《妇产科学教学课件：Endometrial carcinoma》由会员分享，可在线阅读，更多相关《妇产科学教学课件：Endometrial carcinoma（55页珍藏版）》请在金锄头文库上搜索。
1、Endometrial carcinomaEndometrial cancer 子宫内膜癌Nulliparity 未产妇Menopause 更年期; 绝经Diffusing 弥散Adenosquamous carcinoma Adenosquamous carcinoma 腺磷癌腺磷癌Endometrioid AdenoCA 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
2、检查Cachexia 恶病质external OS 子宫外口Senile vaginitis 老年性阴道炎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 wordsoAdriamycin阿霉素ocisplatin顺铂oCarboplatin卡铂oPaclitaxel紫杉醇ocyclo-phosphamide环磷酰胺omegesterol acetate 醋酸甲地孕酮oTamoxifen 他莫昔芬INTRODUCTIONoEndometrial ca
3、ncer is one of the three main malignant tumorsoAccounts for about 7% in female carcinoma o2030% in female reproductive system carcinomaoPeak incident age is 5861oMorbility rises in recent yearsetiologyExcessive estrogen stimulation oObesityoNulliparityoLate menopauseoUnopposed estrogen stimulation:E
4、RToDiabetes mellitusetiologyoover hyperplasia of endometrium(Type1)ohereditary factor:20% has family historyoFamily history or personal history of colon,ovarian or breast canceroFibroid is associated in about 30% fer cent casesoEndometrial hyperplasia precedes carcinma in about 25% cases.pathology G
5、rossoDiffuse :the spread is through the endometrium.the myometrium is commonly invaded;may invade to reach the serosal coat. oLocalised:the usual site is on the fundus.it is either sessile or pedunculated.myometrial invovement is late. Histopathology ooEndometrioid AdenoCA(80%)Endometrioid AdenoCA(8
6、0%)adenocarcinoma G1 adenocarcinoma G1 adenocarcinoma G2 adenocarcinoma G2 Adenocarcinoma with squamous Adenocarcinoma with squamous differention(adenoacanthoma) differention(adenoacanthoma) Adenosquamous Adenosquamous adenocarcinoma adenocarcinoma ooMucinous CAMucinous CA Mucinous carcinomaMucinous
7、 carcinoma.ooPapillary Serous AdenoCA (UPSC):1-9% Papillary Serous AdenoCA (UPSC):1-9% ooClear -Cell AdenoCAClear -Cell AdenoCA Clear cell carcinoma .Clear cell carcinoma .ooSquamous-Cell carcinomaSquamous-Cell carcinomaooUndifferentiated carcinomaUndifferentiated carcinomaooMixed type( adenosquamou
8、s carcinoma)Mixed type( adenosquamous carcinoma)ooMetastatic carcinoma. Metastatic carcinoma. adenocarcinoma G1 adenocarcinoma G2 Endometrioid AdenoCAEndometrioid AdenoCA子宫内膜腺鳞癌子宫内膜腺鳞癌Adenosquamous adenocarcinomaAdenosquamous adenocarcinoma子宫内膜透明细胞癌子宫内膜透明细胞癌 子宫内膜粘液腺癌子宫内膜粘液腺癌 Clear cell carcinomaClea
9、r cell carcinoma Mucinous carcinomaMucinous carcinomaRoute of metastasisoDirect adjacent extensionoExtend by lymphatics metastasis:the chief metastatic path.oBlood vessel path- rarely(1)uterine fundus cancer uper edge of broad ligament suspensory ligament and ovary and paraaortic LN.(2)uterine corne
10、r 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.Lymphatic metastasisFocal point reviewoPa
11、thology of the endometial carcinomaoRoute 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 adenomatoid hyperplasia or carcinoma
12、 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 moderate differentiation; grade3 mean
13、s 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 organs, such as bladder or rectum IVb
14、spreads to distent organsEndometrial CA Staging: surgicalI I cancer is located in the uterine cavityIbIb 1/2 myometrial thickness 1/2 myometrial thickness 1/2 myometrial thicknessII II cancer has spreaded to cervix stromalstromalIII III cancer spreading is beyond uterus but not beyond the true pelvi
15、s IIIa IIIa Uterine Uterine serosa serosa and and (or) (or) adnexal adnexal involvement involvement IIIb IIIb Vaginal and (or) parametrium Vaginal and (or) parametrium metastasesmetastases IIIc IIIc Positive Positive pelvic pelvic and and (or) (or) paraaotic lymph ymph nodesnodesIV IV cancer spreadi
16、ng is beyond true pelvis or involving mucosa of bladder or rectum IVa IVa Bladder or bowel mucosa Bladder or bowel mucosa IVb IVb Distant metastases Distant metastases （FIGO，2009 ）This adenocarcinoma of the endometrium is more obvious. Irregular masses of white tumor are seen over the surface of thi
17、s 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 endometrial adenocarcinoma is present on the myometrummyometrum of this cross section of
18、uterus. Note that the neoplasm is superficially invasive. The cervix is at the right. 子宫内膜癌子宫内膜癌 III 期期 侵肌全层、宫颈、附件侵肌全层、宫颈、附件 侵肌侵肌 a b bFocal point review:Surgical Stage手术病理分期（手术病理分期（FIGOFIGO，19881988 ） Surgical StageSurgical Stage a b cClinical featuresoPatient profile the patient is usually a nulli
