妇产科学课件：Endometrial carcinoma

1、Endometrial carcinomaEndometrial cancer 子宫内膜癌Nulliparity 未产妇Menopause 更年期; 绝经Diffusing 弥散Adenosquamous carcinoma 腺磷癌Endometrioid AdenoCA 子宫内膜样癌 New wordsNew wordsParaaortic LN腹主动脉旁淋巴结fractional curettage分段刮宫biopsy活组织检查Papanicolaou smear hysteroscopy宫腔镜检查Cachexia 恶病质external OS 子宫外口Senile vaginitis 老

2、年性阴道炎Contraindications禁忌症radical hysterectomy and bilateral adnexectomy根治性子宫切除术加双附件切除Pyometra 子宫积脓 New wordsAdriamycin阿霉素cisplatin顺铂Carboplatin卡铂Paclitaxel紫杉醇cyclo-phosphamide环磷酰胺megesterol acetate 醋酸甲地孕酮Tamoxifen 他莫昔芬INTRODUCTIONEndometrial cancer is one of the three main malignant tumorsAccounts f

3、or about 7% in female carcinoma 2030% in female reproductive system carcinomaPeak incident age is 5861Morbility rises in recent yearsetiologyExcessive estrogen stimulation ObesityNulliparityLate menopauseUnopposed estrogen stimulation:ERTDiabetes mellitusetiologyover hyperplasia of endometrium(Type1

4、)hereditary factor:20% has family historyFamily history or personal history of colon,ovarian or breast cancerFibroid is associated in about 30% fer cent casesEndometrial hyperplasia precedes carcinma in about 25% cases.pathology GrossDiffuse :the spread is through the endometrium.the myometrium is c

5、ommonly invaded;may invade to reach the serosal coat. Localised:the usual site is on the fundus.it is either sessile or pedunculated.myometrial invovement is late. Histopathology Endometrioid AdenoCA(80%)adenocarcinoma G1 adenocarcinoma G2 Adenocarcinoma with squamous differention(adenoacanthoma) Ad

6、enosquamous adenocarcinoma Mucinous CA Mucinous carcinoma.Papillary Serous AdenoCA (UPSC):1-9% Clear -Cell AdenoCA Clear cell carcinoma .Squamous-Cell carcinomaUndifferentiated carcinomaMixed type( adenosquamous carcinoma)Metastatic carcinoma. adenocarcinoma G1 adenocarcinoma G2 Endometrioid AdenoCA

7、子宫内膜腺鳞癌Adenosquamous adenocarcinoma子宫内膜透明细胞癌 子宫内膜粘液腺癌 Clear cell carcinoma Mucinous carcinomaRoute of metastasisDirect adjacent extensionExtend by lymphatics metastasis:the chief metastatic path.Blood vessel path- rarely(1)uterine fundus cancer uper edge of broad ligament suspensory ligament and ova

8、ry and paraaortic LN.(2)uterine corner cancer, along round ligament inguinal LN(3)lower segment and cervical canal cancer parauterine,internal iliac,external iliac and common iliac LN .(4)posterior wall cancer along uterosacral ligament rectal LN(5)endometrial cancer can also bladder and vagina.Lymp

9、hatic metastasisFocal point reviewPathology of the endometial carcinomaRoute of metastasisStaging For non-operative patient we adopt FIGO(1971) clinical stage.For patient who has accepted operation,we adopt FIGO(2009) operative-pathologic stageClinical stage of endometrial cancer(FIGO 1971)Stage 0 a

10、denomatoid hyperplasia or carcinoma in situStage I cancer is located in the uterine cavity Ia the length of uterine cavity8cm Ib the length of uterine cavity8cm according to the histological differentiation Ia and Ib is also divided into 3 sub-grades: grade1 means well- diferentiated grade2 means mo

11、derate differentiation; grade3 means undifferenatiated carcinoma Stage II cancer has spreaded to cervix Stage III cancer spreading is beyond uterus but not beyond the true pelvis Stage IV cancer spreading is beyond true pelvis or involving mucosa of bladder or rectum IVa cancer spreads to nearby org

12、ans, such as bladder or rectum IVb spreads to distent organsEndometrial CA Staging: surgicalI cancer is located in the uterine cavityIb 1/2 myometrial thicknessII cancer has spreaded to cervix stromalIII cancer spreading is beyond uterus but not beyond the true pelvis IIIa Uterine serosa and (or) ad

