Endometrial carcinoma.doc

Endometrial carcinomaEndometrial carcinoma is one of the most common malignancies, accounting for 7% of all female malignancies and 20%-30% of malignancies of female genital tract. This is predominantly a disease of postmenopausal and pre-menopausal women and most often occurs in women 50-60 years of age. In recent years, the incidence rate of endometrial carcinoma is increasing worldwide, in large part due to prolonged life expectancy, postmenopausal use of hormone replacement therapy and development of diagnostic techniques.Etiology and Risk FactorsThe cause of endometrial carcinoma remains unknown. However several risk factors for the development of endometrial cancer have been identified, including nulliparity, menarche at less than 12 years of age, menopause after age 52, polycystic ovary syndrome, estrogen-secreting tumors, any state of chronic anovulation and obesity (excess estrone as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat), which can cause endogenous estrogen over-stimulation of the endometrium. Besides, estrogen replacement therapy without progestins and prolonged tamoxifen use arise exogenous estrogen over-stimulation to the endometrium. Most of these risk factors are related to prolonged, unopposed estrogen stimulation of the endometrium. However, there appears to be other endometrial carcinoma that occurs in older women with no source of estrogen stimulation of the endometrium. Comparing with the “estrogen-dependent” tumor which usually develops from hyperplastic endometrium and less differentiated with a poorer prognosis. Other medical conditions, such as diabetes mellitus, hypertension and hypothyroidism, have been found to be related to endometrial cancer. Further investigations are needed to determine whether race is associated with endometrial cancer. Evidence is accumulating that there is a genetic factor in the development of endometrial cancer. Those women with a personal history of ovarian, colon, or breast cancer as well as those with a family history of endometrial cancer may be at a higher risk.PathologyEndometrial carcinoma may start as a discrete focal lesion as in a polyp, or it may also be diffuse in several different areas. In some situations it may involve the entire lining of the endometrial surface. Almost all endometrial carcinomas are primarily adenocarcinomas. The various types of endometrial carcinoma are listed in Table 18-1. endometrioid adenocarcinomas are the most common carcinomas found in the endometrium, representing 80% to 90% of all caicinomas.Patterns of spreadMost endomrtrial carcinomas grow slowly and are limited in uterus for a relatively long time, except some rare types, such as clear-cell adenocarcinoma and serous adenocarcinoma. Endometrial carcinoma can spread by four routes: direct extension of tumor to adjacent sites, transtubal passage of exfoliated cells, lymphatic dissemination, and hemotogenous dissemination. The mechanism of direct spreading is the most common, with resultant penetration through the myometrium and serosa. Endometrial adenocarcinoma can also involve the cervix via direct extension from contiguous spread. Adnexal metastases may also result in this fashion. The presence of cancer cells in pelvic washings and the development of widespread intraabdominal carcinomatosis in the face of early disease support the concept of transtubal spread. Lymphatic dissemination is clearly responsible for spread to pelvic and paraaortic lymph nodes. Hematogenous spread occurs late, with the most common site being the lungs. Other potential sites include the liver, brain, or osseous metastases. Clinical ManifestationsSymptoms of early endometrial adenocarcinoma are relatively few. The hallmark sign is postmenopausal bleeding, followed by abnormal vaginal discharge especially after menopause is present in some patients. Approximately 15% of all postmenopausal bleeding is due to endometrial carcinoma. Endometrial carcinoma should be considered in all females with postmenopausal bleeding, pymetra, and perimenpausal patients with abnormal uterine bleeding and chronic anovulation. About 10% of patients complain of lower abdominal cramps and pain secondary to uterine contractions caused by entrapped detritus and blood behind a stenotic cervical os (hematometra). If the uterine contents become infected, an abscess develops and sepsis may supervene. Signs of advanced disease include pelvic pressure, increased urinay frequency, constipation, the presence of a palpable abdominal mass, or ascites. Metastatic disease can be heralded by a chronic cough suggestive of pulmonary metastases to skeletal pain from bone involvement.Diagnostic TestsAll patients suspected of having endometrial carcinoma should have an endocervical curettage and an office endometrial biopsy. Hysteroscopy and transvaginal ultrasound may prove to be a useful adjunct to biopsy. A histologically positive endometrial biopsy allows the planning of definitive treatment.Because there is a false-negative rate about 10%, a negative endometriual biopsyin a symptomatic patientmust be followed by a factional curettage, which is considered the “gold standard” for determining the histologic nature of the endometrium.TreatmentSurgical Therapy The first step in the management of most endometrial cancer is surgery, which shoule performed as early as