子宫内膜癌与新的figo分期课件

Endometrial Cancer and Updates of FIGO Staging 子宫内膜癌与新的FIGO分期 Wenxin Zheng, M.D. Professor of Pathology Professor of Obstetrics and Gynecology Director of Gynecologic Pathology and Molecular Pathology University of Arizona College of Medicine /index.html Beijing, May 2009 Corpus Cancer Staging (FIGO 1971) StageCharacteristics 0Carcinoma in situ IThe carcinoma is confined to the corpus IA The length of the uterine cavity is 8 cm or less IB The length of the uterine cavity is 8 cm Stage I cases should be subgrouped with regard to the histologic grade of the adenocarcinoma IIThe carcinoma has involved the corpus and the cervix IIIThe carcinoma has extended outside of the uterus but not outside of the true pelvis IVThe carcinoma has extended outside of the true pelvis or has involved the mucosa of the bladder or rectum Intl J Gynecol Obstet: The official organ of the International Federation of Gynecology and Obstetrics, 1971, 9: 172-9 Corpus Cancer Staging (FIGO 1988) StageCharacteristics IA G123Tumor limited to endometrium IB G123Invasion to 1/2 myometrium IIAEndocervical glandular involvement only IIB Cervical stromal invasion IIIATumor invades serosa and/or adnexae and/or positive peritoneal cytology IIIBVaginal involvement or metastasis IIICMetastasis to pelvic and/or para-aortic lymph nodes IVATumor invasion of bladder and/or bowel mucosa IVBDistant metastasis including intra-abdominal and/or inguinal lymph nodes FIGO Announcements: Stages-1988 Revision. Gynecol Oncol 1989, 35:125 5-Year Survival Differences StageFIGO - 1971 FIGO - 1988 I87%91% II86%86% III0%58% IV0%0% Wolfson AH et al., The prognostic significance of surgical staging for endometrial cancer. Gynecol Oncol, 1992, 45: 142-6 Creasman WT et al., Significance of true surgical and pathologic staging: a GOG study. Am J Obstet Gynecol, 1999, 181: 31-4 Significance of this change lChanged from clinical based classification to a surgico-pathologic system lRepresented a dramatic improvement From inaccurate to more predictive and better reproducible lRepresented a significant advance in prognosis and therapy selection lEmphasized the importance of pathology evaluation Endometrial Carcinoma (Prognostic Factors) Adnexal involvement Peritoneal metastasis Positive peritoneal cytol Positive pelvic/paraaortic lymph nodes Histologic type Grade Depth of myom invasion Cervical involvement Vascular invasion Atyp endom hyperplasia ER/PR DNA ploidy + S-phase ExtrauterineUterine GOG 1984-91 Pathologic classification of endometrial adenocarcinomas 1980 2005 AdenocarcinomaEndometrioid AdenoacanthomaEndometrioid with squamous diff Adenosquamous Villoglandular Clear cellSecretory Mucinous Serous (UPSC/ESC) Clear cell Mixed Endometrial Carcinoma Histologic type 5-year Surv Endometrioid77% Villoglandular85% Clear cell56% Serous 53% Dualistic Model of Endometrial Cancer Bokhman Gynecol Oncol 1983 Comparison of Two Types of EC Ambros et al., Human Path 1995 Two Types of Endometrial Cancer ParametersType IType II Peak Age50-60s60-70s ObesityCommonUncommon Estrogen stimuliCommonUncommon PrecancerAEH or EINEmGD Latent PrecancerPTEN null glands P53 signature glands TransitionSlowRapid HistologyEndometrioidSerous or Clear cell Genetic changesPTEN, MSIp53, 1p deletion FamilialHNPCCUnknown PrognosisGood Poor Zheng et al.,2009 Type I endometrial cancer ERp53 H incidence 11% lOften associated with adnexal or nodal spread, high grade, deep invasion lUnivariate analysis increased risk of recurrence in most studies lMultivariate analysis (5 studies) decreased survival in 3/5 lPositive cytology rarely as an isolated poor prognostic factor Stage IIIA Corpus Cancer + adnexal involvement l5 year DFS 37% overall lOften associated with higher grade, lymphatic invasion, other extrauterine disease l5 year DFS - 71% without other extrauterine spread Connell et al, 1999 One compounding factor is that the synchronous tumor present in both endometrium and ovary Stage IIIA Stage IIIA Corpus Cancer + serosal involvement l5 year DFS 29% l5 year DFS 20%, Serosal involvement + other extrauterine sites l5 year DFS 42%, Serosal involvement only Ashman et al, 2001 Invading through the myometrium onto serosa Three forms of Stage IIIA disease not equivalent 5 year recurrence free survival (Mariani et al, 2002) + cytology only, 79% + adnexa/uterine serosa, 57% (Tebeu et al, 2004) + cytology only 91% + adnexa/uterine serosa 50% Stage IIIB vaginal metastases lVery rare, (less than 1% of corpus cancer and about 2% of stage III pts) lVaginal mets often associated with nodal or distant metastases lPrognosis poor 5 year survival about 25% ZainoZaino R, 2008 R, 2008 Stage IIIC Stage IIIC - metastases to pelvic and para-aortic lymph nodes lDoes every patient with endometrial carcinoma require lymphadenectomy or radiotherapy? lIf so, pelvic LND? Paraortic LND or both? ZainoZaino R, 2008 R, 2008 Endometrial Cancer Selective Lymphadenectomy lLymphadenectomy not indicated lLow risk: lEndometrioid lGrade 1&2 lMyometrial Invasion 1/2 myometrium IIApositive peritoneal cytology IIB Uterine serosa, adnexal, or other pelvic spread IIIA1Pelvic nodal metastasis only (micro) IIIA2Pelvic nodal metastasis only (gross) IIIB1Para-aortic nodal (+/- oelvic nodes) metastasis only (micro) IIIB2Para-aortic nodal (+/- oelvic nodes) metastasis only (gross) IIICPelvic or para-aortic nodal me