13、nexal involvement IIIb Vaginal and (or) parametrium metastases IIIc Positive pelvic and (or) paraaotic lymph nodesIV cancer spreading is beyond true pelvis or involving mucosa of bladder or rectum IVa Bladder or bowel mucosa IVb Distant metastases （FIGO，2009 ）This adenocarcinoma of the endometrium i

14、s more obvious. Irregular masses of white tumor are seen over the surface of this uterus that has been opened anteriorly. The cervix is at the bottom of the picture. This enlarged uterus was no doubt palpable on physical examination. Such a neoplasm often present with abnormal bleeding.The endometri

15、al adenocarcinoma is present on the myometrum of this cross section of uterus. Note that the neoplasm is superficially invasive. The cervix is at the right. 子宫内膜癌 III 期 侵肌全层、宫颈、附件 侵肌 a b bFocal point review:Surgical Stage手术病理分期（FIGO，1988 ） Surgical Stage a b cClinical featuresPatient profile the pat

16、ient is usually a nullipara likely to be postmenopausal.there may be history of delayed menopausal .she may be obese ;likely to have hypertension or diabetes.symptomsVaginal bleeding bleeding post-menopause or hypermenorrhea, duration prolonged, intermenstrual bleeding Vaginal dischargeLower abdomin

17、al pain-pyometraCachexiaFew patients(8mm(postmenopause)Hyperechoic endometrium with irregular outlineIncreased vascularity with low vascular resistenceIntrauterine fluid it cannot replace definitive biopsyfractional curettageIt is not only the definitive method of diagnosis but can detect the extent

18、 of growth.It should be done gently to prevent perforation of the uterus.If pyometra is detected, the procedure is withheld for about one week to avoid perforation and systemic infection.The orderly steps to be followed for fractional curettageEndocervical curettageTo pass an uterine sound to note t

19、he length of the uterine cavityDilatation of the internal osUterine curettage at the fundus and lower pert of the body.The specimen should be placed in separate containers,labelled properly and submitted for histological examinationDifferential diagnosisDysfunctional uterine bleeding near menopauseS

20、enile vaginitisSubmucous myomaEndometrial ploypCervical carcinomaSenile chronic endometritis and pyometraTreatment PreventioncurativeTreatmentPrimary prevention includes:-strict weight control beginning early in life-to strict the use of oestrogen after menopause in nonhysterectomise women. -educati

21、on as regards the significance of irregular bleeding per vagina in perimenopause and post menopausal period .TreatmentSecondary prevention includes: screening of “high risk” women at least in menopausal period to detect the premalignant or early carcinoma is a positive step.Screening methods:endomet

22、rial aspiration or endometrial lavage detected suspicious cells-uterine curettage. Treatment -curativeSurgical treatmentIn stage :Extrafascial hysterectomy and bilateral adnexectomySurgical proceduresLongitudinal incisionPeritoneal washings are taken for cytologyThorough palpation of liver,diaphragm

23、,omentum,pelvic organs,pelvic and para-aortic lymph nodes,is done.Total abdoninal extrafascial hysterectomy with bilateral salpingo-oophorectomy is performedUterus is cut opended in the operating room-for evaluatin of tumor size,cervical extension and myometrium invasion.Frozen section biopsyIf any

24、of following up exit, lymphadenectomy should be carried outPapillary Serous AdenoCA, Clear Cell AdenoCA, Squamous Cell, Endometrioid AdenoCA grade 3Invades myometrium more than 50%Tumor size more than 2cmTreatment Surgical treatmentIn stage : radical hysterectomy and bilateral adnexectomy pelvic and

25、 para-aortic lymphadenectomyCaution: collect ascites for cytologyTreatment Surgical treatmentIn stage : Surgical is same to ovary cancer, cytoreductive surgeryshould be done Treatment Radiotherapy ProgestogenChemotherapy RadiotherapyThe primary treatment by radiotherapy is indicated in:Surgically ri

26、sk patientStadge and Contraindications: fibroid, PID, adhesions with gut etc.RadiotherapyCombined radiation therapy:4-6weeks after surgery to prevent tumour recurrence.No myometial invasion:observation onlymyometial invasion 1/2 thickness:whole pelvis external beam radiation.Lymph node metastasis: e

27、xtended field radiation ChemotherapyIs used in advanced and recurrent cases or in metastatic lesionProgestogensTamoxifenCytotoxic drugsProgestogensIs widely used The response is good in well differentiated carcinoma with adequate oestrogen and progesterone receptordrugs: megesterol acetateTo be continued for at least 3 months.Tamoxifenis a nonsteroidal agent with antioestrogenic as well as weakly oestrogenic properties.inhibits oestradiol binding to oestrogen rece