CHAPTER XVI THE DIAGNOSIS OF MALIGNANT DISEASES OF THE (Part 1)

CHAPTER XVI THE DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS Cancer, Sarcoma, and Malignant Chorioepithelioma Cancer of the uterus, p. 266: Definition, p. 266. Varieties, p. 266. Diagnosis of cancer of uterus in general, p. 270. Diagnosis of cancer of the cervix, p. 271; Differential diagnosis of cancer of the cervix, p. 272. Diagnosis of adeno-carcinoma of the cervical canal, p. 275; Differential diagnosis of the adeno-carcinoma of the cervical canal, p. 276. Diagnosis of cancer of the body of the uterus, p. 276; Differential diagnosis of cancer of the body of the uterus, p. 277. Sarcoma of the uterus, p. 278: Frequency and definition, p. 278. Varieties, p. 279. Malignant chorioepithelioma, p. 280: Definition, macroscopic and mi- croscopic appearances, p. 280. Course of the disease, p. 281. Ectopic malignant chorioepithelioma, p. 282. Diagnosis, p. 283. THE DIAGNOSIS OF CANCER OF THE UTERUS By cancer of the uterus we understand a malignant new growth the essential elements of which consist of epithelial cells having a characteristic arrangement. The cancer cells may proliferate and directly invade the surrounding tissues or they may be transported by the lymphatics to distant sites and there proliferate and form metastatic growths. Varieties The mucous membrane of the uterus may be divided into three types: (1) That covering the vaginal portion of the cervix, extend- ing from the vaginal vault to the external os, and composed of squamous-celled epithelium. (2) That lining the cervical canal from the external os to the internal os, and composed of high cylindrical epithelial cells; and (3) That lining the uterine cavity proper from the internal os to the fundus, and composed of low 266 CANTER OF THE UTERUS 261 cylindrical or cuboidal epithelial cells. Cancer of the uterus al- ways originates in the mucous membrane, and the type of cancer is determined by the character of the cells of the mucous mem- brane in which it originates. We have then three kinds of cancer of the uterus: 1. Squamous-celled cancer of the cervix. 2. Adeno-carcinoma of the cervical canal. 3. Adeno-carcinoma of the body of the uterus. Fig. 110. — Early Stage of Squamous-celled Cancer of the Cervix. The Cauli- flower Mass has been Curetted away. (Cullen. Very rarely there is present a squamous-celled cancel- of the body of the uterus. 1. Squaynous-celled cancer of the cervix begins at or near the junc- tion of the cervical and vaginal mucous membranes at the external os. Clinically, three types are recognized: (a) The everting or cauliflower growth, in which there is marked proliferation of the cancer, the growth spreading to and involving by direct extension the vault of the vagina. (6) The infiltrating type, in which the external contour of the cervix may remain normal, the growth extending internally deep into the wall of the cervix, (c rhe ulcerative type, in which ulceration with loss of cervical tissue takes place early and proceeds until the entire cervix is eroded. 268 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS The squamous-celled type of cancer of the cervix is usually of rapid growth and it soon involves the surrounding tissues and organs — the bladder, the ureters, and rectum. The lymph glands of the parametrium and the iliac glands receive the cancer by means of the lymph channels and themselves take up the disease. Microscopically the squamous-celled type begins as an hyper- trophy of the pavement squamous epithelium of the cervix. The cells themselves hypertrophy and have large round or oval vesic- ular nuclei with many mitotic figures. These cells invade the Fig. 111.— Very early Adeno-Carcinoma of the Cervical Canal. (Cullen.) cervical tissue in all directions and without any typical arrange- ment. 2. Adeno-carcinoma of the cervical canal originates in the high cylindrical epithelial cells lining the cervical canal and the glands of the cervical canal. This t}^pe of cancer of the cervix spreads perhaps less rapidly than the squamous-celled variety, although necrosis takes place rather early. The squamous-celled variety seldom spreads beyond the level of the internal os, but the adeno- carcinoma frequently reaches to the fundus. The cervix may be reduced to a mere shell by the necrosis of the latter form of cancer and yet the external contour of the cervix remains unchanged. Metastasis to the surrounding organs, the bladder and rectum, CAXCER OF THE UTERUS 269 takes place usually by direct extension of the growth. The iliac glands are involved sometimes early and sometimes late, as is the case with the squamous-celled variety. Microscopically adeno-carcinoma of the cervix is recognizee! as a proliferation of the cylindrical cells of the cervical mucous membrane, these cells preserving their alveolar or glandular ar- rangement. There is distinct loss or crowding out of the inter- glandular stroma, the proliferating alveoli lying close to one another. 