刘惜时UterineCancer子宫内膜癌(英文).ppt

UterineCancer,Xi-ShiLiuObstetricsandGynecologyHospitalFudanuniversity2010.08,GeneralDescription,Uterinecancerisoneofthemostcommonmalignancyoffemalegenitaltract.Theincidenceisincreasingworldwideinrecentyears.Overall,2%-3%ofwomendeveloputerinecancerduringtheirlifetime.,GeneralDescription,AmalignantepithelialdiseasethatoccursinendometrialglandofuterusAlsocalledendometrialcancer,Classification(pathogenetic,biologicbehavior),Estrogendependenttypehaveahistoryofexposuretounopposedestrogen(eitherendogenousorexogenous).HyperplasticendometriumBetterdifferentiafedER(+),PR(+)Merefavorableprognesis,Estrogenindependenttype,-Havenosourceofestrogenstimulationofendometrium.-Arisinginbackgroundofatrophicendemetrium-Lessdifferentiated-ER(-)PR(-)-Poorprognosis,RiskFactors,1.Medicalconditionsa.Diabetesmellitus,hypertension.b.Overweight-obesity(excessestrogenasaresultofperipheralconversionofadrenallyderivedandrostenedionebyaromatizationinfat).c.Latemenopause.,RiskFactors,2.Somegynecologicdiseases(Long-termendogenousestrogenexposure)-polycysticovarysyndrome-functioningovariantumors-anovulatingdysfunctionalbleeding-Infertility,Nulliparity.,RiskFactors,3.ProlongedUseofestrogena.Prolongedmenopausalestrogenreplacementtherapywithoutprogestogen.b.Prolongeduseoftheantiestrogentamoxifenforbreastcancer.,RiskFactors,4.Geneticfactorsandotherfactorsa.Endometrialandovariancancerarethesimultaneouslyoccurringwithothergenitalmalignancy,reportedincidence(1.43.8%).b.Familyhistoryoftumorishigher.(12-28%),Fivehistologicalsubtypes,EndometrioidadenocarcinomaMucinouscarcinomaSerousadenocarcinomaClearcellcarcinomaOtherraresubtypes,Fivehistologicalsubtypes-EndometrioidAdenocarcinoma,Accountforabout8090%.Welldifferentiated.Prognosisisbetter.,Fivehistologicalsubtypes-Mucinouscarcinoma,Rare(about5%)a.Mostofthemisawelldifferentiated.b.Behaviorissimilartothatofcommonendometrialcarcinoma.,Fivehistologicalsubtypes-Serousadenocarcinoma,a.Architectureisidenticalwithcomplexpapillary.b.Moreaggressivelywithdeepmyometrialandlymphaticinvasion.c.Simulatingthebehaviorofovariancarcinoma.,Fivehistologicalsubtypes-Clearcellcarcinoma,a.Araresubtypeb.Ishighgradeandaggressivec.Prognosisissimilartoorworsethanthatofpapillaryserouscarcinomad.Survivalrateislower33%64%,Fivehistologicalsubtypes-otherraresubtypes,SquamousadenocarcinomaUndifferentiatedcarcinomaMixedadenocarcinoma,ClinicalFeatures-Symptoms,Asymptomaic(aboutlessthan5%)Abnormalvaginalbleeding(premenopausalorpostmenopausal,minimalornonpersistant)Abnormalvaginaldischarge(25%infectionofuterinecontents)Pelvicpressureordiscomfort(uterineenlargementorextrauterinediseasespread),ClinicalFeatures-Signs,NoevidenceinearlystageonphysicalexaminationSlightenlargementofuterinesizeandsoftUterusfixed,immobile,adenexalmessinadvancedstage,SpecialExamination,Dilationandfractionalcurettage(D.C)Mosteffective,definitiveprocedureandcommonlyusedSignificance-Establishedcorrectdiagnosis,clinicalstage-differentiatedfromcervicalcancerorcervicalinvolvement,UltrasonographyUsefuladjuvantmethodSignificancesSizeoflesionInvasionofendometriumorcervixResistantindexofnewvessels,Endometrialcarcinomaina58-year-oldwomanwithsubstantialpostmenopausalbleeding.(A)SagittaltransvaginalUSscanshowstheendometriumwithathicknessof44mmandalargeareaofmixedechogenicitysuggestiveofamass.