婦產(chǎn)科課件-子宮內(nèi)膜癌英文

EndometrialCancerOB/GYNHospitalFudanUniversityXinLU,MD,Ph.D.EndometrialCancerOB/GYNHospi1Endometriodcancer---ContentsIncidenceRiskfactorsClassificationSymptomsPathologyFIGOStagingDiagnosisTreatmentEndometriodcancer---ContentsI2WHOCancerReportGlobalcancerratescouldincreaseby50%to15millionby2020Endometrialcanceristhe4thmostcommoncancerinwomenNewDiagnosedcases:142,000Diedcaseseachyear:42,000incidence~2-3%Averageage:60sWHOCancerReportGlobalcancer3HistologicTypesEndometrialCancersEndometrioid(87%)Adenosquamous(4%)PapillarySerous(3%)ClearCell(2%)Mucinous(1%)Other(3%)HistologicTypesEndometrialCa4

EndometrialCancer:TypeI/IITypeIEstrogenRelatedYoungerandheavierpatientsLowgradeBackgroundofHyperplasiaPerimenopausalExogenousestrogenFamilial/genetic(~15%)LynchIIsyndrome/HNPCCFamilialtrendTypeII(~10%)AggressiveHighgradeUnfavorableHistologyUnrelatedtoestrogenstimulationOccursinolder&thinnerwomenEndometrialCancer:TypeI/IIT5EndometrialCancer:RiskFactorsRiskFactorsRelativeRisk[X]

Obesity2-5

PCOS＞5Estrogenuse10-20Nulliparous3Infertility2-3Diabetes/Hypertension1.3-3Nulliparous3EarlyMenarche(<12y/o)1.5-2AtypicalHyperplasiaOC0.3-0.5From:WilliamsGynecology2009EndometrialCancer:RiskFact6EndometriumCarcinoma

2009Classification

StageCharacteristicStageI*TumorconfinedtothecorpusuteriIA*NoorlessthanhalfmyometrialinvasionIB*InvasionequaltoormorethanhalfofthemyometriumStageII*Tumorinvadescervicalstroma,butdoesnotextendbeyondtheuterus**StageIII*Localand/orregionalspreadofthetumorIIIA*Tumorinvadestheserosaofthecorpusuteriand/oradnexae#IIIB*Vaginaland/orparametrialinvolvement#IIIC*Metastasestopelvicand/orpara-aorticlymphnodes#.IIIC1*?PositivepelvicnodesIIIC2*?PositiveparaaorticlymphnodeswithorwithoutpositivepelviclymphnodesStageIV*Tumorinvadesbladderand/orbowelmucosa,and/ordistantmetastasesIVA*Tumorinvasionofbladderand/orbowelmucosaIVB*Distantmetastases,includingintra-abdominalmetastasesand/oringuinallymphnodes

EndometriumCarcinoma

2009Cla7StageI(73%)ConfinedtouterusStageII(11%)CervixinvolvedStageIII(13%)Uterineserosa,adnexae,positivecytology,vaginalmetastases,pelvic/aorticnodemetastasesStageIV(3%)Bladder,bowel,inguinalnode,distantmetastasisEndometrialCancer:FIGOSurgicalStageStageIConfinedtouterusStage8EndometrialCancerPrognosis:SurvivalbyStage:Stage%5yrsurvivalIA91IB88IC81IIA77IIB67IIIA60IIIB41IIIC32IVA20IVB5SurvivalbyGrade:Grade%5yrsurvival192287374Overall5YrSurvival84%StageandGradearethemostimportantprognosticfactorsAlteredoncogene/tumorsuppressorgeneexpressionisnowbeingevaluated(molecularstagingconcept)EndometrialCancerPrognosis:S9AggressiveHistologicSubtypes(Clear-cell,Serous)Increasingage(over65)VascularinvasionAneuploidyAlteredoncogene/tumorsuppressorgeneexpression(“molecularstaging”concept-p53,PTEN,microsatelliteinstability,MDR-1,HER2/neu,ER/PR,Ki67,PCNA,CD31,EGF-R,MMRgenes)Race?EndometrialCancer:PoorPrognosticFactorsAggressiveHistologicSubtypes10MolecularGeneticsPTENmutations:32%Tumorsuppressorgene(chrom10)PhosphataseEarlyeventincarcinogenesisAssociatedwith:endometrioidhistologyearlystagefavorablesurvivalMolecularGeneticsPTENmutatio11MolecularGeneticsp53tumorsuppressorgeneCellcycleandapoptosisregulationMostcommonlymutatedgeneinhumancancersOverexpression(markerformutation)Associatedwithpoorprognosisearlystage: 10%havep53mutationadvancedstage:50%havep53mutationnotfoundinhyperplasiaslateeventincarcinogenesisMolecularGeneticsp53tumorsu12GeneticSyndromes:HNPCC