3. Adeno-carcinoma of the body of the uterus originates in the low columnar epithelium lining the uterine cavity and the glands Fig. 112. — Early Adeno-Carcinoma of the Body of the (Jterui Cull. of the endometrium. It usually starts at the fundus or in one cornu as a circumscribed area of proliferation of the endometrium. From this point it may spread until it involves the entire uterine; cavity. The growth may proliferate, forming actual outgrowth* of endometrium into the uterine cavity, as well as invade the uterine muscular wall. The growth may ulcerate it- way thro the uterine wall and appear in the peritoneal cavity and form peritonea] metastases. This is generally a late process of a existing cancer. The ordinary benign uterine polyp, I" ereil by endometrium, may become carcinomatous. Adeno-carcin 270 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS of the body seldom extends beyond the internal os, although adeno- carcinoma of the body and cervix may coexist. Glandular metastasis from this form of cancer is late. Microscopically adeno-carcinoma of the body is recognized by the proliferation of the low cylindrical cells of the endometrium of the fundus, these cells preserving their glandular arrangement with distinct loss of interglandular stroma. The cells lining the new glands are from two to four layers deep or possibly entirely fill the alveolus. Diagnosis of Cancer of the Uterus in General" It is important to keep in mind that cancer is always a local disease in the beginning and that prompt removal of the diseased tissues effects a permanent cure ; therefore early diagnosis is espe- cially important. A failure to make a correct diagnosis is followed surely by the death of the patient in from six months to a year and a half. Late operations, except in the case of cancer of the body, are of value only in prolonging life a few months or a year or two, and in lessening suffering. The view commonly held by the laity, and, sad to relate, by too many of the medical profession, that cancer is an incurable disease is not true, provided that it can be recognized and removed before it has gained a good head- way. It appears that progress is being made in getting patients to submit to examination at earlier periods of the disease. G. Win- ter's works in spreading a propaganda, both among the physicians and the laity, in East Prussia, is most encouraging (Zentralblatt fur Gynakologie, 1904, No. 14, p. 441). It is a fact, however, that at the present time a large proportion of the sufferers from this dread disease are permitted to get into an absolutely hopeless state, then to go through the awful months of suffering until a lingering death releases them. The symptoms of uterine cancer are by no means pathognomonic ; they are suggestive and are as follows: Bleeding, particularly in women who have passed the menopause; and hemorrhage or a show of blood after coitus, also a persistent or recurring sero- sanguinolent vaginal discharge. Neither of these is a symptom of the normal menopause, as has been maintained in the past. The CANCER OF THE UTERUS 271 menopause has no local symptoms if the uterine organs arc normal. Bleeding or a vaginal discharge occurring at the time of change of life should lead at once to a vaginal examination to determine the cause. Pain and cachexia are symptoms of the advanced, hope- less stages of the disease, only at this time one does not have to be a physician to make a diagnosis. Although the disease occurs most commonly in women who are between the fortieth and fiftieth years it may occur at any age between eight and seventy-six. Clinically, heredity seems to play a role, though this has been disputed. The disease is relatively rare in the colored race. It is more frequent among women who have borne children than in nulliparae. The diagnosis varies with the progress of the disease, and the variety of cancer present; the early stages, while the normal tissues are being replaced by cancer cells, show only a slight local thicken- ing or proliferation; the later stages, when the tissues