1、Leiomyoma of UterusZhong gang Department of Gynecology and ObstetricTongji HospitalIntroduction vUterine enlargement as a result of leiomyoma is common in clinical practice.vMyoma are the commonest new growths of the uterus and one of the most common tumors of the human body.vThese occur in approxim
2、ately,20% of women over 30, 25% of women over 40.Aetiological factorsvFemale Hormones Estrogens Progestrons vGrowth Factors Basic fibroblast growth factor (BFGF). Insulinlike growth factor (IGF)-I. Epidermal growth factor (EGF). Anatomy of uterusClassificationClassificationvAccording to location of
3、uterine myomata have been divided in vCorporeal fibromyomata (90%)vCervical myomata(10%).ClassificationvAnd corporeal myomata have been divided:vIntramural fibromymata 60-70%vSubserous fibromymata 20%vSubmucous fibromymata 10-15%ClassificationvIntramural fibromymata with intramural fibromyomata enla
4、rgement of the uterine body usually occurs, often with elongation of its cavity so that there is increased menstrual loss.Classification Subserous fibromymata vSize:from small nodules to enormous masses of 20 kg or more in weight.vPedunculated myoma:they tend to grow up into the abdomen and the broa
5、d ligament, vRarely torsion may occur, resulting in interference with the blood supply to the tumor.ClassificationvSubmucous fibromyoma. Some intramural tumors are extruded towards the uterine cavity. vThe uterus contracts in an attempt to expel the tumor and it may be extruded until it is only atta
6、ched to the uterine wall by a stalk and is known as a fibro- myomatous polyp PathologyvNacked eye appearance.on section the fibromyoma is paler, harder and more fibrous than the uterine wall.vOn comparing an intramural tumor with the surrounding false capsule of uterine wall the difference is well m
7、arked.Nacked eye appearanceSmooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus.PathologyvMicroscopical structure. These growths are composed of unstriped muscle and fibrous tissueHere is the microscopic appearance of a
8、 benign leiomyoma. Normal myometrium is at the left, and the neoplasm is well-differentiated so that the leiomyoma at the right hardly appears different. Bundles of smooth muscle are interlacing in the tumor mass.DegenerationvThese tumors grow slowly; in some cases there may be no evident change in
9、size for many years. vIn a few cases growth is more rapid and secondary changes may also cause swelling of the tumor. DegenerationvHyaline degeneration is the commonest change seen in fibromyomata. It is caused by a gradual inadequacy of the blood supply.vCystic degeneration is not uncommon, especia
10、lly after the menopause, and is due to liquefaction of the areas of hyaline change.DegenerationvRed degeneration. In this variety of degeneration the affected area is stained red and resembles raw meat. It is most freguently seen during the pregnancy and in postpartum.Degeneration Malignant change v
11、In 0.1to 1% of cases, malignancy as leiomyosarcoma may develop. It is most likely to be seen in large tumors. vMalignancy is more typical in older patients, especially postmenopausal patients vPresention with rapidly enlarging uterine mass and postmenopausal bleeding.vMetastasis occurs rapidlly in t
12、hese cases.This is a leiomyosarcoma protruding from myometrium into the endometrial cavity of this uterus that has been opened laterally so that the halves of the cervix appear at right and left. Fallopian tubes and ovaries project from top and bottom. The irregular nature of this mass suggests that
13、 is not just an ordinary leiomyoma.SymptomsvBleeding is the most common presenting symptom in uterine fibroids. vMenorrhagia is freguent reason for patients to seek advice. vThe periods increase in amount and duration.SymptomsvBleeding vSubmucous fibromyomata menorrhagia is nearly always present, an
14、d quite small tumors can lead to severe anaemia.vIntramural tumors may increase the lossvSubserous growths do not affect the menstrual loss.SymptomsvBleeding vMechanisms for increased bleeding:vAlteration of normal myometrial contractile functionvInability of the overlying endometrium to respond to
