Cellular Aberrations:

Uterine Cancer
In partial fulfilment of the requirements under

NCM 106

Respectfully submitted by:

Agpaoa, Archiam Joshua Pungtilan, Alexzandria
Castro, Shaynne Angelie Pungtilan, Lord Vito Corleone
Labao, Michelle Saducos, Grechelle Lyka
BSN IV-A, Group V

Respectfully submitted to:

Mrs. Gileen I. Lagadon
Lecturer

November 2017
BACKGROUND

Uterine cancer is defined as any invasive neoplasm of the uterine corpus. Invasive
neoplasms of the female pelvic organs account for almost 15 % of all cancers in women. The
most common of these malignancies is uterine cancers. An estimated 54, 870 cases are diagnosed
annually, leading to 10, 170 deaths. It is the fourth most common cancer, accounting for 7% of
female cancers, following breast, lung, and colorectal cancer. Endometrial adenocarcinoma is the
most common gynecologic malignancy in United States. However, it has a favorable prognosis
because the majority of patients present at an early stage, resulting in only 4% of cancer deaths in
women. Uterine sarcomas comprise <9% of cancers of uterine corpus, however is associated
with more aggressive behavior and poorer prognosis.

Non-cancerous Conditions

1. Fibroids

- benign tumors in the muscle of the uterus

2. Benign Polyps

- abnormal growths in the lining of the uterus

3. Endometriosis

- a condition in which endometrial tissue, which usually lines the inside of the uterus, is
found on the outside of the uterus or other organs

4. Endometrial Hyperplasia

- a condition where there is an increased number of cells and glandular structures in the
uterine lining; can have either normal or atypical cells or complex glandular structure

Types

1. Adenocarcinoma

This type makes up more than 80% of uterine cancers. It develops from cells in the
endometrium. This cancer is commonly called endometrial cancer. One common endometrial
adenocarcinoma is called endometrioid carcinoma, and treatment varies depending on the grade
of the tumor, how far it goes into the uterus, and the stage or extent of disease. A less common
type is called endometrial serous carcinoma. This form is treated like ovarian cancer, which is
also commonly of the serous type.

2. Sarcoma

This type of uterine cancer develops in the supporting tissues of the uterine glands or in
the myometrium, which is the uterine muscle. Sarcoma accounts for about 2% to 4% of uterine
cancers. In most situations, sarcomas are treated differently than adenocarcinomas. Types of
endometrial sarcoma include leiomyosarcoma and endometrial stromal sarcoma.

Staging

The stage provides a common way of describing the cancer, enabling doctors to work
together to plan the best treatments.

FIGO STAGES

Stage I: The cancer is found only in the uterus or womb, and it has not spread to other
parts of the body.

Stage IA: The cancer is found only in the endometrium or less than one-half of
the myometrium.

Stage IB: The tumor has spread to one-half or more of the myometrium.

Stage II: The tumor has spread from the uterus to the cervical stroma but not to other
parts of the body.

Stage III: The cancer has spread beyond the uterus, but it is still only in the pelvic area.

Stage IIIA: The cancer has spread to the serosa of the uterus and/or the tissue of
the fallopian tubes and ovaries but not to other parts of the body.

Stage IIIB: The tumor has spread to the vagina or next to the uterus.

Stage IIIC1: The cancer has spread to the regional pelvic lymph nodes
 Stage IIIC2: The cancer has spread to the para-aortic lymph nodes with or
without spread to the regional pelvic lymph nodes

Stage IV: The cancer has metastasized to the rectum, bladder, and/or distant organs.

Stage IVA: The cancer has spread to the mucosa of the rectum or bladder.

Stage IVB: The cancer has spread to lymph nodes in the groin area, and/or it has
spread to distant organs, such as the bones or lungs.

Grading

Doctors describe this type of cancer by its grade (G), which describes how much cancer
cells resemble healthy cells when viewed under a microscope.

The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually
contains many different types of cells grouped together. If the cancer appears similar to healthy
tissue and contains different cell groupings, it is called differentiated or a low-grade tumor. If the
cancerous tissue looks very different from healthy tissue, it is called poorly differentiated or a
high-grade tumor. The cancers grade may help the doctor predict how quickly the cancer will
spread. In general, the lower the tumors grade, the better the prognosis.

The letter "G" is used to define a grade for uterine cancer.

GX: The grade cannot be evaluated.

G1: The cells are well differentiated.

G2: The cells are moderately differentiated.

G3: The cells are poorly differentiated.