HereditaryNon-PolyposisColonCancerLynchIISyndromeAutosomaldominantinheritanceMMR(mismatchrepair)mutationsGeneticinstabilityleadstoerror-proneDNAreplicationhMSH2(chrom2)hMLH1(chrom3)EarlyageofcolonCa:mean45.2yearsEndometrialCa:secondmostcommonmalignancy20%cumulativeincidencebyage70EarlierageofonsetthansporadiccasesOther:ovary(3.5-8fold),stomach,smallbowel,pancreas,biliarytractGeneticSyndromes:HNPCC

Here13Diagnosisofdisease:PatientAwareness*Morethan95%ofpatientswithEndometrialCancerreporthavingsymptomsPostmenapausalbleedingMenorrhagiaMetrorrhagiaBloodyDischargeEndometrialbiopsyisthemaindiagnostictoolperformedeitherintheofficeorviaD&CinORDiagnosisofdisease:Patient14UterineCancer:

Diagnosis/ScreeningPatientSymptoms/Awareness*Cytology–NotasatisfactoryscreeningtestSonography–NotCosteffectiveHysteroscopy–NotCosteffectiveHistology–Secondarytosymptoms(notasascreeningtest)UterineCancer:

Diagnosis/Scre15EndometrialCancer:

TransvaginalUltrasoundScreeningEndometrialCancer:

Transvagin16EndometrialCancer:

TransvaginalUltrasoundScreeningEndometrialCancer:

Transvagin17EndometrialCancer:

TransvaginalUltrasoundScreeningEndometrialCancer:

Transvagin18Normalendometrialstripe:Postmenopausal 4-8mmPostmenopausalonHRT 4-10mmU/SforDetectionofanyuterinepathologySensitivity: 85-95%Specificity: 60-80%PPV2-10%NPV99%Summary:EndometrialCancer:

TransvaginalUltrasoundScreeningNormalendometrialstripe:Summ19Hysteroscopy–NotsatisfactoryforscreeningtestStudiesoftheefficacyofhysteroscopyasadiagnostictoolvarywidelySensitivityreportedrangingfrom60-95%comparedtoD&CobtainedatthesametimeSpecificity50-99%Hysteroscopy–Notsatisfactor20婦產(chǎn)科課件-子宮內(nèi)膜癌英文21HysteroscopyandPositiveCytology?Studieshavebeenmixed:SomestudiessuggestanincreaseinpositiveperitonealcytologyseenatstaginglaparotomyinpatientswhohavehadhysteroscopyOtherstudieshavefailedtofindadifferenceinpositivecytologyinpatientsdiagnosedviahysteroscopyascomparedtoofficebiopsyorD&CHysteroscopyandPositiveCyto22Hysteroscopy–NotsatisfactoryToomuchcostandrisktobeusedasascreeningtest.Usefulforevaluationofabnormaluterinebleedingwhereofficebiopsyisunrevealing.UseinconjunctionwithuterinecurettageUsefultoseeandresectpolypsandsmallsubmucousfibroidsUsefultoperformdirectedbiopsyofsmalllesions.Hysteroscopy–Notsatisfactor23EndometrialCancer:

WhoNeedsanEndometrialBiopsy?PostmenopausalbleedingPerimenopausalintermenstrualbleedingAbnormalbleedingwithhistoryofanovulationPostmenopausalwomenwithendometrialcellsonPapThickenedendometrialstripeviasonographyEndometrialCancer:

WhoNeeds24SamplingoftheEndometriumOfficebiopsyprocedures(Pipelle,Vabraaspirator,Karmancannula)willagreewithaD&CperformedintheOR~95%ofthetimeOfficebiopsyhasa16%falsenegativeratewhenthelesionisinapolyporthecancercoverslessthan50%oftheendometriumGuidoetal.JReprodMed.1995;40:553PatientswithpersistentPMBafternegativeofficebiopsyshouldhaveD&C(+/-hysteroscopy)D&CisthegoldstandardsamplingmethodpreoperativeD&Cwillagreewithdiagnosisathysterectomy94%ofthetimeSamplingoftheEndometriumOff25婦產(chǎn)科課件-子宮內(nèi)膜癌英文26婦產(chǎn)科課件-子宮內(nèi)膜癌英文27婦產(chǎn)科課件-子宮內(nèi)膜癌英文28TreatmentforEndometrialHyperplasiawithoutatypia:ProgestintherapycontinuousorcyclicalChildbearingage:ProgestindominantOCPsorDepo-Provera150mgIMq3monthsorProvera10mgpo10days/monthandMayfollowwithovulationinductionafternormalbiopsyifpregnancydesiredPeriorPostmenopausal:Provera20mgpo10days/monthorDepo-Provera200mgIMq2monthsRepeatbiopsyin3-4monthsTreatmentforEndometrialHype29TreatmentforAtypicalEndometrialHyperplasia:23%riskofprogressiontocarcinoma(over10years)ifuntreated.Standardtreatmentwhenchildbearingiscompleteistotalhysterectomy(abdominalorvaginal)Frozensectiontoruleoutcarcinoma(upto20%havecoexistingendometrialcancer)TreatmentforAtypicalEndomet30TreatmentforAtypicalEndometrialHyperplasia:Conservativemedicaltherapycanbeattemptedinyoungerpatientswhorequestpreservationoffertility.D&CpriortoinitiationofmedicaltherapytoruleoutcarcinomaMegace40-80mg/day,Norethindroneacetate5mg/dayConservativetherapymayalsobeattemptedinyoungpatientswithearly,welldifferentiatedendometrialcarcinomas.Megace120-200mg/day,Norethindroneacetate5-10mg/dayTreatmentforAtypicalEndomet31Endometroidcarcinoma,GradingFIGO -Gr1-<5%solidtumor -Gr2-6%-50%solid -Gr3->50%solidtumorNUCLEARGRADESize,shape,stainingandchromatin,variability,prominentnucleoli.HighnucleargradeaddsonepointtoFIGOgradeEndometroidcarcinoma,Grading32CA125ChestX-rayMammogramsColonEvaluationOthersasindicatedUterineCancer:Pre-opEvaluationCA125UterineCancer:Pre-opEv33UterineCancer:Pre-opEvaluationTransvaginalU/S?CTScan?MRI?UterineCancer:Pre-opEvaluat34UterineCancer:Pre-opEvaluationUterineCancer:Pre-opEvaluat35UterineCancer:SurgicalStagingPreoperativepreparationAntimicrobialprophylaxisDVTprophylaxisSteepTrendelenburgLonginstrumentsavailableUterineCancer:SurgicalStagi36Availabilityoffrozensectiontodeterminetheextentofstagingprocedure.CapabilityofcompletesurgicalstagingCapabilityoftumorreductionifindicatedEndometrialCancer:Intra-operativeSurgicalPrincipalsAvailabilityoffrozensection37EndometrialCancer:SurgicalApproachTAH-BSO/washingsonlyEndometrioid*Grades1and<50%myometrialinvasion*orGrade2andnoorminimali