妇产科课件-子宫内膜癌英文.ppt

1、Endometrial Cancer,OB/GYN Hospital Fudan University Xin LU, MD, Ph.D.,Endometriod cancer-Contents,Incidence Risk factors Classification Symptoms,Pathology FIGO Staging Diagnosis Treatment,WHO Cancer Report,Global cancer rates could increase by 50% to 15 million by 2020 Endometrial cancer is the 4th

2、most common cancer in women New Diagnosed cases: 142,000 Died cases each year: 42,000 incidence 2-3% Average age: 60s,Histologic Types,Endometrial Cancers Endometrioid (87%) Adenosquamous (4%) Papillary Serous (3%) Clear Cell (2%) Mucinous (1%) Other (3%),Endometrial Cancer:Type I/II,Type I Estrogen

3、 Related Younger and heavier patients Low grade Background of Hyperplasia Perimenopausal Exogenous estrogen Familial/genetic (15% ) Lynch II syndrome/HNPCC Familial trend,Type II (10% ) Aggressive High grade Unfavorable Histology Unrelated to estrogen stimulation Occurs in older & thinner women,Endo

4、metrial Cancer: Risk Factors,From: Williams Gynecology 2009,Endometrium Carcinoma2009 Classification,Stage Characteristic Stage I* Tumor confined to the corpus uteri IA* No or less than half myometrial invasion IB* Invasion equal to or more than half of the myometrium Stage II* Tumor invades cervica

5、l stroma, but does not extend beyond the uterus* Stage III* Local and/or regional spread of the tumor IIIA* Tumor invades the serosa of the corpus uteri and/or adnexae# IIIB* Vaginal and/or parametrial involvement# IIIC* Metastases to pelvic and/or para-aortic lymph nodes#. IIIC1* Positive pelvic no

6、des IIIC2* Positive paraaortic lymphnodes with or without positive pelvic lymph nodes Stage IV* Tumor invades bladder and/or bowel mucosa, and/or distant metastases IVA* Tumor invasion of bladder and/or bowel mucosa IVB* Distant metastases, including intra-abdominal metastases and/or inguinal lymph

7、nodes,Endometrial Cancer: FIGO Surgical Stage,Endometrial Cancer Prognosis:,Overall 5Yr Survival 84% Stage and Grade are the most important prognostic factors Altered oncogene/tumor suppressor gene expression is now being evaluated (molecular staging concept),Aggressive Histologic Subtypes (Clear-ce

8、ll, Serous) Increasing age (over 65) Vascular invasion Aneuploidy Altered oncogene/tumor suppressor gene expression ( “molecular staging” concept- p53, PTEN, microsatellite instability, MDR-1, HER2/neu, ER/PR, Ki 67, PCNA, CD 31,EGF-R, MMR genes) Race?,Endometrial Cancer: Poor Prognostic Factors,Mol

9、ecular Genetics,PTEN mutations: 32% Tumor suppressor gene (chrom 10) Phosphatase Early event in carcinogenesis Associated with: endometrioid histology early stage favorable survival,Molecular Genetics,p53 tumor suppressor gene Cell cycle and apoptosis regulation Most commonly mutated gene in human c

10、ancers Overexpression (marker for mutation) Associated with poor prognosis early stage:10% have p53 mutation advanced stage: 50% have p53 mutation not found in hyperplasias late event in carcinogenesis,Genetic Syndromes: HNPCCHereditary Non-Polyposis Colon Cancer,Lynch II Syndrome Autosomal dominant

11、 inheritance MMR (mismatch repair) mutations Genetic instability leads to error-prone DNA replication hMSH2 (chrom 2) hMLH1 (chrom 3) Early age of colon Ca: mean 45.2 years Endometrial Ca: second most common malignancy 20% cumulative incidence by age 70 Earlier age of onset than sporadic cases Other

12、: ovary (3.5-8 fold), stomach, small bowel, pancreas, biliary tract,Diagnosis of disease: Patient Awareness*,More than 95% of patients with Endometrial Cancer report having symptoms Postmenapausal bleeding Menorrhagia Metrorrhagia Bloody Discharge Endometrial biopsy is the main diagnostic tool perfo

13、rmed either in the office or via D&C in OR,Uterine Cancer:Diagnosis/Screening,Patient Symptoms/Awareness* Cytology Not a satisfactory screening test Sonography Not Cost effective Hysteroscopy Not Cost effective Histology Secondary to symptoms (not as a screening test),Endometrial Cancer:Transvaginal