(B)Transversesonohysterogramshowsa50-mm-diameterpolypoidmassprotrudingintotheendometrialcavity(calipersindicatethestalkofthemass).Histopathologicfindingsindicatedpoorlydifferentiatedendometrialcarcinoma.,A,B,HysteroscopySignificance-Directobservation-Takingsamplecorrectly-Identifyingpolypsandsubmucousmyoma,Paptest-Unreliablediagnostictest-30%-50%abnormalpaptestresultsOthers-MRI,CT,chestx-ray,IVurography,cystoscopy,sigmoidoscopy,Diagnosis,History,andclinicalsign,relatedriskfactorssymptomsDiagnosticmethods,DifferentialDiagnosis,Senileendometritis/vaginitisDysfunctionaluterinebleedingSubmucousmyoma/EndometrialpolypsCervixcancer/Sarcomaofuterus/Primarycarcinomaoffallopiantube,MetastasisRoute,DirectextensionLymphaticmetastasis:importantrouteHematogenousmetastasis,ClinicalStage(FIGO1971),StageIIaThecarcinomaisconfinedtothecorpusandthelengthoftheuterinecavityis8cmIbThecarcinomaisconfinedtothecorpusandthelengthoftheuterinecavityis8cmStageIIThecarcinomahasinvolvedthecorpusandthecervix,buthasnotextendedoutsidetheuterus,ClinicalStage(FIGO1971),StageIIIThecarcinomahasextendedoutsidetheuterus,butnotoutsidethetruepelvisStageIVIVaThecarcinomahasextendedoutsidetheuterusandinvolvesthemucosaofthebladderorrectum(abullousoedemaassuchdoesnotpermitthecasetobeallottedtoStageIV)IVbThecarcinomahasextendedoutsidethetruepelvisandspreadtodistantorgans,Surgicalpathologicstaging(FIGO1988),StageIIa*TumourlimitedtotheendometriumIb*InvasiontolessthanhalfofthemyometriumIc*InvasionequaltoormorethanhalfofthemyometriumStageIIIIa*EndocervicalglandularinvolvementonlyIIb*Cervicalstromalinvasion,Surgicalpathologicstaging(FIGO2000),StageIIIIIIa*Tumourinvadestheserosaofthecorpusuteriand/oradnexaeand/orpositivecytologicalfindingsIIIb*VaginalmetastasesIIIc*Metastasestopelvicand/orpara-aorticlymphnodesStageIVIVa*Tumourinvasionofbladderand/orbowelmucosaIVb*Distantmetastases,includingintra-abdominalmetastasisand/oringuinallymphnodes,StageIa*TumorlimitedtotheendometriumStageIb*InvasiontolessthanhalfofthemyometriumStageIc*Invasionequaltoormorethanhalfofthemyometrium,StageIIa*EndocervicalglandularinvolvementonlyStageIIb*Cervicalstromalinvasion,StageIIIa*Tumorinvadestheserosaofthecorpusuteriand/oradnexaeand/orpositivecytologicalfindingsStageIIIb*VaginalmetastasesStageIIIc*Metastasestopelvicand/orpara-aorticlymphnodes,StageIVa*Tumorinvasionofbladderand/orbowelmucosaStageIVb*Distantmetastases,includingintra-abdominalmetastasisand/oringuinallymphnodes,Treatment,SurgeryRadiationChemotherapyHormonetherapyEarlystage-surge+postoperativeadjuvanttherapyAdvancedstage-radiation+surge+medicine,Principleofchoice,Generalcondition(Age,complication)ClinicalstageTumourpathologictype,Surgery,ObjectOperativepathologicstage,findingprognosisriskfactorsRemoveuterusandmetastasistumourStageI:Abdorminalhysterectomy+bilateralsalpingoophorectomy+selectivelymphadenectomyclearcellorpapillarycarcinomaomentectomy+appenditectomy,StageIIRadicalhysterectomy+pelviclymphadenectomy+paraorticlymphadenectomyStageIII,IVCytoreductivesurgery,Indicationsofpelviclymphadenectomy,SpecialpathogeneticpatternEndometrialcancer,grade3ornodifferentiationMyo-invasionmorethanSizeoflesionmorethan50%ofuterinecavityInvolvementinisthmusofuterus,Radiationtherapy,RadiationaloneRadiationwithsurgery,Radiationcombinedsurgery-Radiationaftersurgery,Adenexal/serosal/parametrialspreadVaginalmetastasisLymphnodemetastasisIntraperitonealspreadBladder/rectalinvasionMyoinvasion50%G350%myoinvasion,Indicationsforradiationalone,ElderlyorobesityMultiplechronicoracutemedicalillness(hypertension,cardialdisease,diabetes,pulmonary,renal)Advancedstageunsuitableforsurgery,HormoneTherapy,mechenismMostendometrialcancershavebothER&PR.(Estrogendependentsubtype)Indications:AdvancedorrecurrentstageEarlystageanddesireforfertilityUseddrugsMPA,Chemotherapy,AdvancedstageorrecurrentcarcinomaPostoperat