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1、Endometrial Cancer,OB/GYN Hospital Fudan UniversityXin LU, MD, Ph.D.,Endometrial CancerOB/GYN Hospi,Endometriod cancer-Contents,IncidenceRisk factorsClassificationSymptoms,PathologyFIGO StagingDiagnosisTreatment,Endometriod cancer-ContentsI,WHO Cancer Report,Global cancer rates could increase by 50%
2、 to 15 million by 2020 Endometrial cancer is the 4th most common cancer in womenNew Diagnosed cases: 142,000 Died cases each year: 42,000 incidence 2-3%Average age: 60s,WHO Cancer ReportGlobal cancer,Histologic Types,Endometrial CancersEndometrioid (87%)Adenosquamous (4%)Papillary Serous (3%)Clear C
3、ell (2%)Mucinous (1%)Other (3%),Histologic TypesEndometrial Ca,Endometrial Cancer:Type I/II,Type IEstrogen RelatedYounger and heavier patientsLow gradeBackground of HyperplasiaPerimenopausalExogenous estrogenFamilial/genetic (15% )Lynch II syndrome/HNPCCFamilial trend,Type II (10% )AggressiveHigh gr
4、adeUnfavorable HistologyUnrelated to estrogen stimulationOccurs in older & thinner women,Endometrial Cancer:Type I/IIT,Endometrial Cancer: Risk Factors,From: Williams Gynecology 2009,Endometrial Cancer: Risk Fact,Endometrium Carcinoma2009 Classification,Stage CharacteristicStage I* Tumor confined to
5、 the corpus uteri IA* No or less than half myometrial invasion IB* Invasion equal to or more than half of the myometriumStage II* Tumor invades cervical stroma, but does not extend beyond the uterus*Stage III* Local and/or regional spread of the tumor IIIA* Tumor invades the serosa of the corpus ute
6、ri and/or adnexae# IIIB* Vaginal and/or parametrial involvement# IIIC* Metastases to pelvic and/or para-aortic lymph nodes#. IIIC1* Positive pelvic nodes IIIC2* Positive paraaortic lymphnodes with or without positive pelvic lymph nodesStage IV* Tumor invades bladder and/or bowel mucosa, and/or dista
7、nt metastases IVA* Tumor invasion of bladder and/or bowel mucosa IVB* Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes,Endometrium Carcinoma2009 Cla,Endometrial Cancer: FIGO Surgical Stage,Stage IConfined to uterusStage,Endometrial Cancer Prognosis:,Overall 5Yr Su
8、rvival 84%Stage and Grade are the most important prognostic factorsAltered oncogene/tumor suppressor gene expression is now being evaluated (molecular staging concept),Endometrial Cancer Prognosis:S,Aggressive Histologic Subtypes (Clear-cell, Serous)Increasing age (over 65)Vascular invasionAneuploid
9、yAltered oncogene/tumor suppressor gene expression ( “molecular staging” concept- p53, PTEN, microsatellite instability, MDR-1, HER2/neu, ER/PR, Ki 67, PCNA, CD 31,EGF-R, MMR genes) Race?,Endometrial Cancer: Poor Prognostic Factors,Aggressive Histologic Subtypes,Molecular Genetics,PTEN mutations: 32
10、%Tumor suppressor gene (chrom 10)PhosphataseEarly event in carcinogenesisAssociated with:endometrioid histologyearly stagefavorable survival,Molecular GeneticsPTEN mutatio,Molecular Genetics,p53 tumor suppressor geneCell cycle and apoptosis regulationMost commonly mutated gene in human cancersOverex
11、pression (marker for mutation)Associated with poor prognosisearly stage:10% have p53 mutationadvanced stage: 50% have p53 mutationnot found in hyperplasiaslate event in carcinogenesis,Molecular Geneticsp53 tumor su,Genetic Syndromes: HNPCCHereditary Non-Polyposis Colon Cancer,Lynch II SyndromeAutoso
12、mal dominant inheritanceMMR (mismatch repair) mutationsGenetic instability leads to error-prone DNA replicationhMSH2 (chrom 2)hMLH1 (chrom 3)Early age of colon Ca: mean 45.2 yearsEndometrial Ca: second most common malignancy20% cumulative incidence by age 70Earlier age of onset than sporadic casesOt
13、her: ovary (3.5-8 fold), stomach, small bowel, pancreas, biliary tract,Genetic Syndromes: HNPCCHere,Diagnosis of disease: Patient Awareness*,More than 95% of patients with Endometrial Cancer report having symptomsPostmenapausal bleedingMenorrhagiaMetrorrhagiaBloody DischargeEndometrial biopsy is the
14、 main diagnostic tool performed either in the office or via D&C in OR,Diagnosis of disease: Patient,Uterine Cancer:Diagnosis/Screening,Patient Symptoms/Awareness*Cytology Not a satisfactory screening testSonography Not Cost effectiveHysteroscopy Not Cost effectiveHistology Secondary to symptoms (not
15、 as a screening test),Uterine Cancer:Diagnosis/Scre,Endometrial Cancer:Transvaginal Ultrasound Screening,Endometrial Cancer:Transvagin,Endometrial Cancer:Transvaginal Ultrasound Screening,Endometrial Cancer:Transvagin,Endometrial Cancer:Transvaginal Ultrasound Screening,Endometrial Cancer:Transvagin
16、,Normal endometrial stripe:Postmenopausal4- 8 mmPostmenopausal on HRT4- 10 mm U/S for Detection of any uterine pathologySensitivity:85-95%Specificity:60-80%PPV 2-10%NPV 99%,Summary: Endometrial Cancer:Transvaginal Ultrasound Screening,Normal endometrial stripe:Summ,Hysteroscopy Not satisfactory for
