婦科培訓(xùn)課件-Endometrial Cancer

EndometrialCancerAimsTomasterThepathogenesisandriskfactorsoftypeIEndometrialCancer(EC)TheclinicalandpathologicalcharacteristicsofECThediagnosisofECThe

surgicalstagingofECBefamiliarwithTheprincipleoftreatmentofECThepreventionofECToknowTheLynchSyndrome（hereditarynonpolyposiscolorectalcancer）ThestagingsurgeryandtheadjuvanttherapyofECPage

2ContentsPage

3OverviewPathogenesisRiskFactorsPatternsofSpread

SurgicalStaging

ClinicalManifestationDiagnosisDifferentialDiagnosisTreatmentPrognosisFollow-upSummaryOverviewPage

4CorpusuteriCervixStructureofUterusEndometriumMyometriumSerouslayerPage

6PeriodicchangeandsheddingoftheendometriumWhatIsEndometrialCancer？AcancerthatarisesfromtheendometriumIssometimescalleduterinecancerOccursmostcommonlyafter

menopauseIsoftendetectedatanearlystage

GYNmalignancies：mostcommoninUS,2ndinChina3rdmostcommoncauseofGYNcanerdeathsKnownriskfactorsPage

8HowCommonIsThisCancer?Page

9CancerstatisticsinChina,2017Page

10WhoGetsThisCancer?Page

11HowManyPeopleSurvive5YearsOrMoreafterBeingDiagnosedwithEndometrialCancer?PathogenesisPage

12TypeIEndometrioidcancer:G1andG2Mostcommon:80%,preorperimenopausalEstrogen-dependentStartasatypicalhyperplasiaandprogresstocancerBetterprognosisPTENmutation,ER+,PR+Page

13TypeIIEndometrioidcancerG3,nonendometrioidhistology:serous,clearcell…10-20%,postmenopausalwomenEstrogenunrelatedWithoutprecancerousdiseasesHighgradewithpoorprognosisP53mutation,ER-,PR-上皮性腫瘤及前驅(qū)病變

