1、Uterine CancerUterine CancerXi-Shi Liu Obstetrics and Gynecology Hospital Fudan university2007.04General Description Uterine 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 durin
2、g their lifetime.General Description A malignant epithelial disease that occurs in endometrial gland of uterus Also called endometrial cancerClassification(pathogenetic,biologic behavior ) Estrogen dependent type- have a history of exposure to unopposed estrogen (either endogenous or exogenous).- Hy
3、perplastic endometrium- Better differentiafed- ER(+),PR(+)- Mere favorable prognesisl Estrogen independent type- Have no source of estrogen stimulation of endometrium.-Arising in background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosis Risk Factors1. Medical conditionsa. Diab
4、etes mellitus, hypertension.b. Overweight-obesity (excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat).c. Late menopause. Risk Factors2. Some gynecologic diseases ( Long-term endogenous estrogen exposure ) - polycystic ovary syndrome - f
5、unctioning ovarian tumors - anovulating dysfunctional bleeding - Infertility, Nulliparity.Risk Factors3. Prolonged Use of estrogena. Prolonged menopausal estrogen replacement therapy without progestogen.b. Prolonged use of the antiestrogen tamoxifen for breast cancer.Risk Factors4. Genetic factors a
6、nd other factorsa. Endometrial 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%) Five histological subtypes Endometrioid adenocarcinoma Mucinous carcinoma Serous adenocarcinoma Clear cell carc
7、inoma Other rare subtypesFive histological subtypes-Endometrioid Adenocarcinoma Account for about 8090%. Well differentiated. Prognosis is better.Five histological subtypes -Mucinous carcinomaRare (about 5%)a. Most of them is a well differentiated.b. Behavior is similar to that of common endometrial
8、 carcinoma. Five histological subtypes -Serous adenocarcinoma a. Architecture is identical with complex papillary.b. More aggressively with deep myometrial and lymphatic invasion.c. Simulating the behavior of ovarian carcinoma.Five histological subtypes-Clear cell carcinomaa. A rare subtypeb. Is hig
9、h grade and aggressivec. Prognosis is similar to or worse than that of papillary serous carcinomad. Survival rate is lower 33%64%Five histological subtypes-other rare subtypes Squamous adenocarcinoma Undifferentiated carcinoma Mixed adenocarcinomaClinical Features-Symptoms Asymptomaic (about less th
10、an 5% ) Abnormal vaginal bleeding (premenopausal or postmenopausal, minimal or nonpersistant) Abnormal vaginal discharge(25% infection of uterine contents) Pelvic pressure or discomfort (uterine enlargement or extrauterine disease spread)Clinical Features-Signs No evidence in early stage on physical
11、 examination Slight enlargement of uterine size and soft Uterus fixed, immobile, adenexal mess in advanced stageSpecial ExaminationDilation and fractional curettage ( D. C) Most effective ,definitive procedure and commonly used Significance-Established correct diagnosis, clinical stage-differentiate
12、d from cervical cancer or cervical involvement Ultrasonography Useful adjuvant method Significances Size of lesion Invasion of endometrium or cervix Resistant index of new vesselsEndometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (A) Sagittal transvaginal US scan
13、shows the endometrium with a thickness of 44 mm and a large area of mixed 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
14、 differentiated endometrial carcinoma. ABHysteroscopySignificance-Direct observation-Taking sample correctly-Identifying polyps and submucous myomaPap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV urography, cystoscopy, sigmoidoscopy, Diagnosis Hist
15、ory, and clinical sign , related risk factors symptoms Diagnostic methodsDifferential Diagnosis Senile endometritis / vaginitis Dysfunctional uterine bleeding Submucous myoma / Endometrial polyps Cervix cancer / Sarcoma of uterus/ Primary carcinoma of fallopian tubeMetastasis Route Direct extension
