Symptoms

1. There may be none. The patient may be asymptomatic.

2. Discharge from the vagina.

3. Vaginal bleeding. May be merely spotting or frank hemorrhage. Especially in the postmenopausal women this should instigate an intensive study to ride out cancer.

4. Pain. This may be a relatively "early" symptom and take the form of cramps of types sometimes associated with menstruation. Or, in more advanced disease, there may be deep-seated pelvic pain with radiation to the lumbar region, suprapubic region, and thighs.

5. Symptoms due to compression or invasion of the bladder, ureters, or rectum may occur in advanced disease but are considerably less common than in cervical cancer.

6. Symptoms of anemia may be noted especially if hemorrhage is prominent

Signs

1. May be none. The uterus may appear entirely normal, and a positive or suspicious cytology on the vaginal smear may be the only clue to the diagnosis.

2. Enlargement of the uterus. The organ may be diffusely enlarged, heavy, and boggy, or an area of localized enlargement may be detectable. The uterus may appear to be movable or fixed, depending on the stage of disease.

3. The parametrium (one or both) may be involved.

4. Occasionally the cervix and even the vagina may be involved.

5. Metastatic disease may be palpable in the inguinal, vaginal, or vulvar regions. Distant metastases are more common than in cervical cancer.

Adequate physical examination may be rendered difficult because of the tendency of patients with endometrial cancer to be obese.

Steps In The Diagnosis And Initial Management Of The Endometrial Cancer Suspect

Whether the physician is required to rule out endometrial cancer only because of an abnormal vaginal smear revealing cytology suspicious or positive for adenocarcinoma or as a result of suggestive symptoms or signs, the sequence is more or less the same.

1. Careful bimanual pelvic examination with particular emphasis on outlining the size, contour, and mobility of the uterus proper and separating it from the adnexa.

2. Vaginal and cervical smears. Presumably these will have been done as part of the initial screening examination on presumably healthy women. If any suspicion has been aroused, both smears should be repeated.

3. Endometrial aspiration (Fig. 58). This can be an office procedure if one has the proper equipment and interest. It is particularly useful in sampling the endometrial cells when cervical stenosis or other conditions have prevented the usual descent of exfoliated cells into the vaginal pool.

4. Endometrial curette biopsy. This should be done only by one trained in gynecologic techniques. The combination of vaginal smear, endometrial aspiration, and endometrial curettage raises the over-all accuracy of diagnostic procedures in endometrial cancer to over 95%.

5. Dilatation and curettage. The need for a formal dilatation and curettage of the conventional type may be dictated by the circumstances of the particular case and the inclinations and training of the physician. It remains the most definitive way short of surgical exploration for ruling the diagnosis of cancer in or out. Its only disadvantages are the necessity for hospitalization with its attendant loss of time and money. 6. Follow-up. Any women in whom there remains any lingering doubt about the diagnosis after the evaluation just outlined should be followed at three- to six-month intervals by means of repeat pelvic examination, vaginal and cervical smears, and possibly endometrial aspiration or curettage. If the degree of suspicion warrants, surgical exploration may be required to resolve the issue in some patients.

Confirm tho position of the uterus. Point the cervix with 7% tincture of iodine. Introduce the Jordan cannula with the obturator in place until the stop disk rests against the external 01.

Remove the ebturotor and attach a 20 cc. (ml.) Luer-Lok or Martin aspiration biopsy syringe. Exert suction while gently rotating the cannula 180°.

Expel the aspirated material on a clean glass slide and spread Into a thin smear with the side of the cannula. If a largo amount of material is obtained, submit the remainder in 10% formalin for pathologic examination.

Fix the slide Immediately in equal parts of ether and 95% alcohol.

Insert a regular tampon, and Instruct the patient to remove it in twelve to twenty-four hears.

Fig. 58. Technique of endometrial aspiration.

Other sites of the female genital tract-vulva, vagina, ovary

Although the external female genitalia and the vagina are not frequent sites of cancer, they are accessible to detection procedures and thus merit consideration on this basis.

Vulva

Leukoplakia and kraurosis vulvae appear as white filmy surface changes in the early stage to thickening in the advanced stage. They are properly considered precancerous and should be given serious attention. Any area of thickening distinguished from adjacent nonpalpable lesions should be biopsied. In cases of persistent leukoplakia or kraurosis consideration should be given to prophylactic excision.

Pigmented lesions of the genitalia are of particular precancerous significance and should be excised and examined histologically as a preventive measure.

Vagina

Abnormalities of the vaginal mucosa are usually related to chronic or acute infections or to senile atrophic changes. On rare occasions vaginal carcinoma (squamous cell) presents as a localized lesion which may fungate and bleed. This can be seen on inspection and felt on palpation and should be directly biopsied for diagnosis. The only suggestion of vaginal carcinoma in its earlier stages may be the appearance of malignant cells on routine Papanicolaou smear. In almost all cases, when cells of the squamous type are detected cytologically, they will prove, on further diagnostic evaluation of the patient, to originate in a carcinoma of the cervix. In the rare instance of occult vaginal rather than cervical cancer, the iodine stain test can be helpful in identifying the area of vaginal mucosa to be biopsied.

Ovary

Bimanual palpation of the uterus and adnexa is an essential part of a complete cancer detection examination of women. By this means the position and size of the uterus are checked, and enlargement, most frequently due to fibro-myomas or adenomyosis, is discovered.

Ovarian enlargement is frequently more difficult to interpret but is potentially of greater importance for cancer detection. The following facts are helpful in evaluating the patient with an ovarian mass:

1. Regardless of size or consistency of the mass, the older the patient, the greater is the likelihood that an ovarian tumor is malignant rather than benign.

2. Of patients with carcinoma of the ovary, 407 are premenopausal (between the ages of 30 and 50 years) and 60% are postmenopausal.

3. A history of infertility is present in 40% of women with ovarian cancer, in contrast to the usual 5 to 10% of women.

4. From 25 to 30% of patients with ovarian cancer give a history of abnormal bleeding, which may be only a mild deviation from normal, generally due to estrin activation of the endometrium.

Symptoms

In women who have periodic pelvic examinations, ovarian carcinoma may be detected as an ovarian enlargement before the onset of symptoms. Otherwise ovarian carcinoma is usually not suspected until symptoms develop.

The most common symptom of ovarian cancer is pain, which occurs in 70% of patients. Other symptoms include increase in size of the abdomen (50%), urinary symptoms consisting of bladder pressure, frequency, and urgency (40%), vague gastrointestinal symptoms, vague discomfort and pressure, loss of weight (more common in cystic tumors), and ascites.

Management

Ovarian enlargement and/or irregularity in the adnexal region should be carefully noted. If the findings leave the question of tumor in doubt, the patient should be scheduled for re-examination ten days after the onset of her next menses if premenopausal or in three to four weeks if postmenopausal.

In obese patients or patients not easily examined, where there is fullness in the adnexal region with questionable enlargement of the ovary, examination under anesthesia should be considered, particularly in patients over 35 years of age.

Indications for laparotomy are the presence of an ovarian mass over 6 cm. in diameter or increase in the size of a smaller mass.

Surgical removal is the best primary method of treatment of all ovarian cysts and tumors.