分割性（絨毛葉狀）平滑肌瘤0前驅(qū)病變

彌散性平滑肌瘤病1

增生過(guò)長(zhǎng)不伴不典型脈管內(nèi)平滑肌瘤病1

不典型增生過(guò)長(zhǎng)/子宮內(nèi)膜上皮內(nèi)瘤變EIN2

轉(zhuǎn)移性平滑肌瘤1子宮內(nèi)膜癌惡性潛能未定平滑肌腫瘤1

內(nèi)膜樣腺癌3平滑肌肉瘤3

鱗狀上皮分化3

上皮樣平滑肌肉瘤3

絨毛管狀3

粘液樣平滑肌肉瘤3

分泌性3子宮內(nèi)膜間質(zhì)和相關(guān)腫瘤

粘液性癌3

內(nèi)膜間質(zhì)結(jié)節(jié)0漿液性子宮內(nèi)膜上皮內(nèi)癌2

低級(jí)別子宮內(nèi)膜間質(zhì)肉瘤3

漿液性癌3

高級(jí)別子宮內(nèi)膜間質(zhì)肉瘤3

透明細(xì)胞癌3

未分化子宮肉瘤3

神經(jīng)內(nèi)分泌腫瘤

類似于卵巢性索腫瘤的子宮腫瘤1

低級(jí)別神經(jīng)內(nèi)分泌腫瘤雜類間葉源性腫瘤

類癌3

橫紋肌肉瘤3

高級(jí)別神經(jīng)內(nèi)分泌癌

血管周上皮樣細(xì)胞腫瘤

小細(xì)胞神經(jīng)分泌分癌3

良性0

大細(xì)胞神經(jīng)內(nèi)分泌癌3

惡性3

混合細(xì)胞腺癌3其他

未分化癌3

去分化癌混合性上皮和間葉腫瘤腺肌瘤0腫瘤樣病變不典型息肉狀腺肌瘤0

息肉腺纖維瘤0

化生腺肉瘤3A-S反應(yīng)癌肉瘤3

淋巴瘤樣病變雜類腫瘤間葉源性腫瘤腺瘤樣瘤0平滑肌瘤0神經(jīng)外胚層腫瘤

富細(xì)胞平滑肌瘤0生殖細(xì)胞腫瘤

伴奇異核的平滑肌瘤0

核分裂活躍的平滑肌瘤0淋巴樣和髓樣腫瘤

水腫變性平滑肌瘤0淋巴瘤

卒中性平滑肌瘤0髓樣腫瘤

脂肪瘤性平滑肌瘤（脂肪平滑肌瘤）0

上皮樣平滑肌瘤0繼發(fā)性腫瘤

粘液樣平滑肌瘤0DisorderedproliferativeendometriumNormalproliferativeendometriumTypeIendometrialcancerSimplehyperplasiaComplexhyperplasiaAtypicalhyperplasia/EIN(EndometrialIntraepithelialneoplaisa)TypeIEndometrialcancerEndometrioidcancerG1,G2Hyperplasia17ClassificationoftheendometrialhyperplasiaandprogressiontoECArchitecturalTypeCytologicAtypiaProfressiontoEC(in%)SimplehyperplasiaAbsent1ComplexhyperplasiaAbsent3AtypicalsimplehyperplasiaPresent10AtypicalcomplexhyperplasiaPresent30DegreeofDifferentiationGrade3Grade1Grade2Lessthan5%ofthetumorhasasolidgrowthpattern6-50%ofthetumorisarrangedinsolidnestsMorethan50%ofthetumorisarrangedassolidsheetsofneoplasticcellsTypeIITypeISerousadenocarcinomaClearcelladenocarcinomaMucinousSquamousTransitionalcellMesonephricUndifferentiatedPostmenopausalwomenRiskfactorunknownMightberelatedtoFSHstimulationTypeIIEndometrialcancerSerousClearcellRiskFactorsPage

20RiskFactorsOnlyfortypeIendometrialcancerTwomajoraspects:UnopposedestrogenexposureHereditaryPage

21EndogenousestrogenPolycysticovarysyndromeAnovulationFunctioningovariantumorsInfertility,NulliparityLatemenopauseHereditaryLynchSyndromeExogenousestrogenTamoxifenEstrogenreplacementtherapyInsulinresistanceDiabetesmellitusHypertensionOverweightobesityRiskFactorsRiskfactorRelativerisk(RR)(otherstatisticsarenotedwhenused)IncreasingageWomen50-to70-years-oldhavea1.4percentriskofendometrialcancerUnopposedestrogentherapy2to10Tamoxifentherapy2EarlymenarcheNALatemenopause(afterage55)2Nulliparity2Polycysticovarysyndrome(chronicanovulation)3Obesity2to4Diabetesmellitus2Estrogen-secretingtumorNA

Lynchsyndrome(hereditarynonpolyposiscolorectalcancer)22to50percentlifetimeriskFamilyhistoryofendometrial,ovarian,breast,orcoloncancerNALynchsyndromeAn

dominant

geneticdisorderMainlycausescolorectalcancer

andendometrialcancerEspeciallybeforemenopauseMutationofmismatchrepairgenes：MLH1,MSH2,

MSH6,

PMS2Endometrialcancerrisk：

MLH1mutations,54%;MSH2,21%;MSH6,16%Page

23RiskFactors:GeneticsEEC:EndometroidendometrialcancerLH:LaparoscopichysterectomyBSO:bilateralsalpingooophorectomyCT:ChemotherapyRT:RadiotherapyBilateralinguinallymphnodedissection+25RT+6CTMetastaticserousadenocarcinomaRectalcancerEEC,IA,G12011.42015.22015.72015.9Dixon’ssurgery+6roundsofCTFollowupFollowupLH+BSORightinguinallymphnodebiopsyMetastaticadenocarcinomaformEECFigure1Theschematicdiagramofdiseaseprogressionandmanagement.4IIIIII32143218765432110111298765109CCHCCCCCHCHCHCCC+EC+SACCCHCFigure2Pedigreestructureofthepatient’sfamily.Squareandcirclesdenotedmalesandfemalesrespectively.Romannumeralsindicategenerations.Arrowindicatestheproband(III5).CC:coloncancer;EC:endometrialcancer;HC:hepaticcancer;SAC:serousadenocarcinoma.Figure4Aheterozygousgermlinemutation(c.2089_2090delCT)inMLH1gene(NM_000249)detectedinthepatient.ABProtectiveFactorsSmoking:reducesriskby20%TheuseoftheprogestinOCPsHormonalIUD(Mirena,LevonorgestrelIntrauterineSystem)Multiparity:morethan5childrenBreastfeeding:morethan18monthsreducesriskby23%Page

