婦產(chǎn)科教學(xué)課件子宮腫瘤(英文)

1、Uterine CancerXi-Shi Liu Obstetrics and Gynecology Hospital Fudan university2009.09General DescriptionUterine cancer is one of the most common malignancy of female genital tract.The incidence is increasing worldwide in recent years.Overall,2%-3% of women develop uterine cancer during their lifetime.

2、General DescriptionA malignant epithelial disease that occurs in endometrial gland of uterusAlso called endometrial cancerClassification(pathogenetic,biologic behavior )Estrogen dependent typehave a history of exposure to unopposed estrogen (either endogenous or exogenous).Hyperplastic endometriumBe

3、tter differentiafedER(+),PR(+)Mere favorable prognesis Estrogen independent type- Have no source of estrogen stimulation of endometrium.-Arising in background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosis Risk Factors1. Medical conditionsa. Diabetes mellitus, hypertension.b.

4、Overweight-obesity (excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat).c. Late menopause. Risk Factors2. Some gynecologic diseases ( Long-term endogenous estrogen exposure ) - polycystic ovary syndrome - functioning ovarian tumors - ano

5、vulating dysfunctional bleeding - Infertility, Nulliparity.Risk Factors3. Prolonged Use of estrogena. Prolonged menopausal estrogen replacement therapy without progestogen.b. Prolonged use of the antiestrogen tamoxifen for breast cancer.Risk Factors4. Genetic factors and other factorsa. Endometrial

6、and ovarian cancer are the simultaneously occurring with other genital malignancy ,reported incidence (1.43.8%).b. Family history of tumor is higher.(12-28%) Five histological subtypesEndometrioid adenocarcinomaMucinous carcinomaSerous adenocarcinomaClear cell carcinomaOther rare subtypesFive histol

7、ogical subtypes-Endometrioid AdenocarcinomaAccount for about 8090%.Well differentiated.Prognosis is better.Five histological subtypes -Mucinous carcinomaRare (about 5%)a. Most of them is a well differentiated.b. Behavior is similar to that of common endometrial carcinoma. Five histological subtypes

8、-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.Five histological subtypes-Clear cell carcinomaa. A rare subtypeb. Is high grade and aggressivec. Prognosis is s

9、imilar to or worse than that of papillary serous carcinomad. Survival rate is lower 33%64%Five histological subtypes-other rare subtypesSquamous adenocarcinomaUndifferentiated carcinomaMixed adenocarcinomaClinical Features-SymptomsAsymptomaic (about less than 5% )Abnormal vaginal bleeding (premenopa

10、usal or postmenopausal, minimal or nonpersistant)Abnormal vaginal discharge(25% infection of uterine contents)Pelvic pressure or discomfort (uterine enlargement or extrauterine disease spread)Clinical Features-SignsNo evidence in early stage on physical examinationSlight enlargement of uterine size

11、and softUterus fixed, immobile, adenexal mess in advanced stageSpecial ExaminationDilation and fractional curettage ( D. C)Most effective ,definitive procedure and commonly usedSignificance-Established correct diagnosis, clinical stage-differentiated from cervical cancer or cervical involvement Ultr

12、asonographyUseful adjuvant methodSignificances Size of lesionInvasion of endometrium or cervixResistant index of new vesselsEndometrial 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 l

13、arge area of mixed echogenicity suggestive of a 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.ABHysteroscopySig

14、nificance-Direct observation-Taking sample correctly-Identifying polyps and submucous myomaPap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV urography, cystoscopy, sigmoidoscopy, DiagnosisHistory, and clinical sign , related risk factors symptomsDia

15、gnostic methodsDifferential DiagnosisSenile endometritis / vaginitisDysfunctional uterine bleedingSubmucous myoma / Endometrial polypsCervix cancer / Sarcoma of uterus/ Primary carcinoma of fallopian tubeMetastasis Route Direct extensionLymphatic metastasis: important route Hematogenous metastasis C

16、linical 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 uterine cavity is 8 cmStage II The carcinoma has involved the corpus and the cervix, but has not extended outside t

17、he uterusClinical Stage(FIGO 1971)Stage III The carcinoma has extended outside the uterus, but not outside the true pelvisStage IV IVa The carcinoma has extended 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 S

18、tage IV) IVb The carcinoma has extended outside the true pelvis and spread to distant organsSurgical pathologic staging (FIGO 1988)Stage 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 myometriumStage II IIa* End

19、ocervical glandular involvement only IIb* Cervical stromal invasionSurgical pathologic staging (FIGO 2000)Stage 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 nod

20、esStage IV IVa* Tumour invasion of bladder and/or bowel mucosa IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodesStage 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 t

21、he myometriumStage IIa* Endocervical glandular involvement onlyStage IIb* Cervical stromal invasionStage 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 node

22、sStage IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodesTreatmentSurgery RadiationChemotherapy Hormone therapyEarly stage - surge+ postoperative adjuvant therapyAdvanced stage - radiation+ surge+ medicine

23、Principle of choiceGeneral condition (Age, complication)Clinical stageTumour pathologic typeSurgeryObjectOperative pathologic stage, finding prognosis risk factorsRemove uterus and metastasis tumourStage I :Abdorminal hysterectomy + bilateral salpingoophorectomy + selective lymphadenectomy clear cel

24、l or papillary carcinoma omentectomy+appenditectomyStage IIRadical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenectomyStage III,IVCytoreductive surgeryIndications of pelvic lymphadenectomySpecial pathogenetic patternEndometrial cancer, grade 3 or no differentiationMyo-invasion more tha

25、n Size of lesion more than 50% of uterine cavityInvolvement in isthmus of uterusRadiation therapyRadiation aloneRadiation with surgeryRadiation combined surgery-Radiation after surgeryAdenexal / serosal / parametrial spreadVaginal metastasisLymph node metastasisIntraperitoneal spreadBladder / rectal

26、 invasionMyoinvasion 50%G3 50% myoinvasionIndications for radiation aloneElderly or obesityMultiple chronic or acute medical illness(hypertension, cardial disease, diabetes, pulmonary, renal)Advanced stage unsuitable for surgeryHormone TherapymechenismMost endometrial cancers have both ER & PR.(Estrogen dependent subtype)Indications: Advanced or recurrent stage Early stage and desire for fertilityUsed drugsMPAChemotherapyAdvanced stage or recurrent carcinomaPost