14、 Ultrasound Screening,Endometrial Cancer:Transvaginal Ultrasound Screening,Endometrial Cancer:Transvaginal Ultrasound Screening,Normal endometrial stripe: Postmenopausal4- 8 mm Postmenopausal on HRT4- 10 mm U/S for Detection of any uterine pathology Sensitivity:85-95% Specificity:60-80% PPV 2-10% NP

15、V 99%,Summary: Endometrial Cancer:Transvaginal Ultrasound Screening,Hysteroscopy Not satisfactory for screening test,Studies of the efficacy of hysteroscopy as a diagnostic tool vary widely Sensitivity reported ranging from 60-95% compared to D&C obtained at the same time Specificity 50-99%,Hysteros

16、copy and Positive Cytology?,Studies have been mixed: Some studies suggest an increase in positive peritoneal cytology seen at staging laparotomy in patients who have had hysteroscopy Other studies have failed to find a difference in positive cytology in patients diagnosed via hysteroscopy as compare

17、d to office biopsy or D&C,Hysteroscopy Not satisfactory,Too much cost and risk to be used as a screening test. Useful for evaluation of abnormal uterine bleeding where office biopsy is unrevealing. Use in conjunction with uterine curettage Useful to see and resect polyps and small submucous fibroids

18、 Useful to perform directed biopsy of small lesions.,Endometrial Cancer:Who Needs an Endometrial Biopsy?,Postmenopausal bleeding Perimenopausal intermenstrual bleeding Abnormal bleeding with history of anovulation Postmenopausal women with endometrial cells on Pap Thickened endometrial stripe via so

19、nography,Sampling of the Endometrium,Office biopsy procedures (Pipelle, Vabra aspirator, Karman cannula) will agree with a D40:553 Patients with persistent PMB after negative office biopsy should have D&C (+/- hysteroscopy) D&C is the gold standard sampling method preoperative D&C will agree with di

20、agnosis at hysterectomy 94% of the time,Treatment for Endometrial Hyperplasia without atypia:,Progestin therapy continuous or cyclical Childbearing age: Progestin dominant OCPs or Depo-Provera 150mg IM q3 months or Provera 10mg po 10 days/month and May follow with ovulation induction after normal bi

21、opsy if pregnancy desired Peri or Postmenopausal: Provera 20mg po 10 days/month or Depo-Provera 200mg IM q2 months Repeat biopsy in 3-4 months,Treatment for Atypical Endometrial Hyperplasia:,23% risk of progression to carcinoma (over 10 years) if untreated. Standard treatment when childbearing is co

22、mplete is total hysterectomy (abdominal or vaginal) Frozen section to rule out carcinoma (up to 20% have coexisting endometrial cancer),Treatment for Atypical Endometrial Hyperplasia:,Conservative medical therapy can be attempted in younger patients who request preservation of fertility. D&C prior t

23、o initiation of medical therapy to rule out carcinoma Megace 40-80mg/day, Norethindrone acetate 5mg/day Conservative therapy may also be attempted in young patients with early, well differentiated endometrial carcinomas. Megace 120-200mg/day, Norethindrone acetate 5-10mg/day,Endometroid carcinoma, G

24、rading,FIGO- Gr 1 - 50% solid tumor NUCLEAR GRADE Size, shape , staining and chromatin, variability, prominent nucleoli. High nuclear grade adds one point to FIGO grade,CA125 Chest X-ray Mammograms Colon Evaluation Others as indicated,Uterine Cancer: Pre-op Evaluation,Uterine Cancer: Pre-op Evaluati

25、on,Transvaginal U/S? CT Scan? MRI?,Uterine Cancer: Pre-op Evaluation,Uterine Cancer: Surgical Staging,Preoperative preparation Antimicrobial prophylaxis DVT prophylaxis Steep Trendelenburg Long instruments available,Availability of frozen section to determine the extent of staging procedure. Capability of complete surgical staging Capability of tumor reduction if indicated,Endometrial Cancer: Intra-operative Surgical Principals,Endometrial Cancer: Surgical Approach,TAH-BSO/washings only Endometrioid* Grades 1 and 50% myometrial invasion* or Grade 2 and no or minimal invasi