What is a Microscopic Cancer of the Uterus?
Frederick R. Jelovsek MD, MS
Microscopic Cancer Of The Uterus
"What is microscopic cancer of the uterus? Is treatment needed after surgery?
I am 67 years old and had a complete hysterectomy three weeks ago. The report came back that I had microscopic cancer. I had been bleeding (not heavily) for eight months prior to seeing the doctor. Did not tell him because I was going through a depression since my husband's death and really thought this was the answer to my prayers...I wanted to die. Doctor found it on his own and said I needed surgery. As stated this was done three weeks ago.
My doctor called me with the results of the lab work - because it was so unexpected to me when he called, I couldn't think of the questions I had for him then - but will ask more at my appointment in another week. " Evie
The uterus can have several types of cancer, but the two major types are cancer of the endometrium, which is the lining of the uterus, and cancer of the cervix which is the entrance to the uterus. In addition, there are different cell types such as glandular or squamous (like skin) cells which can be the abnormal cancerous component. Therefore it is somewhat difficult to answer your question precisely without more information.
I will assume that the bleeding you had was from the inside of the uterus - the endometrium, and that your physician performed an endometrial biopsy in the office or a D&C (dilatation of the cervix and curettage or scraping of the endometrium). Then based upon the results, the hysterectomy was recommended. At the time of the surgery, there was probably not a visible cancer present but when the pathologist looked at the uterine specimen that was removed, they saw cancerous cells under the microscope and now there is a decision about whether any additional surgery, radiation therapy or chemical therapy is needed to prevent recurrent cancer in the future or to kill off any remaining microscopic cancer.
Cancer Questions And Answers
Let us look at the different possibilities so that you can understand what additional questions to ask and what are the issues and decisions your doctor is likely to bring up at your next visit.
If I have vaginal bleeding after the menopause, what does that mean and what needs to be done?
First we have to determine where the bleeding is coming from. Not infrequently, some woman may not know for sure if the bleeding is from the rectum, the urethra which leads from the bladder, or the vagina. If you are not certain, be sure to let the physician know. If you are quite sure the bleeding is coming from inside the vagina, the doctor will perform a vaginal speculum exam to see if the bleeding is from:
- an irritation, cut or growth in the vagina
- an irritation, a lesion or ulcer, or polyp or other growth on the cervix
- inside the uterus with no evidence of vaginal or cervical lesions, active bleeding or irritated tissue.
If there is a visible irritation of the vagina or cervix, the doctor will recommend treating that prior to any further investigation. Antibiotics and/or estrogen creme or pills may be used to stimulate the cervical and vaginal skin to heal itself. If there is any tissue that looks like a polyp from the cervix, it will be removed by biopsy. If there are any suspicious lesions or abnormal tissue in the vagina or on the cervix, then a biopsy of that area will be performed to see if there is cancerous tissue present. If there is no abnormal tissue in the vagina or on the cervix, an external cervical Pap smear and an endocervical canal brush Pap smear will be performed. This is done to diagnose if there is any microscopic cancer of the cervix or endocervix tissue present.
If there are no obvious causes for the bleeding seen on vaginal and cervical exam, then the next step is to obtain a tissue sample from the inside of the uterus. This is called an endometrial biopsy and can usually be performed in the office unless the cervix is scarred shut (cervical stenosis). If a biopsy instrument is too big to go into the cervix, a D&C in an outpatient surgical suite may need to be performed. Sometimes at this point, the doctor may order an ultrasound exam to measure endometrial thickness. If that thickness is less than 5 mm, then a biopsy or D&C can be avoided because it is unlikely (less than 1%) that cancer of the endometrium is present (1, 2, 3)
If an endometrial biopsy returns with normal endometrium (proliferative or atrophic) or if there is just very little tissue obtained and it is insufficient to make a pathological diagnosis and the doctor feels that the uterine cavity was well sampled, then this is considered a negative result and no further diagnostic studies are needed at that time. If the biopsy returns showing any endometrial hyperplasia with or without atypical changes or evidence of endometrial polyps, most physicians would go ahead with a hysteroscopy and D&C unless a hysterectomy was being considered. The endometrial biopsy which shows no cancer means that unsuspected cancer at hysterectomy would be at the 1% level or less, but if any hyperplasia is present, then that number rises and a D&C to rule out any more advanced changes is a good idea before instituting any medical therapy for the hyperplasia.
What is microscopic cancer of the endometrium (lining of the uterus)?
When a uterus is removed at the time of hysterectomy, if any hyperplasia or cancer is suspected, the inside of the uterus is visually inspected to see if a grossly visible cancer is present. If there is a cancer seen and it seems to invade half way through the uterine muscle or more, then lymph nodes in the pelvis are excised to examine microscopically by the pathologist to see if there is any spread of the cancer outside of the uterus. If no cancer is seen, the uterine tissue is sent to the pathologist to look microscopically at the tissue. If the pathologist sees cancer, the distance from the deep edge of the endometrial lining into the muscle is measured. The pathologist also grades the cancer, based on how abnormal the cells appear, into well-differentiated, moderately-differentiated and poorly differentiated. The doctor then determines any further treatment based on the stage (extension from the lining) and grade of the cancer.
