子宫癌（Uterine Cancer）-妇科八年制教学课件

1、Uterine CancerXi-Shi Liu Obstetrics and Gynecology Hospital Fudan university2007.04General DescriptionUterine cancer is one of the most common malignancy of female genital tract.The incidence is increasing worldwide in recent years.Overall,2%-3% of women develop uterine cancer during their lifetime.

2、General DescriptionA malignant epithelial disease that occurs in endometrial gland of uterusAlso called endometrial cancerClassification(pathogenetic,biologic behavior )Estrogen dependent typehave a history of exposure to unopposed estrogen (either endogenous or exogenous).Hyperplastic endometriumBe

3、tter differentiafedER(+),PR(+)Mere favorable prognesis Estrogen independent type- Have no source of estrogen stimulation of endometrium.-Arising in background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosis Risk Factors1. Medical conditionsa. Diabetes mellitus, hypertension.b.

4、Overweight-obesity (excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat).c. Late menopause. Risk Factors2. Some gynecologic diseases ( Long-term endogenous estrogen exposure ) - polycystic ovary syndrome - functioning ovarian tumors - ano

5、vulating dysfunctional bleeding - Infertility, Nulliparity.Five histological subtypesEndometrioid adenocarcinomaMucinous carcinomaSerous adenocarcinomaClear cell carcinomaOther rare subtypesFive histological subtypes-Endometrioid AdenocarcinomaAccount for about 8090%.Well differentiated.Prognosis is

6、 better.Five histological subtypes -Mucinous carcinomaRare (about 5%)a. Most of them is a well differentiated.b. Behavior is similar to that of common endometrial carcinoma.Clinical Features-SymptomsAsymptomaic (about less than 5% )Abnormal vaginal bleeding (premenopausal or postmenopausal, minimal

7、or nonpersistant)Abnormal vaginal discharge(25% infection of uterine contents)Pelvic pressure or discomfort (uterine enlargement or extrauterine disease spread)Clinical Features-SignsNo evidence in early stage on physical examinationSlight enlargement of uterine size and softUterus fixed, immobile,

8、adenexal mess in advanced stageSpecial ExaminationDilation and fractional curettage ( D. C)Most effective ,definitive procedure and commonly usedSignificance-Established correct diagnosis, clinical stage-differentiated from cervical cancer or cervical involvement UltrasonographyUseful adjuvant metho

9、dSignificances Size of lesionInvasion of endometrium or cervixResistant index of new vesselsHysteroscopySignificance-Direct observation-Taking sample correctly-Identifying polyps and submucous myomaPap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV u

10、rography, cystoscopy, sigmoidoscopy, DiagnosisHistory, and clinical sign , related risk factors symptomsDiagnostic methodsDifferential DiagnosisSenile endometritis / vaginitisDysfunctional uterine bleedingSubmucous myoma / Endometrial polypsCervix cancer / Sarcoma of uterus/ Primary carcinoma of fal

11、lopian tubeMetastasis Route Direct extensionLymphatic metastasis: important route Hematogenous metastasis Clinical Stage(FIGO 1971)Stage I Ia The carcinoma is confined to the corpus and the length of the uterine cavity is 8 cm Ib The carcinoma is confined to the corpus and the length of the uterine

12、cavity is 8 cmStage II The carcinoma has involved the corpus and the cervix, but has not extended outside the uterusClinical Stage(FIGO 1971)Stage III The carcinoma has extended outside the uterus, but not outside the true pelvisStage IV IVa The carcinoma has extended outside the uterus and involves

13、 the mucosa of the bladder or rectum (a bullous oedema as such does not permit the case to be allotted to Stage IV) IVb The carcinoma has extended outside the true pelvis and spread to distant organsSurgical pathologic staging (FIGO 1988)Stage I Ia* Tumour limited to the endometrium Ib* Invasion to

14、less than half of the myometrium Ic* Invasion equal to or more than half of the myometriumStage II IIa* Endocervical glandular involvement only IIb* Cervical stromal invasionSurgical pathologic staging (FIGO 2000)Stage III IIIa* Tumour invades the serosa of the corpus uteri and/or adnexae and/or pos

15、itive cytological findings IIIb* Vaginal metastases IIIc* Metastases to pelvic and/or para-aortic lymph nodesStage IV IVa* Tumour invasion of bladder and/or bowel mucosa IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodesStage Ia* Tumor limited to the endometriu

16、m Stage Ib* Invasion to less than half of the myometrium Stage Ic* Invasion equal to or more than half of the myometriumStage IIa* Endocervical glandular involvement onlyStage IIb* Cervical stromal invasionStage IIIa* Tumor invades the serosa of the corpus uteri and/or adnexae and/or positive cytolo

17、gical findingsStage IIIb* Vaginal metastases Stage IIIc* Metastases to pelvic and/or para-aortic lymph nodesStage IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodesTreatmentSurgery RadiationChemotherapy Ho

18、rmone therapyEarly stage - surge+ postoperative adjuvant therapyAdvanced stage - radiation+ surge+ medicinePrinciple of choiceGeneral condition (Age, complication)Clinical stageTumour pathologic typeSurgeryObjectOperative pathologic stage, finding prognosis risk factorsRemove uterus and metastasis t

19、umourStage I :Abdorminal hysterectomy + bilateral salpingoophorectomy + selective lymphadenectomy clear cell or papillary carcinoma omentectomy+appenditectomyStage IIRadical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenectomyStage III,IVCytoreductive surgeryIndications of pelvic lympha

20、denectomySpecial pathogenetic patternEndometrial cancer, grade 3 or no differentiationMyo-invasion more than Size of lesion more than 50% of uterine cavityInvolvement in isthmus of uterusRadiation therapyRadiation aloneRadiation with surgeryRadiation combined surgery-Radiation after surgeryAdenexal

21、/ serosal / parametrial spreadVaginal metastasisLymph node metastasisIntraperitoneal spreadBladder / rectal invasionMyoinvasion 50%G3 50% myoinvasionIndications for radiation aloneElderly or obesityMultiple chronic or acute medical illness(hypertension, cardial disease, diabetes, pulmonary, renal)Ad

22、vanced stage unsuitable for surgeryHormone TherapymechenismMost endometrial cancers have both ER & PR.(Estrogen dependent subtype)Indications: Advanced or recurrent stage Early stage and desire for fertilityUsed drugsMPAChemotherapyAdvanced stage or recurrent carcinomaPostoperative adjunctive treatment for high risk factorUsed drugs: DDP (cisplatin), CTX (cyclophosphamide), ADM (doxorubicin ), 5-Fu,Taxal MMC,