of the cervix are very rare. They are described by Neumann (Winter's "Lehrbuch der Gynakologischen Diagnostik," hi. Auf.) as occurring about the os externum and on either or l><>th the anterior and posterior lips of the cervix. The ulcers are ellip- tical in shape with sharply defined wdgv*, shallow or deep, generally with yellow purulent covering. Good-sized fungous granulations are apt to be found on the surface. These ulcers are to be differ- entiated from cancerous ulcerations by their irregular and sinuous borders, their rapid disintegration, and the crater-like excavations of their tissues. Syphilitic lesions elsewhere in the body assist in making the diagnosis, the microscope being the court of last resort.
<Callout type="important" title="Important">Diagnosis of Adeno-carcinoma of the Cervical Canal</Callout> In this form the diagnosis is of necessity difficult. Palpation will show usually thickening of the cervix and perhaps a nodular feeling. If the external os is normal, a nodular thickening and the detection of a bloody discharge from the os may be all of the pious signs. If the os is open because of tears, ulcerated and indurated tissue in the canal may be both palpated by the finger in the canal and seen with a uterine or bladder speculum. With the aid of a sharp, stiff-shanked curette, tissue is removed for microscopic examination. In the infiltrating variety where there is no ulceration, palpation having shown localized thickening of the tissues, the external os should be dilated under ether and a piece of tissue excised for a microscopic examination. In curetting the body and fundus of the uterus it is very easy to overlook this situation.
<Callout type="risk" title="Risk">Cervical Canal as Point of Origin</Callout> The physician should bear in mind always that the cervical canal is one of the points of origin of cancer. Differential Diagnosis of Adeno-carcinoma of the Cervical Canal This form of cancer of the uterus is to be differentiated from interstitial myoma, and chronic cervical endometritis in old women. As to the former, the infiltration of the tissues surrounding the center of the disease distinguishes carcinoma from myoma. In the case of the latter the mucous membrane of a chronic endocervi- citis is more normal to sight, although not necessarily so to the touch, and the curette carries away little tissue. Tissue is removed and the microscope tells the last word.
<Callout type="tip" title="Tip">Cancer of the Body of the Uterus</Callout> The symptoms are the chief guide to a diagnosis of cancer of the body of the uterus. Bleeding alternating with a watery discharge, occurring in a woman who is past the menopause, and the exclusion of fibroids and of cancer of the cervix, make cancer of the body probable. Cancer of the body of the uterus is more common in nulliparae than in women who have borne children. There is sometimes a characteristic odor to the uterine discharge in cancer. It can not be described, however. A recurrent pain, similar to labor pains, coming on regular days and of several hours' duration, the so-called Simpson symptom, has been described as characteristic of cancer of the body. This sort of pain is found also in myoma of submucous evolution and must be interpreted as the result of the stimulation of the uterus by a foreign body which it is trying to expel.
<Callout type="warning" title="Warning">Microscopic Examination Required</Callout> A uterine discharge occurring in a woman past forty should lead to an investigation. So, also, palpation gives no characteristic feeling. There should be slight enlargement of the body; there may be tenderness. In patients with very thin or lax abdominal walls it may be possible in exceptional cases to make out a localized tumor in the body of the uterus. This is unusual. The diagnosis is established by exploration of the cavity of the uterus, first with the sound and then with the curette forceps or the finger. The sound will detect friable tissue, the curette forceps will remove it for microscopic examination. Every part of the uterine cavity must be reached by the curette, as the initial lesion may be very small and easily overlooked.
<Callout type="important" title="Important">Sarcoma of the Uterus</Callout> Sarcoma of the uterus is of very rare occurrence. It is most often found between the ages of forty and sixty. W. A. Edwards (Amer. Jour. Med. Sci., July, 1909) has recently collected 16 cases of sarcoma of the uterus in children who were fifteen years of age or younger. It forms about 4.8 per cent of all malignant growths and 2 per cent of all uterine tumors. (E. Hurdon, Kelly and Noble, "Gynecology and Abdominal Surgery," Vol. L, p. 151.) It is a disease originating from connective-tissue elements as contrasted with epithelial elements from which carcinoma arises.
<Callout type="risk" title="Risk">Metastases in Sarcoma</Callout> Metastases by way of the blood current occur in about a fourth of the cases of sarcoma of the endometrium, according to G. Winter. They are in the lungs, intestine, and peritoneum. The lymph glands are very seldom involved. Metastases from sarcomata of the uterine wall or myomata invaded by sarcoma are more frequent, being found in the lungs, liver, and intestine.
<Callout type="tip" title="Tip">Chorioepithelioma Diagnosis</Callout> The diagnosis depends on the apparent recurrence of a placental polyp after abortion or a hydatidiform mole, with hemorrhage, and a watery, foul discharge. Rapidly developing anemia under such conditions is a suspicious symptom, as the anemia develops more rapidly in this than in any known disease. Tissue removed by the curette or curette forceps is submitted to microscopic examination. Better still the cervix is dilated until the canal will admit the physician's forefinger and digital exploration demonstrates the presence of a soft tumor. The tissue of a chorioepithelioma is much more friable and softer than that of a placental or other polypus. The uterus is found to be somewhat enlarged when the bimanual touch is practiced. In most cases it is not sensitive. In cases of hydatidiform mole the physician should keep his patient under observation for several weeks after the mole has been delivered and should bear in mind the possibility of the development of a chorioepithelioma.
Early removal of a chorioepi- thelioma is attended by lasting cure.
Key Takeaways
- Use palpation and microscopic examination to diagnose uterine cancers and sarcomas.
- Look for specific symptoms like bleeding, discharge, and pain in the diagnosis of uterine cancer.
- Understand that sarcoma is rare but can occur in women of reproductive age.
- Be aware of metastases as a significant risk in both uterine cancer and sarcoma.
Practical Tips
- Always perform thorough microscopic examinations to confirm diagnoses, especially for cancers and sarcomas.
- Keep an eye out for unusual symptoms like recurrent pain similar to labor pains, which can indicate uterine cancer.
- Regularly monitor patients who have had a hydatidiform mole or abortion for the development of chorioepithelioma.
Warnings & Risks
- Do not overlook the possibility of metastases when diagnosing uterine cancers and sarcomas, as they can spread to distant organs.
- Be cautious with tissue removal techniques; ensure proper sterilization and handling to prevent infection or contamination.
- Avoid misdiagnosing interstitial myoma as adeno-carcinoma due to similar symptoms.
Modern Application
While the specific diagnostic methods described in this chapter are outdated, the principles of thorough examination and microscopic confirmation remain crucial for modern survivalists. Understanding these diseases can help in recognizing early signs and seeking appropriate medical attention.
Frequently Asked Questions
Q: How can a chorioepithelioma be diagnosed?
A chorioepithelioma is diagnosed by the appearance of a watery, foul discharge after an abortion or hydatidiform mole, along with bleeding and rapid developing anemia. Microscopic examination of tissue removed during curettage confirms the diagnosis.
Q: What are the common symptoms of uterine cancer?
Common symptoms include alternating bleeding and watery discharge in post-menopausal women, as well as a recurrent pain similar to labor pains (Simpson symptom). Other signs may include an enlarged uterus or tenderness.
Q: Why is microscopic examination crucial for diagnosing uterine cancers?
Microscopic examination is essential because it can distinguish between different types of tissue and confirm the presence of cancer cells, which cannot be determined through physical examination alone.