子宮癌（UterineCancer）婦科八年制教學(xué)課件

1、子宮癌（UterineCancer）婦科八年制教學(xué)Uterine CancerUterine CancerXi-Shi Liu Obstetrics and Gynecology Hospital Fudan university2007.04子宮癌（UterineCancer）婦科八年制教學(xué)General Description Uterine cancer is one of the most common malignancy of female genital tract. The incidence is increasing worldwide in recent years. O

2、verall,2%-3% of women develop uterine cancer during their lifetime.子宮癌（UterineCancer）婦科八年制教學(xué)General Description A malignant epithelial disease that occurs in endometrial gland of uterus Also called endometrial cancer子宮癌（UterineCancer）婦科八年制教學(xué)Classification(pathogenetic,biologic behavior ) Estrogen de

3、pendent type- have a history of exposure to unopposed estrogen (either endogenous or exogenous).-Hyperplastic endometrium-Better differentiafed-ER(+),PR(+)-Mere favorable prognesis子宮癌（UterineCancer）婦科八年制教學(xué)l Estrogen independent type- Have no source of estrogen stimulation of endometrium.-Arising in

4、background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosis子宮癌（UterineCancer）婦科八年制教學(xué) Risk Factors1. Medical conditionsa. Diabetes mellitus, hypertension.b. Overweight-obesity (excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatizat

5、ion in fat).c. Late menopause. 子宮癌（UterineCancer）婦科八年制教學(xué)Risk Factors2. Some gynecologic diseases ( Long-term endogenous estrogen exposure ) - polycystic ovary syndrome - functioning ovarian tumors - anovulating dysfunctional bleeding - Infertility, Nulliparity.子宮癌（UterineCancer）婦科八年制教學(xué)Risk Factors3.

6、 Prolonged Use of estrogena. Prolonged menopausal estrogen replacement therapy without progestogen.b. Prolonged use of the antiestrogen tamoxifen for breast cancer.子宮癌（UterineCancer）婦科八年制教學(xué)Risk Factors4. Genetic factors and other factorsa. Endometrial and ovarian cancer are the simultaneously occurr

7、ing with other genital malignancy ,reported incidence (1.43.8%).b. Family history of tumor is higher.(12-28%) 子宮癌（UterineCancer）婦科八年制教學(xué)Five histological subtypes Endometrioid adenocarcinoma Mucinous carcinoma Serous adenocarcinoma Clear cell carcinoma Other rare subtypes子宮癌（UterineCancer）婦科八年制教學(xué)Five

8、 histological subtypes-Endometrioid Adenocarcinoma Account for about 8090%. Well differentiated. Prognosis is better.子宮癌（UterineCancer）婦科八年制教學(xué)Five histological subtypes -Mucinous carcinomaRare (about 5%)a. Most of them is a well differentiated.b. Behavior is similar to that of common endometrial car

9、cinoma.子宮癌（UterineCancer）婦科八年制教學(xué) Five histological subtypes -Serous adenocarcinoma a. Architecture is identical with complex papillary.b. More aggressively with deep myometrial and lymphatic invasion.c. Simulating the behavior of ovarian carcinoma.子宮癌（UterineCancer）婦科八年制教學(xué)Five histological subtypes-

10、Clear cell carcinomaa. A rare subtypeb. Is high grade and aggressivec. Prognosis is similar to or worse than that of papillary serous carcinomad. Survival rate is lower 33%64%子宮癌（UterineCancer）婦科八年制教學(xué)Five histological subtypes-other rare subtypes Squamous adenocarcinoma Undifferentiated carcinoma Mi

11、xed adenocarcinoma子宮癌（UterineCancer）婦科八年制教學(xué)Clinical Features-Symptoms Asymptomaic (about less than 5% ) Abnormal vaginal bleeding (premenopausal or postmenopausal, minimal or nonpersistant) Abnormal vaginal discharge(25% infection of uterine contents) Pelvic pressure or discomfort (uterine enlargeme

12、nt or extrauterine disease spread)子宮癌（UterineCancer）婦科八年制教學(xué)Clinical Features-Signs No evidence in early stage on physical examination Slight enlargement of uterine size and soft Uterus fixed, immobile, adenexal mess in advanced stage子宮癌（UterineCancer）婦科八年制教學(xué)Special ExaminationDilation and fractional

13、 curettage ( D. C) Most effective ,definitive procedure and commonly used Significance-Established correct diagnosis, clinical stage-differentiated from cervical cancer or cervical involvement 子宮癌（UterineCancer）婦科八年制教學(xué) Ultrasonography Useful adjuvant method Significances Size of lesion Invasion of e

14、ndometrium or cervix Resistant index of new vessels子宮癌（UterineCancer）婦科八年制教學(xué)Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (A) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixed echogenicity suggestive of a

15、mass. (B) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma. AB子宮癌（UterineCancer）婦科八年制教學(xué)HysteroscopySignificance-Direct obser

16、vation-Taking sample correctly-Identifying polyps and submucous myoma子宮癌（UterineCancer）婦科八年制教學(xué)Pap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV urography, cystoscopy, sigmoidoscopy, 子宮癌（UterineCancer）婦科八年制教學(xué)Diagnosis History, and clinical sign , rel

