrol acetate (MGA) can be used for uterine cancer. The side effects of this therapy are minor, however, in older patients, attention must be paid to an increased risk of thrombosis and embolism, an increased blood sugar level and a change in the calcium level. The therapy often brings about an improvement in general well-being and pain relief, but does not lead to healing.

The choice of treatment method depends on the stage of the disease. In the best case scenario, one operation can be sufficient. If there are risk factors for the spread of the disease and relapse, additional treatment after surgery is necessary, with radiation therapy being the method of choice here. In the case of tumor infestation of lymph nodes, irradiation is carried out after the operation and the radiation field is extended to the regions of the lymph nodes in order to combat the spread of tumor cells in these locations. In special cases, combined radiation and chemotherapy are also necessary. Local irradiation of the vagina after removal of the uterus is also advisable in high-risk patients.

If the cancer recurs, treatment is again dependent on the extent of the disease. Repeated surgery or chemotherapy may be necessary. If no adjuvant radiation therapy was performed primarily, this can be done in the event of a relapse.

Whether hormone replacement therapy should be given to women going through menopause after treated uterine cancer is controversial. Progestins (luteal hormone, progesterone) can be given. Estrogen therapy appears possible when there is a low risk of metastasis or relapse.

What are the chances of a cure in uterine cancer

The prospect of a cure and the choice of treatment method depend on the stage of the cancer (see above), the general state of health and also the histological type of tumor. (There are different classifications here: Grading 1: good prognosis, Grading 2: moderate prognosis, Grading3: worst prognosis). In the early stages, the receptor status (the tumor's response to female hormones) also influences cancer growth.

The mean 5-year survival rate for all stages is 65.1%; broken down into the individual stages, this is 72.3% for stage I, 56.4% for stage II, 31.5% for stage III and 10.6 % for stage IV.

The quality of life is usually not severely restricted after surgery and / or radiation therapy. Some women have lymphedema of the leg, which can be treated with lymphatic drainage and support stockings. Radiation therapy side effects only occur in 0.7-8% of cases. The psychological stress and v. a. The fear of a recurrence of the disease represents a limitation of the quality of life and the ability to perform for the first few years after diagnosis.

What should you watch out for after such an illness?

After cancer, the patients remain under close supervision (follow-up care). The clinical examination is carried out at three-month intervals during the first two years after the initial treatment in order to rule out a recurrence (recurrence) in the vagina or pelvis. These recurrences are curable. Furthermore, the risk of a secondary malignant disease in the digestive tract and chest area should be considered. Help should be given in dealing with psychological problems (self-help groups, psychotherapy).