17、screening test,Studies of the efficacy of hysteroscopy as a diagnostic tool vary widelySensitivity reported ranging from 60-95% compared to D&C obtained at the same timeSpecificity 50-99%,Hysteroscopy Not satisfactor,妇产科子宫内膜癌英文课件,Hysteroscopy and Positive Cytology?,Studies have been mixed:Some studi
18、es suggest an increase in positive peritoneal cytology seen at staging laparotomy in patients who have had hysteroscopyOther studies have failed to find a difference in positive cytology in patients diagnosed via hysteroscopy as compared to office biopsy or D&C,Hysteroscopy and Positive Cyto,Hystero
19、scopy Not satisfactory,Too much cost and risk to be used as a screening test.Useful for evaluation of abnormal uterine bleeding where office biopsy is unrevealing. Use in conjunction with uterine curettageUseful to see and resect polyps and small submucous fibroidsUseful to perform directed biopsy o
20、f small lesions.,Hysteroscopy Not satisfactor,Endometrial Cancer:Who Needs an Endometrial Biopsy?,Postmenopausal bleedingPerimenopausal intermenstrual bleedingAbnormal bleeding with history of anovulationPostmenopausal women with endometrial cells on PapThickened endometrial stripe via sonography,En
21、dometrial Cancer:Who Needs,Sampling of the Endometrium,Office biopsy procedures (Pipelle, Vabra aspirator, Karman cannula) will agree with a D40:553Patients with persistent PMB after negative office biopsy should have D&C (+/- hysteroscopy)D&C is the gold standard sampling method preoperative D&C wi
22、ll agree with diagnosis at hysterectomy 94% of the time,Sampling of the EndometriumOff,妇产科子宫内膜癌英文课件,妇产科子宫内膜癌英文课件,妇产科子宫内膜癌英文课件,Treatment for Endometrial Hyperplasia without atypia:,Progestin therapy continuous or cyclicalChildbearing age:Progestin dominant OCPs orDepo-Provera 150mg IM q3 months orPro
23、vera 10mg po 10 days/month andMay follow with ovulation induction after normal biopsy if pregnancy desiredPeri or Postmenopausal:Provera 20mg po 10 days/month orDepo-Provera 200mg IM q2 monthsRepeat biopsy in 3-4 months,Treatment for Endometrial Hype,Treatment for Atypical Endometrial Hyperplasia:,2
24、3% risk of progression to carcinoma (over 10 years) if untreated.Standard treatment when childbearing is complete is total hysterectomy (abdominal or vaginal)Frozen section to rule out carcinoma (up to 20% have coexisting endometrial cancer),Treatment for Atypical Endomet,Treatment for Atypical Endo
25、metrial Hyperplasia:,Conservative medical therapy can be attempted in younger patients who request preservation of fertility.D&C prior to initiation of medical therapy to rule out carcinomaMegace 40-80mg/day, Norethindrone acetate 5mg/dayConservative therapy may also be attempted in young patients w
26、ith early, well differentiated endometrial carcinomas.Megace 120-200mg/day, Norethindrone acetate 5-10mg/day,Treatment for Atypical Endomet,Endometroid carcinoma, Grading,FIGO- Gr 1 - 50% solid tumorNUCLEAR GRADESize, shape , staining and chromatin, variability, prominent nucleoli. High nuclear grad
27、e adds one point to FIGO grade,Endometroid carcinoma, Grading,CA125Chest X-rayMammogramsColon EvaluationOthers as indicated,Uterine Cancer: Pre-op Evaluation,CA125Uterine Cancer: Pre-op Ev,Uterine Cancer: Pre-op Evaluation,Transvaginal U/S?CT Scan?MRI?,Uterine Cancer: Pre-op Evaluat,Uterine Cancer:
28、Pre-op Evaluation,Uterine Cancer: Pre-op Evaluat,Uterine Cancer: Surgical Staging,Preoperative preparationAntimicrobial prophylaxisDVT prophylaxisSteep TrendelenburgLong instruments available,Uterine Cancer: Surgical Stagi,Availability of frozen section to determine the extent of staging procedure.C
29、apability of complete surgical stagingCapability of tumor reduction if indicated,Endometrial Cancer: Intra-operative Surgical Principals,Availability of frozen section,Endometrial Cancer: Surgical Approach,TAH-BSO/washings only Endometrioid*Grades 1 and 50% myometrial invasion*or Grade 2 and no or m
30、inimal invasion and 2 cm tumor diameter*,*Verified via frozen section,Endometrial Cancer: Surgical A,Endometrial Cancer: Surgical Approach,Complete Surgical Staging*All Grade 3Any 50% myometrial invasionAny 2 cm tumor diameterAll Serous/clear cell subtype*Pre operative assessment of advanced disease
31、 (gross cervical or vaginal dz, etc),*TAH-BSO, washings, lymphadenectomy *omental/peritoneal biopsy,Endometrial Cancer: Surgical A,Endometrial Cancer: Adjuvant Therapy,BrachytherapyExternal beam radiotherapyHormonal therapyCytotoxic chemotherapyCombination therapy,Endometrial Cancer: Adjuvant T,Endo
32、metrial Cancer: Recurrence,Pelvic examinationPap smearsCA125 (high-risk)Chest X-ray (high-risk),Endometrial Cancer: Recurrence,Endometrial Cancer: Site of RecurrenceIn Radiated Patients,Endometrial Cancer: Site of Re,Endometrial Cancer: Follow-Up,75-95% of recurrences are in first 36 months60% of patients have symptoms (pain, wgt loss, vaginal bleeding) Rare to cure distant recurrences50% vaginal recurrences cured,Endometrial Cancer: Follow-Up7,