Risk Factors

1. Age Women between the ages of 50 and 70 are at increased risk. The chance of being
diagnosed with endometrial cancer increases with age. More than half of women with
endometrial cancer are diagnosed after age 55.
2. Obesity- women who are obese are two to four times more likely to develop endometrial
cancer than women of normal weight. This is because fat in the body can change other
 hormones into estrogen. The higher a womens estrogen levels, the greater her risk of
developing endometrial cancer, especially if she is more than 50 pounds overweight.
3. Women who use unopposed estrogen therapy- using unopposed estrogen means taking an
estrogen-containing pill or supplement that does not contain the estrogen-balancing
hormone, progesterone. Additionally, non-hormonal medications, such as Tamoxifen,
used for breast cancer patients, can increased the risk of endometrial cancer.
4. Women who have complex atypical hyperplasia. This is an abnormal tissue in the uterus
that is likely to turn into cancer if not treated.
5. Women who began menstruating early, before age 12. Estrogen is a key component in
menstrual cycles, so early menstruation means that a womans lifetime exposures to
levels of estrogen are higher.
6. Women who undergo menopause after the age 50. Menopause leads to loss of estrogen
when the ovaries stop working, resulting in symptoms of hot flashes. If menstrual cycles
continue after the age 50.
7. Women who have infrequent periods or a history of polycystic ovarian syndrome
(PCOS), a metabolism disorder that causes ovulation irregularities.
8. Women with a gene inherited at birth that increases the risk. This ca include women who
have 3 or more family members, of whom at least one parent, sibling(brother or sister) or
child, with one of the following diagnosis.
Colon cancer
Hepatobiliary cancer (cancer of the liver or gallbladder)
Ovarian cancer
Stomach cancer
Small intestine cancer
Brain cancer
Some forms of skin cancer

Manifestations

1. Abnormal Bleeding or Spotting

 - The most significant early warning sign is unusually heavy or prolonged vaginal
bleeding. Roughly 90 percent of women diagnosed with this cancer report abnormal
vaginal bleeding. Abnormal bleeding includes bleeding that occurs after menopause,
or bleeding that occurs between periods.
- In most women, abnormal uterine bleeding is caused by a hormone imbalance.
- Abnormal bleeding is caused by hormone imbalance is more common in teenagers or
in women who are approaching menopause.
- When menopause begins, women have months they dont ovulate. This also can
cause uterine bleeding, including heavy period and lighter, irregular bleeding.
- Thickening of the lining of the uterus is also another cause of bleeding in their 40s
and 50s, and this could be a warning of uterine cancer.
2. Pelvic Pain
- About 10% of women with uterine sarcomas have pelvic pain or a mass that can be
felt.
- The uterus has become enlarged due to the cancer, and may experience pain and
cramping. There is also the feeling of mass in the uterus and feeling of fullness in the
pelvis.
- Painful intercourse
3. Changes in Bathroom Habits
- Bladder and bowel can be a good indicator of uterine problems
- It is caused by having a pressure in the
- There is already trouble in getting urine out or theres already a painful urination
- There is also the presence of blood in the bowel movement, or it may hurt when
trying to pass stool.
4. Dropping Pounds for no Reason
- It means that the body of person has been dealing with a problem for a long time.
- Weight loss is rare unless its more advanced cancer.
5. Weakness and pain in the lower abdomen, back, or legs. This happens when
the cancer has spread to other organs.
Diagnostic Procedure:

1. Pelvic Examination
An inspection of a womans reproductive organs. To check for the uterus, two
fingers will be inserted inside the vagina while pressing the abdomen with the
other hand (Bimanual Examination)

Paps Smear-It may help identify uterine cancer because the cervical fluid
collected during Paps Smear can contain cells, including cancer have been shed
from the ovaries or endometrium.

2. Pelvic Ultrasound
It shows the size of the ovaries, uterus, any masses present in the uterus.
A pelvic ultrasound uses sound waves to create a picture of the uterus and ovaries.
A computer creates an image based on the echoes produced when sound waves
meet something dense, like an organ or tumor.
It can be done in two ways:
Abdominal Ultrasound- To get good pictures of the uterus and ovaries
during an abdominal ultrasound the bladder needs to be full.
Transvaginal Ultrasound- A transducer wand which is covered with a
disposable plastic sheath and gel will be inserted in the vagina.
3. Hysteroscopy and Biopsy
Hysteroscopy
A telescope-like device called hysteroscope will be inserted through the vagina
into the uterus which allows the examiner to view the inside of the uterus and
examine the lining for abnormalities.
Biopsy is the removal of some tissue from the uterine lining which will be send
on a pathologist for examination. Tissue sample can be taken in different ways:
A. Dilatation and Curettage- part of the uterine lining is lightly scraped
out. It is the most common and accurate way to remove tissue for a
biopsy.
 B. Endometrial Biopsy- a long, thin plastic tube (Pipelle) is used to
gently suck cells from the womb.
4. CT Scan
A CT Scan can be used to measure the tumors size.
5. Magnetic Resonance Imaging
It is used to measure the tumors size. Often used in women with low grade
cancer to see how far the cancer has grown into the wall of the uterus.