possible. The extent of surgery is due to the stage of the disease. The cornerstone of treatment for endometrial carcinoma is total abdominal hysterectomy and bilateral salpingo-oophorectomy, and this operation should be performed in all cases whenever feasible. Now primary surgery followed by individualized radiation therapy has become the most widely accepted treatment for early-stage endometrial cancers.Irradiation Therapy For patients who are not able to undergo or tolerate a surgical procedure, radiation, including external bean and intracavitary implant, is an alternative to surgery. It should be noted, however, that radiation alone has a poorer overall survival rate as compared with surgery.Hormone Therapy Progestins are currently recommended as initial treatment for stageand stagecancers with positive hormone receptors and for stage cancer when palliative treatment may be needed. If an objective response is obtained, the long-term, high-dose progestin therapy is worth trying because of their low toxicity. Side effects, which are usually minor, include weight gain, edema, thrombophlebitis, headache, drug hepatitis, and occasionally hypertension, which may disappear after cessation. Sometimes tamoxifen, which is a nonsteroidal antiestrogen with some estrogenic properties, is given along with progestins. The side effects with tamoxifen include nausea and vomiting, hot flashes, and osteoporosis, etc.Nursing AssessmentNursing HistoryThe nurse takes a complete history of the patients complaints, including a reproductive history and family history. The nurse also notes the presence of risk factors for endometrial cancer, such as obesity, diabetes, hypertension, nulliparity, early menarche, late menopause, long-term use of HRT, etc.Physical AssessmentEndometrial carcinoma usually presents with abnormal uterine bleeding. This may be menorrahgia or metrorrhagia in the premenopausal woman or may represent any type of postmenopausal bleeding. Other symptoms can include pyometra, pelvic pain, or pelvic mass. Many of the younger patients who develop adenocarcinoma tend to be obese and to have anovulatory menstrual cycles. Patients with estrogen-independent tumors tend to be older(mean, 65 years) and will frequently present with occult tumor or watery discharge. These patients also have higher grade and poor prognostic cell types.Psychological AssessmentMost patients with endometrial cancer are menopausal women, some of them already quitted their jobs, some are going to quit. At that time most of them are facing the change of life style and suffering some feeling of loss. The diagnosis of cancer undoubtedly increases their psychological stress and arises more psychological problems. If they can not cope successfully, severe anxiety may emerge. Before a diagnosis is made, the patient may deny that the symptoms are related to cancer. During the diagnostic phase, the woman may express fears and concerns about having a malignancy. After the diagnosis is confirmed, she may express disbelief, anger, depression, anxiety, or withdrawal behaviors. The patient may also express anxiety or fears about the proposed treatment.Nursing DiagnosisKnowledge deficit related to ignorance of the disease and its management.Fatigue related to blood loss.Fear related to a diagnosis of cancer and the proposed treatment.Sleep pattern disturbance related to pain and anxiety.Expected Outcomes1. The patient will understand the basic knowledge of the disease and treatment outcomes, as evidenced by her statements.2. The patients strength will be improved.3. The fear will disappear.4. The patient will sleep well.Nursing InterventionsPreventive Instruction The nurse may have responsibility for instructing women that postmenopausal bleeding or persistent irregular uterine bleeding in a premenopausal woman demands early investigation for the possibility of endometrial cancer. In addition, the nurse should make sure that women be well informed of when and how to use hormone replacement therapy appropriately. Unfortunately, there is no ideal screening method for endometrial cancer. Therefore mass screening of the population is not practical. However special attention should be given to high-risk persons for early diagnosis, including:postmenopausal women on exogenous estrogens; obese postmenopausal women, particularly when there is a family history of endometrial, breast, bowel, or ovarian cancer; women whose menopause occurred after 52 years of age; premenopausal women with anovulatory cycle, such as those with polycystic ovarian disease. In addition, the overweight women should be advised to lose weight and the women with diabetes and hypertension should be monitored for adequate control.Psychological Counseling Women beed to discuss their concerns about the presence of cancer and the potential for recurrence. The nurse provides emotional support and tries to create an atmosphere that encourages the woman to ask questions or express her fears and concerns. Significant others are included in discussions when possible.Nursing Care of The Patients Who Have Had an Abdominal Surgery Refer to section 8 for the detailed nursing care.Nursing Care of The Patients Receiving Hormone Therapy For the patient receiving hormone therapy, the nurse should underline the significance of strict medication and explain any medication prescribed in terms