妇产科精品-子宫内膜癌英文PPT课件.ppt

EndometrialCancer,OB/GYNHospitalFudanUniversityXinLU,MD,Ph.D.,1,Endometriodcancer-Contents,IncidenceRiskfactorsClassificationSymptoms,PathologyFIGOStagingDiagnosisTreatment,2,WHOCancerReport,Globalcancerratescouldincreaseby50%to15millionby2020Endometrialcanceristhe4thmostcommoncancerinwomenNewDiagnosedcases:142,000Diedcaseseachyear:42,000incidence2-3%Averageage:60s,3,HistologicTypes,EndometrialCancersEndometrioid(87%)Adenosquamous(4%)PapillarySerous(3%)ClearCell(2%)Mucinous(1%)Other(3%),4,EndometrialCancer:TypeI/II,TypeIEstrogenRelatedYoungerandheavierpatientsLowgradeBackgroundofHyperplasiaPerimenopausalExogenousestrogenFamilial/genetic(15%)LynchIIsyndrome/HNPCCFamilialtrend,TypeII(10%)AggressiveHighgradeUnfavorableHistologyUnrelatedtoestrogenstimulationOccursinolder&thinnerwomen,5,EndometrialCancer:RiskFactors,From:WilliamsGynecology2009,6,EndometriumCarcinoma2009Classification,StageCharacteristicStageI*TumorconfinedtothecorpusuteriIA*NoorlessthanhalfmyometrialinvasionIB*InvasionequaltoormorethanhalfofthemyometriumStageII*Tumorinvadescervicalstroma,butdoesnotextendbeyondtheuterus*StageIII*Localand/orregionalspreadofthetumorIIIA*Tumorinvadestheserosaofthecorpusuteriand/oradnexae#IIIB*Vaginaland/orparametrialinvolvement#IIIC*Metastasestopelvicand/orpara-aorticlymphnodes#.IIIC1*PositivepelvicnodesIIIC2*PositiveparaaorticlymphnodeswithorwithoutpositivepelviclymphnodesStageIV*Tumorinvadesbladderand/orbowelmucosa,and/ordistantmetastasesIVA*Tumorinvasionofbladderand/orbowelmucosaIVB*Distantmetastases,includingintra-abdominalmetastasesand/oringuinallymphnodes,7,EndometrialCancer:FIGOSurgicalStage,8,EndometrialCancerPrognosis:,Overall5YrSurvival84%StageandGradearethemostimportantprognosticfactorsAlteredoncogene/tumorsuppressorgeneexpressionisnowbeingevaluated(molecularstagingconcept),9,AggressiveHistologicSubtypes(Clear-cell,Serous)Increasingage(over65)VascularinvasionAneuploidyAlteredoncogene/tumorsuppressorgeneexpression(“molecularstaging”concept-p53,PTEN,microsatelliteinstability,MDR-1,HER2/neu,ER/PR,Ki67,PCNA,CD31,EGF-R,MMRgenes)Race?,EndometrialCancer:PoorPrognosticFactors,10,MolecularGenetics,PTENmutations:32%Tumorsuppressorgene(chrom10)PhosphataseEarlyeventincarcinogenesisAssociatedwith:endometrioidhistologyearlystagefavorablesurvival,11,MolecularGenetics,p53tumorsuppressorgeneCellcycleandapoptosisregulationMostcommonlymutatedgeneinhumancancersOverexpression(markerformutation)Associatedwithpoorprognosisearlystage:10%havep53mutationadvancedstage:50%havep53mutationnotfoundinhyperplasiaslateeventincarcinogenesis,12,GeneticSyndromes:HNPCCHereditaryNon-PolyposisColonCancer,LynchIISyndromeAutosomaldominantinheritanceMMR(mismatchrepair)mutationsGeneticinstabilityleadstoerror-proneDNAreplicationhMSH2(chrom2)hMLH1(chrom3)EarlyageofcolonCa:mean45.2yearsEndometrialCa:secondmostcommonmalignancy20%cumulativeincidencebyage70EarlierageofonsetthansporadiccasesOther:ovary(3.5-8fold),stomach,smallbowel,pancreas,biliarytract,13,Diagnosisofdisease:PatientAwareness*,Morethan95%ofpatientswithEndometrialCancerreporthavingsymptomsPostmenapausalbleedingMenorrhagiaMetrorrhagiaBloodyDischargeEndometrialbiopsyisthemaindiagnostictoolperformedeitherintheofficeorviaD&CinOR,14,UterineCancer:Diagnosis/Screening,PatientSymptoms/Awareness*CytologyNotasatisfactoryscreeningtestSonographyNotCosteffectiveHysteroscopyNotCosteffectiveHistologySecondarytosymptoms(notasascreeningtest),15,EndometrialCancer:TransvaginalUltrasoundScreening,16,EndometrialCancer:TransvaginalUltrasoundScreening,17,EndometrialCancer:TransvaginalUltrasoundScreening,18,Normalendometrialstripe:Postmenopausal4-8mmPostmenopausalonHRT4-10mmU/SforDetectionofanyuterinepathologySensitivity:85-95%Specificity:60-80%PPV2-10%NPV99%,Summary:EndometrialCancer:TransvaginalUltrasoundScreening,19,HysteroscopyNotsatisfactoryforscreeningtest,StudiesoftheefficacyofhysteroscopyasadiagnostictoolvarywidelySensitivityreportedrangingfrom60-95%comparedtoD&CobtainedatthesametimeSpecificity50-99%,20,21,HysteroscopyandPositiveCytology?,Studieshavebeenmixed:SomestudiessuggestanincreaseinpositiveperitonealcytologyseenatstaginglaparotomyinpatientswhohavehadhysteroscopyOtherstudieshavefailedtofindadifferenceinpositivecytologyinpatientsdiagnosedviahysteroscopyascomparedtoofficebiopsyorD&C,22,2019/12/12,23,HysteroscopyNotsatisfactory,Toomuchcostandrisktobeusedasascreeningtest.Usefulforevaluationofabnormaluterinebleedingwhereofficebiopsyisunrevealing.UseinconjunctionwithuterinecurettageUsefultoseeandresectpolypsandsmallsubmucousfibroidsUsefultoperformdirectedbiopsyofsmalllesions.,24,EndometrialCancer:WhoNeedsanEndometrialBiopsy?,PostmenopausalbleedingPerimenopausalintermenstrualbleedingAbnormalbleedingwithhistoryofanovulationPostmenopausalwomenwithendometrialcellsonPapThickenedendometrialstripeviasonography,25,SamplingoftheEndometrium,Officebiopsyprocedures(Pipelle,Vabraaspirator,Karmancannula)willagreewithaD40:553PatientswithpersistentPMBafternegativeofficebiopsyshouldhaveD&C(+/-hysteroscopy)D&CisthegoldstandardsamplingmethodpreoperativeD&Cwillagreewithdiagnosisathysterectomy94%ofthetime,26,27,28,29,TreatmentforEndometrialHyperplasiawithoutatypia:,ProgestintherapycontinuousorcyclicalChildbearingage:ProgestindominantOCPsorDepo-Provera150mgIMq3monthsorProvera10mgpo10days/monthandMayfollowwithovulationinductionafternormalbiopsyifpregnancydesiredPeriorPostmenopausal:Provera20mgpo10days/monthorDepo-Provera200mgIMq2monthsRepeatbiopsyin3-4months,30,TreatmentforAtypicalEndometrialHyperplasia:,23%riskofprogressiontocarcinoma(over10years)ifuntreated.Standardtreatmentwhenchildbearingiscompleteistotalhysterectomy(abdominalorvaginal)Frozensectiontoruleoutcarcinoma(upto20%havecoexistingendometrialcancer),31,TreatmentforAtypicalEndometrialHyperplasia:,Conservativemedicaltherapycanbeattemptedinyoungerpatientswhorequestpreservationoffertility.D&CpriortoinitiationofmedicaltherapytoruleoutcarcinomaMegace40-80mg/day,Norethindroneacetate5mg/dayConservativetherapymayalsobeattemptedinyoungpatientswithearly,welldifferentiatedendometrialcarcinomas.Megace120-200mg/day,Norethindroneacetate5-10mg/day,32,Endometroidcarcinoma,Grading,FIGO-Gr1-50%solidtumorNUCLEARGRADESize,shape,stainingandchromatin,variability,prominentnucleoli.HighnucleargradeaddsonepointtoFIGOgrade,33,CA125ChestX-rayMammogramsColonEvaluationOthersasindicated,UterineCancer:Pre-opEvaluation,34,UterineCancer:Pre-opEvaluation,TransvaginalU/S?CTScan?MRI?,35,UterineCancer:Pre-opEvaluation,36,UterineCancer:SurgicalStaging,PreoperativepreparationAntimicrobialprophylaxisDVTprophylaxisSteepTrendelenburgLonginstrumentsavailable,37,Availabilityoffrozensectiontodeterminetheextentofstagingprocedure.CapabilityofcompletesurgicalstagingCapabilityoftumorreductionifindicated,EndometrialCancer:Intra-operati