16、Lymphatic metastasis: important route Hematogenous metastasis Clinical 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 cm Stage II The carcinoma has i
17、nvolved the corpus and the cervix, but has not extended outside the uterusClinical Stage(FIGO 1971) Stage III The carcinoma has extended outside the uterus, but not outside the true pelvis Stage IV IVa The carcinoma has extended outside the uterus and involves the mucosa of the bladder or rectum (a
18、bullous 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 organsSurgical pathologic staging (FIGO 1988) Stage I Ia* Tumour limited to the endometrium Ib* Invasion to less than half of the myometrium Ic* In
19、vasion equal to or more than half of the myometrium Stage II IIa* Endocervical glandular involvement only IIb* Cervical stromal invasionSurgical pathologic staging (FIGO 2000) Stage III IIIa* Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findings IIIb* Vagi
20、nal metastases IIIc* Metastases to pelvic and/or para-aortic lymph nodes Stage IV IVa* Tumour invasion of bladder and/or bowel mucosa IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodesStage Ia* Tumor limited to the endometrium Stage Ib* Invasion to less than ha
21、lf of the myometrium Stage Ic* Invasion equal to or more than half of the myometriumStage IIa* Endocervical glandular involvement onlyStage IIb* Cervical stromal invasionStage IIIa* Tumor invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findingsStage IIIb* Vaginal me
22、tastases Stage IIIc* Metastases to pelvic and/or para-aortic lymph nodesStage IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodesTreatment Surgery Radiation Chemotherapy Hormone therapyEarly stage - surge+
23、postoperative adjuvant therapyAdvanced stage - radiation+ surge+ medicinePrinciple of choice General condition (Age, complication) Clinical stage Tumour pathologic typeSurgery Object Operative pathologic stage, finding prognosis risk factors Remove uterus and metastasis tumour Stage I : Abdorminal h
24、ysterectomy + bilateral salpingoophorectomy + selective lymphadenectomy clear cell or papillary carcinoma omentectomy+appenditectomy Stage IIRadical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenectomy Stage III,IVCytoreductive surgeryIndications of pelvic lymphadenectomy Special pathog
25、enetic pattern Endometrial cancer, grade 3 or no differentiation Myo-invasion more than Size of lesion more than 50% of uterine cavity Involvement in isthmus of uterusRadiation therapy Radiation alone Radiation with surgeryRadiation combined surgery-Radiation after surgery Adenexal / serosal / param
26、etrial spread Vaginal metastasis Lymph node metastasis Intraperitoneal spread Bladder / rectal invasion Myoinvasion 50% G3 50% myoinvasionIndications for radiation alone Elderly or obesity Multiple chronic or acute medical illness(hypertension, cardial disease, diabetes, pulmonary, renal) Advanced s
27、tage unsuitable for surgeryHormone Therapy mechenism Most endometrial cancers have both ER & PR.(Estrogen dependent subtype)lIndications: Advanced or recurrent stage Early stage and desire for fertility Used drugs MPAChemotherapy Advanced stage or recurrent carcinoma Postoperative adjunctive treatme
28、nt for high risk factor Used drugs: DDP (cisplatin), CTX (cyclophosphamide), ADM (doxorubicin ), 5-Fu,Taxal MMC, VP16.Prognostic Factors Tumour bilologic bihavior Cell type Histological grade Depth of myometrium infiltration lymph-node metastasis Presence of lymph vascular space involvement Positive
29、 peritoneal cytology General condition Old age Acute or chronic medical illness Choice of treatment 5-Year Survival Rate Stage I b: 94% Stage I c: 87% Stage II : 84% Stage III : 40-60%Follow-up 75-95% disease will recur within 2-3 years after operation. Items Main complaints Pelvic examination Vaginal discharge smear Chest X ray Serum CA125 Blood routine test Blood biochemistry examination CT/MRIQuestions How to make diagnosis of uterine cancer? Whats the principle of treatment on patients with uterine cancer? Whatre associated with prognosis of uterine cancer?