are breaking down and degenerating, show ulceration, bleeding, and detritus with foul odor. As has been pointed out in describing the different forms which cancer assumes, the disease advances in different manners and at different rates of speed in individual cases. It may progress to a fatal termination in a year; on the other hand, I have had a patient who had the erosion type of cancer of the cervix where there was every indication that the disease had existed for twenty years. The tissues may be brittle and easily disintegrating, or tough and hard. The tissues most commonly Invaded by the differenl kinds of cancer have been noted, therefore in making a diagnosis the routes of extension of the disease must be taken into account. We employ both touch and sighl in makings diagnosis, as well as microscopic examination of tissues removed. Diagnosis of Cancer of the Cervix This, of all forms of uterine cancer, Is the easiesl of diagnosis because the lesions can be detected by both touch and sight. (a) The cauliflower growth is the simplest, growing as h -I'" a polyp-like mass projecting from the cervix into the vagina. In the early stages this appears a- an indurated, reddened area raised 272 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS above the surrounding mucous membrane. In its later progress one expects to find a larger tumor, recldish-gray in color, with softened, disintegrated tissue. The sound perforates it with ease, and any manipulation causes hemorrhage. (b) If the infiltrating sort is present the tissues are indurated and the contour of the cervix may be altered or not. If the vaginal mucous membrane overlying the growth is intact the diagnosis is difficult. In all suspicious cases a wedge-shaped piece of tissue should be removed and submitted to the pathologist for micro- scopic examination. (c) The ulcerating variety is distinguished by an ulcer of exca- vating tendency. There is much loss of substance; the edges of the ulcer are rough and irregular; the base is necrotic; the under- lying tissues are hard to the feel. If portions of the deeper parts of the edge of an ulcer crumble on pressure by the ringer or sound the condition is suspicious of cancer; also, if the edge of the ulcer has a porky consistency and is of a yellowish-gray color. In all doubtful cases a piece of tissue must be removed for microscopic examination. To do this fix the cervix with a double tenaculum just outside the diseased area and let an assistant hold the tenacu- lum. If the cervix proves to be sensitive inject into the sound tissue surrounding the diseased area, in several places, a few minims of two-per-cent sterile solution of cocaine with a hypodermic syringe. Wait five minutes. With a single tenaculum and a scalpel or scissors cut out a good-sized piece of the diseased tissue in the shape of a wedge. Be prepared to place a catgut stitch with a curved needle should there be much bleeding. Often an application of tincture of iodine and carbolic acid followed by a dry tampon will be sufficient to stop all bleeding. The patient should not be dismissed until it is known that the bleeding has been controlled. Differential Diagnosis of Cancer of the Cervix (a) Cauliflower Form. — The cauliflower form of cancer of the cervix must be differentiated from: (1) Follicular hypertrophic polyp, (2) Mucous polyp. (3) Papillary tuberculosis. CANCER OF THE UTERUS 273 (4) Myoma of the cervix. (5) Condylomata acuminata. (1) The follicular hypertrophies of the cervix produce discrete tumors, in some cases similar to polypi. They are soft, of a red color, and show the rounded, yellow, shot-like, dilated Nabothian follicles in their substance, the condition being not unlike that in the tonsil. The follicles may be seen and felt also in the surround- ing normal mucous membrane of the cervix. There is lacking the crumbling consistency, the sharp edges, and the indurated base of the cauliflower cancer. The microscope will confirm the diag- nosis. (2) Mucous polypi, especially if multiple and having a lumpy appearance, may be mistaken for cancer. Polypi are covered everywhere with mucous membrane, they are soft, and the sound will detect the position and size and shape of their pedicles. (3) Papillary tuberculosis, although relatively rare, may simulate closely polypoid carcinoma in its early stages. The external os may be surrounded by a papillary excrescence. It is possible in favorable cases to determine the presence of the little glassy tuber- cles the size of a millet seed lying in