Uterine Cancer医学课件

1、Uterine Cancer2021/4/261General 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.2021/4/262General DescriptionA malignant epithelial disease

2、 that occurs in endometrial gland of uterusAlso called endometrial cancer2021/4/263Classification(pathogenetic,biologic behavior )Estrogen dependent typehave a history of exposure to unopposed estrogen (either endogenous or exogenous).Hyperplastic endometriumBetter differentiafedER(+),PR(+)Mere favo

3、rable prognesis2021/4/264 Estrogen independent type- Have no source of estrogen stimulation of endometrium.-Arising in background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosis2021/4/265 Risk Factors1. Medical conditionsa. Diabetes mellitus, hypertension.b. Overweight-obesity

4、(excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat).c. Late menopause. 2021/4/266Risk Factors2. Some gynecologic diseases ( Long-term endogenous estrogen exposure ) - polycystic ovary syndrome - functioning ovarian tumors - anovulating

5、dysfunctional bleeding - Infertility, Nulliparity.2021/4/267Risk Factors3. Prolonged Use of estrogena. Prolonged menopausal estrogen replacement therapy without progestogen.b. Prolonged use of the antiestrogen tamoxifen for breast cancer.2021/4/268Risk Factors4. Genetic factors and other factorsa. E

6、ndometrial and ovarian cancer are the simultaneously occurring with other genital malignancy ,reported incidence (1.43.8%).b. Family history of tumor is higher.(12-28%) 2021/4/269Five histological subtypesEndometrioid adenocarcinomaMucinous carcinomaSerous adenocarcinomaClear cell carcinomaOther rar

7、e subtypes2021/4/26109、 人的价值，在招收诱惑的一瞬间被决定。2022/7/122022/7/12Tuesday, July 12, 202210、低头要有勇气，抬头要有低气。2022/7/122022/7/122022/7/127/12/2022 9:32:57 PM11、人总是珍惜为得到。2022/7/122022/7/122022/7/12Jul-2212-Jul-2212、人乱于心，不宽余请。2022/7/122022/7/122022/7/12Tuesday, July 12, 202213、生气是拿别人做错的事来惩罚自己。2022/7/122022/7/122

8、022/7/122022/7/127/12/202214、抱最大的希望，作最大的努力。12 七月 20222022/7/122022/7/122022/7/1215、一个人炫耀什么，说明他内心缺少什么。七月 222022/7/122022/7/122022/7/127/12/202216、业余生活要有意义，不要越轨。2022/7/122022/7/1212 July 202217、一个人即使已登上顶峰，也仍要自强不息。2022/7/122022/7/122022/7/122022/7/12Five histological subtypes-Endometrioid Adenocarcinom

9、aAccount for about 8090%.Well differentiated.Prognosis is better.2021/4/26129、 人的价值，在招收诱惑的一瞬间被决定。2022/7/122022/7/12Tuesday, July 12, 202210、低头要有勇气，抬头要有低气。2022/7/122022/7/122022/7/127/12/2022 9:32:58 PM11、人总是珍惜为得到。2022/7/122022/7/122022/7/12Jul-2212-Jul-2212、人乱于心，不宽余请。2022/7/122022/7/122022/7/12Tuesd

10、ay, July 12, 202213、生气是拿别人做错的事来惩罚自己。2022/7/122022/7/122022/7/122022/7/127/12/202214、抱最大的希望，作最大的努力。12 七月 20222022/7/122022/7/122022/7/1215、一个人炫耀什么，说明他内心缺少什么。七月 222022/7/122022/7/122022/7/127/12/202216、业余生活要有意义，不要越轨。2022/7/122022/7/1212 July 202217、一个人即使已登上顶峰，也仍要自强不息。2022/7/122022/7/122022/7/122022/7/

11、12Five histological subtypes -Mucinous carcinomaRare (about 5%)a. Most of them is a well differentiated.b. Behavior is similar to that of common endometrial carcinoma.2021/4/2614 Five histological subtypes -Serous adenocarcinoma a. Architecture is identical with complex papillary.b. More aggressivel

12、y with deep myometrial and lymphatic invasion.c. Simulating the behavior of ovarian carcinoma.2021/4/2615Five histological subtypes-Clear cell carcinomaa. A rare subtypeb. Is high grade and aggressivec. Prognosis is similar to or worse than that of papillary serous carcinomad. Survival rate is lower

13、 33%64%2021/4/2616Five histological subtypes-other rare subtypesSquamous adenocarcinomaUndifferentiated carcinomaMixed adenocarcinoma2021/4/2617Clinical Features-SymptomsAsymptomaic (about less than 5% )Abnormal vaginal bleeding (premenopausal or postmenopausal, minimal or nonpersistant)Abnormal vag