17、ated risk factors symptoms Diagnostic methods子宮癌（UterineCancer）婦科八年制教學(xué)Differential Diagnosis Senile endometritis / vaginitis Dysfunctional uterine bleeding Submucous myoma / Endometrial polyps Cervix cancer / Sarcoma of uterus/ Primary carcinoma of fallopian tube子宮癌（UterineCancer）婦科八年制教學(xué)Metastasis R

18、oute Direct extension Lymphatic metastasis: important route Hematogenous metastasis 子宮癌（UterineCancer）婦科八年制教學(xué)Clinical Stage(FIGO 1971) Stage I Ia The carcinoma is confined to the corpus and the length of the uterine cavity is 8 cm Ib The carcinoma is confined to the corpus and the length of the uter

19、ine cavity is 8 cm Stage II The carcinoma has involved the corpus and the cervix, but has not extended outside the uterus子宮癌（UterineCancer）婦科八年制教學(xué)Clinical Stage(FIGO 1971) Stage III The carcinoma has extended outside the uterus, but not outside the true pelvis Stage IV IVa The carcinoma has extended

20、 outside the uterus and involves the mucosa of the bladder or rectum (a bullous oedema as such does not permit the case to be allotted to Stage IV) IVb The carcinoma has extended outside the true pelvis and spread to distant organs子宮癌（UterineCancer）婦科八年制教學(xué)Surgical pathologic staging (FIGO 1988) Stag

21、e I Ia* Tumour limited to the endometrium Ib* Invasion to less than half of the myometrium Ic* Invasion equal to or more than half of the myometrium Stage II IIa* Endocervical glandular involvement only IIb* Cervical stromal invasion子宮癌（UterineCancer）婦科八年制教學(xué)Surgical pathologic staging (FIGO 2000) St

22、age III IIIa* Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findings IIIb* Vaginal metastases IIIc* Metastases to pelvic and/or para-aortic lymph nodes Stage IV IVa* Tumour invasion of bladder and/or bowel mucosa IVb* Distant metastases, including intra-abd

23、ominal metastasis and/or inguinal lymph nodes子宮癌（UterineCancer）婦科八年制教學(xué)Stage Ia* Tumor limited to the endometrium Stage Ib* Invasion to less than half of the myometrium Stage Ic* Invasion equal to or more than half of the myometrium子宮癌（UterineCancer）婦科八年制教學(xué)Stage IIa* Endocervical glandular involvemen

24、t onlyStage IIb* Cervical stromal invasion子宮癌（UterineCancer）婦科八年制教學(xué)Stage IIIa* Tumor invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findingsStage IIIb* Vaginal metastases Stage IIIc* Metastases to pelvic and/or para-aortic lymph nodes子宮癌（UterineCancer）婦科八年制教學(xué)Stage

25、IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodes子宮癌（UterineCancer）婦科八年制教學(xué)Treatment Surgery Radiation Chemotherapy Hormone therapyEarly stage - surge+ postoperative adjuvant therapyAdvanced stage - radiat

26、ion+ surge+ medicine子宮癌（UterineCancer）婦科八年制教學(xué)Principle of choice General condition (Age, complication) Clinical stage Tumour pathologic type子宮癌（UterineCancer）婦科八年制教學(xué)Surgery Object Operative pathologic stage, finding prognosis risk factors Remove uterus and metastasis tumour Stage I : Abdorminal hyst

27、erectomy + bilateral salpingoophorectomy + selective lymphadenectomy clear cell or papillary carcinoma omentectomy+appenditectomy子宮癌（UterineCancer）婦科八年制教學(xué) Stage IIRadical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenectomy Stage III,IVCytoreductive surgery子宮癌（UterineCancer）婦科八年制教學(xué)Indic

28、ations of pelvic lymphadenectomy Special pathogenetic pattern Endometrial cancer, grade 3 or no differentiation Myo-invasion more than Size of lesion more than 50% of uterine cavity Involvement in isthmus of uterus子宮癌（UterineCancer）婦科八年制教學(xué)Radiation therapy Radiation alone Radiation with surgery子宮癌（U

29、terineCancer）婦科八年制教學(xué)Radiation combined surgery-Radiation after surgery Adenexal / serosal / parametrial spread Vaginal metastasis Lymph node metastasis Intraperitoneal spread Bladder / rectal invasion Myoinvasion 50% G3 50% myoinvasion子宮癌（UterineCancer）婦科八年制教學(xué)Indications for radiation alone Elderly

30、or obesity Multiple chronic or acute medical illness(hypertension, cardial disease, diabetes, pulmonary, renal) Advanced stage unsuitable for surgery子宮癌（UterineCancer）婦科八年制教學(xué)Hormone Therapy mechenism Most endometrial cancers have both ER & PR.(Estrogen dependent subtype)lIndications: Advanced or recurrent stage Early stage and desire for fertility Used drugs MPA子宮癌（UterineCancer）婦科八年制教學(xué)Chemotherapy Advanced stage or recurrent carcinoma Postoper