Your doctor may consult a gynecologic oncologist or may refer you to one to decide if you need any further diagnosis or treatment. I cannot tell what they will recommend in your case because it will depend upon the particulars of the pathologist report and your doctor's observations at surgery. Basically if the chance is low that you have any spread of cancer beyond the uterus, they will recommend no further surgery or treatment at the present time. If there is more than a few percent chance of tumor spread, they may recommend further surgery to remove and sample the pelvic lymph nodes or they may even recommend treatment with radiation therapy just in case. Most of the time, cancer found microscopically at hysterectomy does not require further treatment because it is grade 1 (well-differentiated) and is only superficially invasive into the uterine muscle or less and there is a low risk that it is spread beyond the uterus. Try not to worry, but do not fail to follow-up with whatever your doctor suggests.
Early Stages of Endometrial Cancer and their Treatments
| Stage | Grade | Definition | Treatment | |
|---|---|---|---|---|
| 0 | Carcinoma in situ (CIS), intraepithelial carcinoma. Stage 0 is not an invasive cancer. | simple hysterectomy | ||
| I | The cancer is strictly confined to the body of the uterus and does not go into the cervix or beyond the uterus to adjacent structures. | |||
| IA | 1, 2 | cancer confined to endometrium | hysterectomy alone | |
| IA | 3 | cancer confined to endometrium | hysterectomy with supplemental radiation therapy if lymph nodes have tumor or if lymph node status is unknown | |
| IB | 1 | cancer invading to less than one half of the uterine muscle (myometrium) | hysterectomy alone | |
| IB | 2, 3 | cancer invading to less than one half of the uterine muscle (myometrium) | hysterectomy with supplemental radiation therapy if lymph nodes have tumor or if lymph node status is unknown | |
| IC | 1,2, 3 | cancer invading to more than one half of the uterine muscle (myometrium) | hysterectomy with supplemental radiation therapy if lymph nodes have tumor or if lymph node status is unknown | |
Grade 1 = well-differentiated histologic type
Grade 2 = moderately-differentiated histologic type
Grade 3 = poorly-differentiated histologic type
What is microscopic cancer of the cervix?
There is also a microscopic cancer of the cervix although with the history you give, this is less likely. Sometimes this is called microinvasive cancer of the cervix because the invasion can only be seen microscopically and not by just looking at the cervix. If you had bleeding and the doctor saw a cervical lesion and biopsied it, or there was no lesion but the Pap smear returned abnormal, then it is possible you ended up having a hysterectomy because the doctor found you had a severe dysplasia or a carcinoma-in-situ (confined to the skin lining and not invasive) of the cervix. While these conditions do not mandate a hysterectomy, that often is a choice especially if a woman is having other uterine problems such as bleeding or pain.
When the pathologist looks at the cervix from the hysterectomy specimen (most hysterectomies include removal of the cervix as well as teh body of the uterus) a check will be made to see if there are any cancer cells that are not confined to the surface of the cervix. If the cells penetrate the bottom edge of the skin lining and invade deeper into the cervical tissue, then this becomes and invasive cancer and it is staged depending upon how deep those cells can be seen microscopically. The early stages of cervical cancer are:
Early Stages of Cervix Cancer and their Treatments
| Stage | Definition | Treatment |
|---|---|---|
| 0 | Carcinoma in situ (CIS), intraepithelial carcinoma. Stage 0 is not an invasive cancer. | Cone biopsy of cervix or simple hysterectomy |
| I | The cancer is strictly confined to the cervix. | |
| IA | Invasion is limited to measured invasion into the cervical body with a maximum depth of 5 mm and the area of cancerous cells is no wider than 7 mm. (The depth of invasion should not be more than 5 mm taken from the base of the epithelium, either surface or glandular, from which it originates. Vascular space involvement, either venous or lymphatic, should not alter the staging.) | |
| IA1 | Measured invasion no greater than 3 mm in depth and no wider than 7 mm. | Cone biopsy or simple hysterectomy unless lymph vascular involvement seen on microscope |
| IA2 | Measured invasion greater than 3 mm and no greater than 5 mm in depth and no wider than 7 mm in area. | Radical hysterectomy |
| IB | Clinical lesions visibly confined to the cervix or microscopically greater than IA. | |
| IB1 | Clinically visible lesions no greater than 4 cm in size. | Radical hysterectomy and pelvic lymphadenectomy or radiation therapy |
| IB2 | Clinically visible lesions greater than 4 cm in size. | Radical hysterectomy and pelvic lymphadenectomy or radiation therapy |
There are not universal agreements on the exact treatment of microscopic cervical cancer and also the treatments can often be varied between surgery and radiation therapy depending upon your preferences and medical risk factors. Again, this would be something your doctor would seek advice about from a gynecologic cancer specialist or have you referred to see the specialist yourself.
In summary, it is possible that you do not need any further treatment other than the hysterectomy you have already had. If further surgery or treatment is suggested, however, the chance of cure is so high that you really have to consider undergoing the recommended procedures even though you may still be somewhat depressed of the loss of your husband. I hope all goes well for you.
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