14、inal discharge(25% infection of uterine contents)Pelvic pressure or discomfort (uterine enlargement or extrauterine disease spread)2021/4/2618Clinical Features-SignsNo evidence in early stage on physical examinationSlight enlargement of uterine size and softUterus fixed, immobile, adenexal mess in a

15、dvanced stage2021/4/2619Special 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 2021/4/2620UltrasonographyUseful adjuvant m

16、ethodSignificances Size of lesionInvasion of endometrium or cervixResistant index of new vessels2021/4/2621Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (A) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixe

17、d echogenicity suggestive of a mass. (B) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma.AB2021/4/2622HysteroscopySignifica

18、nce-Direct observation-Taking sample correctly-Identifying polyps and submucous myoma2021/4/2623Pap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV urography, cystoscopy, sigmoidoscopy, 2021/4/2624DiagnosisHistory, and clinical sign , related risk fac

19、tors symptomsDiagnostic methods2021/4/2625Differential DiagnosisSenile endometritis / vaginitisDysfunctional uterine bleedingSubmucous myoma / Endometrial polypsCervix cancer / Sarcoma of uterus/ Primary carcinoma of fallopian tube2021/4/2626Metastasis Route Direct extensionLymphatic metastasis: imp

20、ortant route Hematogenous metastasis 2021/4/2627Clinical 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 cavity is 8 cmStage II The carcinoma has involved the corp

21、us and the cervix, but has not extended outside the uterus2021/4/2628Clinical 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 the mucosa of the bladder or rectum (a bullous

22、 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 organs2021/4/2629Surgical pathologic staging (FIGO 1988)Stage I Ia* Tumour limited to the endometrium Ib* Invasion to less than half of the myometrium Ic*

23、 Invasion equal to or more than half of the myometriumStage II IIa* Endocervical glandular involvement only IIb* Cervical stromal invasion2021/4/2630Surgical pathologic staging (FIGO 2000)Stage III IIIa* Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive cytological finding

24、s 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 nodes2021/4/2631Stage Ia* Tumor limited to the endometrium Stage Ib* In

25、vasion to less than half of the myometrium Stage Ic* Invasion equal to or more than half of the myometrium2021/4/2632Stage IIa* Endocervical glandular involvement onlyStage IIb* Cervical stromal invasion2021/4/2633Stage IIIa* Tumor invades the serosa of the corpus uteri and/or adnexae and/or positiv

26、e cytological findingsStage IIIb* Vaginal metastases Stage IIIc* Metastases to pelvic and/or para-aortic lymph nodes2021/4/2634Stage IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodes2021/4/2635TreatmentSu

27、rgery RadiationChemotherapy Hormone therapyEarly stage - surge+ postoperative adjuvant therapyAdvanced stage - radiation+ surge+ medicine2021/4/2636Principle of choiceGeneral condition (Age, complication)Clinical stageTumour pathologic type2021/4/2637SurgeryObjectOperative pathologic stage, finding

28、prognosis risk factorsRemove uterus and metastasis tumourStage I :Abdorminal hysterectomy + bilateral salpingoophorectomy + selective lymphadenectomy clear cell or papillary carcinoma omentectomy+appenditectomy2021/4/2638Stage IIRadical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenecto

29、myStage III,IVCytoreductive surgery2021/4/2639Indications of pelvic lymphadenectomySpecial pathogenetic patternEndometrial cancer, grade 3 or no differentiationMyo-invasion more than Size of lesion more than 50% of uterine cavityInvolvement in isthmus of uterus2021/4/2640Radiation therapyRadiation a

30、loneRadiation with surgery2021/4/2641Radiation combined surgery-Radiation after surgeryAdenexal / serosal / parametrial spreadVaginal metastasisLymph node metastasisIntraperitoneal spreadBladder / rectal invasionMyoinvasion 50%G3 50% myoinvasion2021/4/2642Indications for radiation aloneElderly or ob

31、esityMultiple chronic or acute medical illness(hypertension, cardial disease, diabetes, pulmonary, renal)Advanced stage unsuitable for surgery2021/4/2643Hormone TherapymechenismMost endometrial cancers have both ER & PR.(Estrogen dependent subtype)Indications: Advanced or recurrent stage Early stage

32、 and desire for fertilityUsed drugsMPA2021/4/2644ChemotherapyAdvanced stage or recurrent carcinomaPostoperative adjunctive treatment for high risk factorUsed drugs: DDP (cisplatin), CTX (cyclophosphamide), ADM (doxorubicin ), 5-Fu,Taxal MMC, VP16.2021/4/2645Prognostic FactorsTumour bilologic bihaviorCell type Histological grade Depth of myometrium infiltration lymph-node metastasisPresence of lymph vascular space involvement Positive peritoneal cytologyGeneral conditionOld age Acute or chronic medica