27PatternsofSpreadPage

28ThreeprimaryroutesofspreadDirectextensionLymphaticsystemHematogenousSurgicalStagingPage

30The2009FIGOstagingsystemSurgicalStagingFIGO,

2009StageIAandIBendometrialcancerStage

II

endometrial

cancerStageIIIendometrialcancerStageIVendometrialcancerⅢC1ⅢC2ClinicalManifestationsPage

33SignsandsymptomsVaginalbleedingor

discharge

notrelatedtomenstruation(periods).VaginalbleedingaftermenopauseVaginaldischarge~10%Asymptomatic:foundincidentallyinhysterectomyorhysteroscopePainfulsexualintercoursePelvicpainPelvicmassWeightloss90%PhysicalexaminationObesityHypertensionSignsformetastaticdisease:peripherallymphnodes,mass,ascites……Pelvicexamination:alwaysnormalPage

35DiagnosisPage

36DiagnosticevaluationHistoryAgeRiskfactorsPostmenopausalbleedingAbnormaluterinebleedingPhysicalexaminationThesourceofbleedingDiagnosticevaluationLaboratorytestingUrineHCGCA125，HE4….TSH,PRL,FSH….TCT，HPVImagingexaminationTransvaginalultrasoundEndometrialthickness(morethan4mm),

homogeneityofthetissuePolypoidendometrialmassUterineeffusionCT/MRI:PreoperativeimagingoftumorsInvestigateextrapelvicdiseaseNearbylymphnodesDiagnosticevaluationEndometrialsamplingOfficeendometrialbiopsy:accuracyof90%-98%DiagnosticevaluationEndometrialsamplingDilationandcurettage(D&C)SuspiciousofficeendometrialbiopsyContinuestohavesymptomsafternegativeofficeendometrialbiopsyHeavybleedingHysteroscopyDifferentialDiagnosisPage

41PostmenopausalbleedingCauseofBleedingFrequency（%）Endometrialatrophy60-80Exogenousestrogen/

HRT15-25Endometrialcancer10-15Endometrialorcervicalpolyps2-12Endometrialhyperplasia5-10Miscellaneous10Confirmthesourceofbleeding:uterus,virginal,anus,urinarytractTheamountofbleedingdoesnotcorrelatewithriskofmalignancybCervicalcancerPreorperimenopausalbleeding

Abnormaluterinebleeding(AUB)ComplicationsofpregnancymustbehighonthelistTreatmentPage

44TreatmentOptionsSurgeryLaparoscopic/robotPelvicwashingTH+BSOLymphnoderesectionRadiotherapy：AdjuvanttreatmentChemotherapyProgestins：fertilitypreservingTargetedtherapyMonoclonalantibodymTORinhibitorsSignaltransductioninhibitorsClinicaltrialsStageIIIndicationsforparaaorticlymphnodedissectionSuspectedpelvicorparaaorticLNmetastasisAlltypeIIEC:serous,clearcell,squamouscell,carcinosarcoma,undifferentiated,andG3EECMorethan?myometriuminvasion(IB)Lesioncovermorethan50%oftheuterinecavity(≥3cmindiameter)46EndometrialcanceroperableTotalhysterectomy+bilateralsalpingo-oophorectomyandsurgicalstagingAdjuvanttherapyforsurgicallystaged(radiotherapy/chemotherapy)PatientdesiresfertilitysparingoptionHormonetherapyMedicallyinoperableTumordirectedRTOrConsiderhormonetherapyinselectedpatientsTreatment子宮內(nèi)膜癌手術(shù)視頻Page

48PrognosisPage

495-yearrelativesurvivalratesPage

50MajorindependentprognosticfactorsAge>60ysDepthofthemyometrialinvasion>50%myometrialinvasionHistologictype:serous,clearcell…Histologicgrade:G3tumorsTumorsize:lagertumors>2cmSurgicalstage:stageIIIandIVLymphovascularinvolvementPeritonealcytologyPage

51Follow-upPage

5275-95%diseasewillrecurwithin2-3yearsafteroperationEvery3monsfor3ysEvery6monsfor2ysAnnuallyPage

53RectovaginalexaminationTCTX-ra