the greasy, cheesy substance characteristic of broken-down tuberculous tissue. In tuberculous disease of the cervix the ulcerated form is more common than the papillary. The diagnosis must be made by the microscope. (4) Myoma of the cervix is rare. A cervical myoma is covered with a smooth mucous membrane, it disintegrates by ordinary gangrene, and has a firm and not a crumbly consistency. (5) Pointed condylomata may simulate papillary cancer, especially during pregnancy. They form a circumscribed tumor of irregular surface; but they have no infiltrated base and no real ulceration, only a papillary surface with thick epithelium. They are of a reddish-white color. As a rule they occur in more than one Bitua tion at the sarin; time, i.e., on the wall of the vagina or Oil the vulva. (6) Infiltrating Cancer. Infiltrating cancer is confused mosl often with inflammatory diseases of the cervix occurring in connection with tears, especially when the tissues are indurated and nodular, as they often are. As a rule the inflammatory process involves the entire cervix, the consistency is not so hard as in cancer, and the external mucous membrane is qo1 involved. If the cervix is riddled with diseased Nabothian follicles the similarity of the two 13 274 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS conditions is often great. But here the cancer is limited, whereas the inflammatory affection is universal. In all cases a piece of tissue should be removed for examination. (c) Ulcerating Form. — The ulcerating form of carcinoma must be differentiated from: 1. Erosion. 2. Simple ulcer; as in prolapse. 3. Tuberculous ulcer. 4. Chancroids. 5. Syphilitic ulcer. 1. If there is very little infiltration and induration a cancerous ulceration may simulate a simple erosion, especially in those cases where the erosion has a thick, roughened surface. The character- istics of the malignant ulceration are to be borne in mind. Also, the erosion as seen through the speculum presents a bright red, shining appearance, while the cancerous ulceration shows loss of substance and a dull red or yellowish-gray color. The erosion has no sharp edge, but shows a gradual transition of the pavement epithelium of the normal mucous membrane to the erosion by a border of irregular outline, and there are apt to be islands of normal mucous membrane in the erosion. If there is infection of the erosion, scar formation results. In doubtful cases the microscope must be brought in. (2) Simple Ulcers. — These occur in prolapse; they are generally not situated at the external os, while the carcinomatous ulcers are more apt to be in that situation. They are apt to have a light yellow base and show cicatrization about the periphery, and there are islands of mucous membrane in the central portions. After the prolapsed uterus has been replaced for a day, all traces of infiltration of the tissues under such ulcers disappear and evidences of repair at the edges can be seen. As a rule there is little or no thickening of the tissues under these ulcers. This is the case also with ulcers caused by an ill-fitting pessary. They heal readily. (3) Tuberculous Ulcer. — This, although rare, is very similar to carcinomatous ulcer. Both are generally situated around the external os; the base of the tuberculous ulcer is yellow in color, nodular but not infiltrated. Yellow, miliary tubercles may be seen in the mucous membrane in the neighborhood of the ulcer. CANCER OF THE UTERUS There fs apt to be present also tuberculosis of the endometrium and of the tubes. The microscope settles the diagnosis. (4) Chancroids are generally small in size and multiple; their base has a diphtheritic, grayish appearance, and is not indurated, and the edges are indented and raised. Similar lesions arc to be found generally in the vagina and vulva. (5) Syphilitic ulcer may occur on the cervix in three forms: (a) as an ulcerated initial lesion, (b) as broken-down papules, or (c) as a degenerated gumma. (a) The initial lesion is solitary and of great hardness. The ulcer has a sharp edge and is of a dirty reddish-brown color: its discharge being of a greasy consistency. It may extend into the cervical canal in the case of a parous woman with open os externum. (b) Ulcers from papules are generally multiple and are elevated above the surrounding surface of the normal mucous membrane. Their surface is covered with disorganized white or yellowish tissue. Near them are to be found non-ulcerated papules, especially on the walls of the vagina and vulva. (c) Gummata