15、the normal E/P menstrual phases.vPressure necrosis of the overlying endometrial bed.SymptomsvAn abdominal tumour is sometimes the first thing that the patient notices. The tumor is not tender and rarely gives rise to pain.vDischarge is rarely a prominent symptom except during the extrusion of fibrom
16、yomatos polyp through the cervical canal.SymptomsvPain is not a common symptom.vwhen it occur it is generally an indication that there is associated vendometriosis vor pelvic inflammatory disease, vor some complication of the tumor such as red degeneration or torsion.SymptomsvPelvic pressure: pressu
17、re on the bladder leading to frequency and retention of urine.Physical signsvThe physical signs vary with the size, position and number of the tumors. vA symmetrical enlargement of the uterus is found with a submucos growth.vMore often the enlargement is asymmetrical; it is often nodular on the surf
18、ace because there are multiple tumor.vSubserous tumors with little myometrial covering often fell particularly hard.Physical signsvOn pelvic examination the cervix may be found to be pushed down or displaced to one side. If it is expanded by an intracervical tumor , or it may be dilated with the low
19、er pole of a tumor left within it. DiagnosisvThe diagnosis of these tumors is usually made vby clinical examination, include abdominal and bimanual palpation, vor imaging studies. vIn addition, irregularities of the uterine cavity can be detected at the time of endometrial currettage.DiagnosisvPelvi
20、c ultrasound is the most commonly used for confirmation of uterine myomas.vDilation and curettage may provide relevant information, because larger tissue specimens, including small submucous myomas, may be obtained.Pelvic ultrasoundPelvic ultrasoundHysteroscopyvHysteroscopy may also be used to evalu
21、ate the enlarged uterus by directly visualizing the endometrial cavity.Differential diagnosisvOther conditions which cause menorrhagiavDysfunctional uterine bleedingvCarcinoma of the uterusvEndometrial polyp of uterusvOther conditions which give rise to a swelling in the pelvisvAdenomyoma, ovarian t
22、umors, inflammatory swelling in the pelvis, pregnancy This uterus has been opened anteriorly through cervix and into the endometrial cavity. High in the fundus and projecting into the endometrial cavity is a small endometrial polyp. Such benign polyps may cause uterine bleeding.The thickened and spo
23、ngy appearing myometrial wall of this sectioned uterus is typical of adenomyosis. There is also a small white leiomyoma at the lower left.This adenocarcinoma of the endometrium is more obvious. Irregular masses of white tumor are seen over the surface of this uterus that has been opened anteriorly.
24、The cervix is at the bottom of the picture. This enlarged uterus was no doubt palpable on physical examination. Abnormality of uterusTreatmentvFollow up vhormonal treatment vfibroid embolisation vSurgical management 1.hysterectomy 2.myomectomyvmyolysisTreatmentvFollow up: the majority of patients wi
25、th uterine myomas do not require surgical treatment. vSmall tumors and not causing symptomsvPatients in the late reproductive or perimenopausal years. vManagement:repeat pelvic exminations and assisted by serial pelvic ultrasound measurements vEvery 3-6 months.TreatmentvDrug therapy: bleeding is not
26、 heavy enough to cause anemia and small myoma.vMechanisms:vPharmacologic inhibition of estrogen secretionvAn attempt may be made to minimize uterine bleeding vThis treatment is commonly used for 3 to 6 months. TreatmentvDrugsvandrogen vGnRH-a supplementation. vGestrinonevMifepristonevChinese medicin
27、eTreatmentSurgical treatment is indicated in cases with:1.Heavy or prolonged bleeding2.Tumors of large size over 2.5 gestation months, even if these are not causing symptoms.3.Possible malignant change, such as a tumor which grows after the menopause.4.Pressure symptoms, pressure against bladder, bo
28、wel, and pelvic floor.5.Tumors which have undergone torsionTreatmentvSurgical forms:vMyomectomy is occasionally warranted in younger patients whose fertility is compromised by the presence of myomas.vHysterectomy: although hysterectomy is commonly performed for uterine myomas, it should be considered as definitive treatment only in symptomatic women who have completed childbearing.Uterine Fibroid Embolization (Uterine Artery Embolization)Uterine Fibroid Embolization (Uterine Artery Embolization)