19、para likely to be postmenopausal.there may be history of delayed menopausal .she may be obese ;likely to have hypertension or diabetes.symptomsoVaginal bleeding bleeding post-menopause or hypermenorrhea, duration prolonged, intermenstrual bleeding oVaginal dischargeoLower abdominal pain-pyometraoCac
20、hexiaoFew patients(8mm(postmenopause)oHyperechoic endometrium with irregular outlineoIncreased vascularity with low vascular resistenceoIntrauterine fluid it cannot replace definitive biopsyfractional curettageoIt is not only the definitive method of diagnosis but can detect the extent of growth.oIt
21、 should be done gently to prevent perforation of the uterus.oIf 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 curettageoEndocervical curettageoTo pass an uterine sound to note the length
22、of the uterine cavityoDilatation of the internal osoUterine 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 diagnosisoDysfunctional uterine bleeding near menopauseoSenile
23、vaginitisoSubmucous myomaoEndometrial ploypoCervical carcinomaoSenile chronic endometritis and pyometraTreatment oPreventionocurativeTreatmentoPrimary prevention includes:-strict weight control beginning early in life-to strict the use of oestrogen after menopause in nonhysterectomise women. -educat
24、ion as regards the significance of irregular bleeding per vagina in perimenopause and post menopausal period .TreatmentoSecondary 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:endom
25、etrial aspiration or endometrial lavage detected suspicious cells-uterine curettage. Treatment -curativeSurgical treatmentIn stage :Extrafascial hysterectomy and bilateral adnexectomySurgical proceduresoLongitudinal incisionoPeritoneal washings are taken for cytologyoThorough palpation of liver,diap
26、hragm,omentum,pelvic organs,pelvic and para-aortic lymph nodes,is done.oTotal abdoninal extrafascial hysterectomy with bilateral salpingo-oophorectomy is performedoUterus is cut opended in the operating room-for evaluatin of tumor size,cervical extension and myometrium invasion.oFrozen section biops
27、yIf any of following up exit, lymphadenectomy should be carried outooPapillary Serous AdenoCA, Clear Cell Papillary Serous AdenoCA, Clear Cell AdenoCA, Squamous Cell, Endometrioid AdenoCA, Squamous Cell, Endometrioid AdenoCA grade 3AdenoCA grade 3ooInvades myometrium more than 50%Invades myometrium
28、more than 50%ooTumor size more than 2cmTumor size more than 2cmTreatment Surgical treatmentIn stage : oradical hysterectomy and bilateral adnexectomy opelvic and para-aortic lymphadenectomyCaution: collect ascites for cytologyCaution: collect ascites for cytologyTreatment Surgical treatmentIn stage
29、: oSurgical is same to ovary cancer, cytoreductive surgeryshould be done Treatment Radiotherapy ProgestogenChemotherapy RadiotherapyThe primary treatment by radiotherapy is indicated in:oSurgically risk patientoStadge and Contraindications: fibroid, PID, adhesions with gut etc.RadiotherapyCombined r
30、adiation therapy:4-6weeks after surgery to prevent tumour recurrence.oNo myometial invasion:observation onlyomyometial invasion 1/2 thickness:whole pelvis external beam radiation.oLymph node metastasis: extended field radiation ChemotherapyIs used in advanced and recurrent cases or in metastatic les
31、ionoProgestogensoTamoxifenoCytotoxic drugsProgestogensoIs widely used oThe response is good in well differentiated carcinoma with adequate oestrogen and progesterone receptorodrugs: megesterol acetateoTo be continued for at least 3 months.Tamoxifenois a nonsteroidal agent with antioestrogenic as wel
32、l as weakly oestrogenic properties.oinhibits oestradiol binding to oestrogen receptoro10mg twice daily along with progestogen therapy.oit is effective in patients with hormone receptor positive tumorsCytotoxic drugsoBeing tried either singly or in combination oThe drugs commonly used are adriamycin,
33、cisplatin,carboplatin,paclitaxel and cyclo-phosphamideRecurrent diseaseoRadiation therapy is the choice for isolated recurrence following surgical treatmentoExtensive surgery for recurrent endometrial cancer is of limited value.oHormonal therapy and chemotherapy have been used depending on the indiv
34、idual case.Focal point reviewofractional curettageoPlanning of treatment modalities for endometrial carcinomaFollow up oFollowing initial therapy,patient is examined every3 months for the first 2-3 years,every 6 months for next 2 years and thereafter annually.oEvaluation of symptoms,thorough clinical examination and x-ray chestoRegular estimation of serum CA125 may be helpful in some cases.