MANAGEMENT OF ENDOMETRIAL CANCER

1. Hysterectomy
A hysterectomy is the surgical removal of a woman's uterus
The surgery will depend on how much of the reproductive system may be
affected by endometrial cancer.
A hysterectomy for endometrial cancer may be done with an incision (cut) in
the abdomen.
In both procedures, general anesthesia usually is used. T
The type of hysterectomy depends on the medical history and general state of
health and on the extent of the cancer growth.

Types of Hysterectomy
1. Total hysterectomy
The removal of the uterus and cervix.
Total hysterectomy with bilateral salpingo-oophorectomy is the
removal of the uterus, cervix, fallopian tubes, and ovaries. This is the
most common surgery done for endometrial cancer.
2. Radical hysterectomy
The removal of the uterus, cervix, surrounding tissue, upper vagina,
and usually the pelvic lymph nodes.
The number of lymph nodes removed depends on how far the cancer
has spread.
 3. Abdominal hysterectomy
The uterus, ovaries, and fallopian tubes are removed through an
incision (laparotomy) in the lower abdomen.
An abdominal incision provides a large opening into the abdomen for
the surgeon to easily see the organs and to find out the extent of the
cancer.
An abdominal hysterectomy will leave a scar (usually 5 inches) on the
abdomen.
The usual stay in the hospital after an abdominal hysterectomy is 3
days.

4. Laparoscopic hysterectomy
Laparoscopic surgery is done with a tiny camera and special
instruments.
The surgeon puts these tools through several small incisions (cuts) in
the belly.
In a laparoscopic hysterectomy, the surgeon usually can see the organs
well enough to find out the extent of the cancer.
A laparoscopic hysterectomy leaves several very small scars on the
abdomen.
The stay in the hospital for 1 or 2 days after a laparoscopic
hysterectomy. Or the patient may be able to go home the same day.
When done by an experienced surgeon, laparoscopic hysterectomy
may have a quicker recovery and fewer complications than abdominal
hysterectomy.

Some surgeons do this surgery by guiding robotic arms that hold the surgery tools.
This is called robot-assisted laparoscopy.

2. Pelvic exenteration
Removal of the contents of the pelvis which includes bladder uterus and
rectum or internal reproductive organs such as the ovaries, womb, cervix and
vagina.
This operation is only done if there are no signs of cancer anywhere else in the
body.

3. Lymphadenectomy
effective to true stage II
Lymphadenectomy is surgery to remove lymph nodes.
 Also called lymph node dissection
May be done to examine the pelvic and para-aortic lymph nodes for
endometrial cancer cells.
The removal and examination of the cancerous lymph nodes will determine
the exact stage and grade of the cancer and may reduce the spread of the
disease. The procedure can be done through an abdominal incision or by
laparoscope.

A lymphadenectomy may be done:

If cancer cells are found in certain lymph nodes that were removed in an
earlier surgical procedure.
As part of a hysterectomy if cancer has invaded the deep part of the muscle,
the cancer is of higher grade, or the doctor suspects that cancer may spread to
other parts of the body.
Lymphadenectomy usually is an extensive operation in which lymph nodes
are removed. This is needed because cancer can spread through the lymph
system to other areas of the body.

Why It Is Done
Some doctors recommend that a lymphadenectomy be done in all cases of
endometrial cancer. Others believe that this procedure might not be needed
when the cancer is diagnosed at a very early stage and is found to be a slow-
growing grade. Lymphadenectomy may be needed if:
o Cancer cells are found in selected lymph nodes that were removed in
an earlier surgical procedure.
o Cancer cells are found in a lymph node at the time you are having surgery.
o The pelvic lymph nodes are enlarged.
o Cancer cells are faster-growing.
o Cancer cells have grown into the muscle of the uterus, the cervix, or other
areas of the pelvis.

4. Radiotherapy
Pre and post operative radiotherapy done as an adjuvant therapy for stage II,
III and IV.
May also be used alone for old women who cannot undergo surgical
procedure.
An internal radiation device may be implanted during surgery on preload or at
the patients bedside on afterload.
 Side effect includes hemorrhage, cystitis, urethral stricture and rectal
ulceration.

5. Hormonal therapy
This type of treatment uses hormones or hormone-blocking drugs to fight
cancer.
Side effect includes nausea, depression, rash, or mild fluid retention

Hormone treatment for endometrial cancer can include:

Progestins (the main hormone treatment used)
Tamoxifen
Luteinizing hormone-releasing hormone agonists
Aromatase inhibitors

1. Progestins
The main hormone treatment for endometrial cancer uses progesterone or similar
drugs (called progestins).
The 2 most commonly used progestins are:
Medroxyprogesterone acetate (Provera, which can be given as an injection or as a
pill)
Megestrol acetate (Megace, which is given as a pill or liquid).
These drugs slow the growth of endometrial cancer cells.

2. Tamoxifen
An anti-estrogen drug often used to treat breast cancer, may also be used to treat
advanced or recurrent endometrial cancer.
The goal of tamoxifen therapy is to prevent any estrogens circulating in the
woman's body from stimulating growth of the cancer cells.
Even though tamoxifen may prevent estrogen from nourishing the cancer cells, it
acts like a weak estrogen in other areas of the body.
It does not cause bone loss, but it can cause hot flashes and vaginal dryness. People
taking tamoxifen also have an increased risk of serious blood clots in the leg.

3. Luteinizing hormone-releasing hormone agonists

Most women with endometrial cancer have had their ovaries removed as a part of
treatment. In others, radiation treatments have made their ovaries inactive. This reduces
the production of estrogen and may also slow the growth of the cancer.
Luteinizing hormone-releasing hormone agonists (LHRH agonists) are a way to lower
estrogen levels in women who still have functioning ovaries.
These drugs switch off estrogen production by the ovaries in women who are
premenopausal.
 Examples of GNRH agonists include goserelin (Zoladex) and leuprolide (Lupron).
These drugs are injected every 1 to 3 months.
Side effects can include any of the symptoms of menopause, such as hot flashes and
vaginal dryness. They can also cause muscle and joint aches. If they are taken for a long
time (years), these drugs can weaken bones (sometimes leading to osteoporosis). These
drugs are also called gonadotropin-releasing hormone (GNRH) agonists.

4. Aromatase inhibitors
Even after the ovaries are removed (or are not functioning), estrogen is still made in fat
tissue. This becomes the body's main source of estrogen.
Drugs called aromatase inhibitors can stop this estrogen from being formed and lower
estrogen levels even further.
Examples of aromatase inhibitors include letrozole (Femara), anastrozole (Arimidex),
and exemestane (Aromasin).
These drugs are most often used to treat breast cancer, but may be helpful in treating
endometrial cancer, too. Side effects can include joint and muscle pain as well as hot
flashes. If they are taken for a long time (years), these drugs can weaken bones
(sometimes leading to osteoporosis). These drugs are still being studied for use in treating
endometrial cancer.

6. Chemotherapy
Chemotherapy (chemo) is the use of cancer-fighting drugs given into a vein or by
mouth.
These drugs enter the bloodstream and reach throughout the body, making this
treatment potentially useful for cancer that has spread beyond the endometrium.
Chemo is often given in cycles: a period of treatment, followed by a rest period.
The chemo drugs may be given on one or more days in each cycle.
Most often, 2 or more drugs are combined for treatment. The most common
combinations include carboplatin with paclitaxel and cisplatin with doxorubicin.
Less often, paclitaxel and doxorubicin and cisplatin/paclitaxel/doxorubicin may
be used.

Drugs used in treating endometrial cancer may include:

Paclitaxel (Taxol)
Carboplatin
Doxorubicin (Adriamycin) or liposomal doxorubicin (Doxil)
Cisplatin
 Sometimes chemo is given for a few cycles, followed by radiation. Then chemo is given
again. This is called sandwich therapy and is sometimes used for endometrial papillary
serous cancer and uterine carcinosarcoma.
Another treatment option is to give chemo with radiation (called chemoradiation). The
chemo can help the radiation work better, but it can be harder on the patient because it
causes more side effects.

7. Pelvic irradiation
Radiation therapy uses high-energy radiation (such as x-rays) to kill cancer cells. It can
be given in 2 ways to treat endometrial cancer:

1. By placing radioactive materials inside the body. This is called internal radiation therapy
or brachytherapy.
2. By using a machine that focuses a beam of radiation at the tumor, much like having an x-
ray. This is called external beam radiation therapy.

In some cases, both brachytherapy and external beam radiation therapy are given. When
that is done, usually the external beam radiation is given first, followed by the
brachytherapy.
The stage and grade of the cancer help determine what areas need to be exposed to
radiation therapy and which methods are used.
If the treatment plan includes radiation after surgery, you will be given time to heal from
the operation before starting radiation. Often, at least 4 to 6 weeks are needed.
NURSING CARE PLAN

1. Nursing Diagnosis
Acute pain related to the compression of nerve tissue secondary to growth of
tumor as manifested by grimacing face, guarding behavior, and a pain scale of 7/10.

Nursing Inference
In uterine cancer there is presence of a tumor on the uterus. Due to the presence or
growth of tumor, nerve tissues are compressed thereby causing pain.
Nursing Goal
After 3-4 hours of rendering appropriate nursing intervention the patients pain
will be relieved as manifested by a pain scale of 5/10.

Nursing Intervention

INTERVENTION RATIONALE
Provide comfort measures: frequent changes Promotes relaxation and redirects attention.
of position, back rubs, support with pillows. Relieves discomfort and augments therapeutic
effects of analgesia.

Encourage use of relaxation techniques, Promotes relaxation and redirects attention.

visualization, guided imagery, and
appropriate diversional activities
Provide warm compress. To relieve pain.

Administer analgesics, as ordered. Maintaining a constant drug level avoids

cyclic periods of pain, aids in muscle healing,
improving respiratory function and emotional
comfort and coping.

Nursing Evaluation
After 3-4 hours of rendering appropriate nursing intervention the patients pain
was relieved as manifested by a pain scale of 5/10.
2. Nursing Diagnosis

Mild anxiety related to upcoming surgery as evidenced by excessive sweating, shaking of

hands and restlessness

Nursing Inference

A vague uneasy feeling of discomfort or dread accompanied by an automatic response

the source often unknown to the individual a feeling of apprehension caused by anticipation of
danger. It is an altering signal that warns of impending danger and enables the individual to take
measures to deal with threat.

Nursing Goal

After 15-30 minutes of rendering proper nursing interventions the patient will be able to
lessen her anxiety and able to demonstrate relaxation.

Nursing Interventions

Intervention Rationale
Recognize awareness of the patients anxiety Acknowledgement of the patients feelings
validates the feelings and communicates
acceptance of those feelings
Use presence of touch, verbalization and Being supportive and approachable promotes
demeanour to remind patients that they are not communication
alone and to encourage expression of
clarification f needs and concerns
Allow patient to talk about anxious feelings It can help the patient perceive situations
and examine anxiety provoking situations if realistically and recognize factors leading to
they are identifiable the anxious feelings
Assist patient in developing new anxiety Provides the patient with variety of ways to
reducing technique such as deep breathing manage anxiety
exercise and positive verbalization
Explain all activities, procedures and issues Patient will lessen anxiety and emotional
that involve the patient wherein use non distress and have increased coping skills
medical terms and calm, slow speech. Do this because they know what to expect.
in advance of procedures and validate patients
understanding

Nursing Evaluation

After 15-30 minutes of rendering proper nursing interventions the patient was able to
lessen her anxiety and able to demonstrate relaxation.
Nursing Diagnosis #3

Impaired urinary elimination related to disruption of bladder innervation secondary to

tumor growth as manifested by difficulty urinating and decreased urine output (<30 ml/hr).

Nursing Inference

In uterine cancer, tumor growth would be primarily responsible for the compression of
the nerves that innervates bladder elimination. Thus, impaired urinary elimination.

Nursing Goals

Short-term:
After 10-15 minutes of imparting proper and necessary health teachings, the patient will
be able to identify the cause of the impairment of bladder elimination, verbalize understanding
on the condition, and provide rationale for the treatments.

Long-term:
After 3-5 days of rendering appropriate health interventions, the patient will be able to
maintain a balanced intake and output ratio.

Nursing Interventions
Nursing Interventions Rationale

1. Observe for cloudy or bloody urine and foul Signs of urinary tract or kidney infection that
odor. can potentiate sepsis.

2. Promote continued mobility. Decrease risk of developing UTI.

3. Catheterize as per doctors order. Catheterization is necessary as treatment and

for evaluation if patient is unable to empty
bladder or retains urine.
4. Educate patient about the importance of These chemicals are known to be bladder
limiting alcohol and caffeine intake. irritants and they can increase detrusor
overactivity.

5. Recommend and encourage proper hand Reduces risks of skin irritation and ascending
washing and perineal care. infection.

Nursing Evaluation

Short-term:
After 10-15 minutes of imparting proper and necessary health teachings, the patient was
able to identify the cause of the impairment of bladder elimination, verbalize understanding on
the condition, and provide rationale for the treatments.

Long-term:
After 3-5 days of rendering appropriate health interventions, the patient was able to
maintain a balanced intake and output ratio.