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1、Uterine Cancer,Xi-Shi Liu Obstetrics and Gynecology Hospital Fudan university2019.04,General 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 during their lifeti
2、me.,General Description,A malignant epithelial disease that occurs in endometrial gland of uterusAlso called endometrial cancer,Classification(pathogenetic,biologic behavior ),Estrogen dependent typehave a history of exposure to unopposed estrogen (either endogenous or exogenous).Hyperplastic endome
3、triumBetter differentiafedER(+),PR(+)Mere favorable prognesis,Estrogen independent type,- Have no source of estrogen stimulation of endometrium.-Arising in background of atrophic endemetrium-Less differentiated-ER(-)PR(-)-Poor prognosis,Risk Factors,1. Medical conditionsa. Diabetes mellitus, hyperte
4、nsion.b. Overweight-obesity (excess estrogen as a result of peripheral conversion of adrenally derived androstenedione by aromatization in fat).c. Late menopause.,Risk Factors,2. Some gynecologic diseases ( Long-term endogenous estrogen exposure ) - polycystic ovary syndrome - functioning ovarian tu
5、mors - anovulating dysfunctional bleeding - Infertility, Nulliparity.,Risk Factors,3. Prolonged Use of estrogena. Prolonged menopausal estrogen replacement therapy without progestogen.b. Prolonged use of the antiestrogen tamoxifen for breast cancer.,Risk Factors,4. Genetic factors and other factorsa
6、. 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 adenocarcinomaMucinous carcinomaSerous adenocarcinomaClear cell carcinomaOther rare subt
7、ypes,Five histological subtypes-Endometrioid Adenocarcinoma,Account for about 8090%.Well differentiated.Prognosis is better.,Five histological subtypes -Mucinous carcinoma,Rare (about 5%)a. Most of them is a well differentiated.b. Behavior is similar to that of common endometrial carcinoma.,Five his
8、tological 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 carcinoma,a. A rare subtypeb. Is high grade and aggres
9、sivec. 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 adenocarcinomaUndifferentiated carcinomaMixed adenocarcinoma,Clinical Features-Symptoms,Asymptomaic (about less than 5% )Abnormal va
10、ginal 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 examinationSlight e
11、nlargement of uterine size and softUterus fixed, immobile, adenexal mess in advanced stage,Special Examination,Dilation and fractional curettage ( D. C)Most effective ,definitive procedure and commonly usedSignificance-Established correct diagnosis, clinical stage-differentiated from cervical cancer
12、 or cervical involvement,UltrasonographyUseful adjuvant methodSignificances Size of lesionInvasion of endometrium or cervixResistant index of new vessels,Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (A) Sagittal transvaginal US scan shows the endometrium wit
13、h 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 differentiated endometri
14、al carcinoma.,A,B,HysteroscopySignificance-Direct observation-Taking sample correctly-Identifying polyps and submucous myoma,Pap test-Unreliable diagnostic test-30%-50% abnormal pap test resultsOthers-MRI, CT, chest x-ray, IV urography, cystoscopy, sigmoidoscopy,Diagnosis,History, and clinical sign
15、, related risk factors symptomsDiagnostic methods,Differential Diagnosis,Senile endometritis / vaginitisDysfunctional uterine bleedingSubmucous myoma / Endometrial polypsCervix cancer / Sarcoma of uterus/ Primary carcinoma of fallopian tube,Metastasis Route,Direct extensionLymphatic metastasis: impo
16、rtant 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 cmStage II The carcinoma has involved the corpus and the
17、cervix, but has not extended outside the uterus,Clinical Stage(FIGO 1971),Stage III The carcinoma has extended outside the uterus, but not outside the true pelvisStage IV IVa The carcinoma has extended outside the uterus and involves the mucosa of the bladder or rectum (a bullous oedema as such does
18、 not permit the case to be allotted to Stage IV) IVb The carcinoma has extended outside the true pelvis and spread to distant organs,Surgical pathologic staging (FIGO 1988),Stage I Ia* Tumour limited to the endometrium Ib* Invasion to less than half of the myometrium Ic* Invasion equal to or more th
19、an half of the myometriumStage II IIa* Endocervical glandular involvement only IIb* Cervical stromal invasion,Surgical pathologic staging (FIGO 2000),Stage III IIIa* Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findings IIIb* Vaginal metastases IIIc* Metas
20、tases to pelvic and/or para-aortic lymph nodesStage IV IVa* Tumour invasion of bladder and/or bowel mucosa IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodes,Stage Ia* Tumor limited to the endometrium Stage Ib* Invasion to less than half of the myometrium Stage
21、 Ic* Invasion equal to or more than half of the myometrium,Stage IIa* Endocervical glandular involvement onlyStage IIb* Cervical stromal invasion,Stage IIIa* Tumor invades the serosa of the corpus uteri and/or adnexae and/or positive cytological findingsStage IIIb* Vaginal metastases Stage IIIc* Met
22、astases to pelvic and/or para-aortic lymph nodes,Stage IVa* Tumor invasion of bladder and/or bowel mucosaStage IVb* Distant metastases, including intra-abdominal metastasis and/or inguinal lymph nodes,Treatment,Surgery RadiationChemotherapy Hormone therapyEarly stage - surge+ postoperative adjuvant
23、therapyAdvanced stage - radiation+ surge+ medicine,Principle of choice,General condition (Age, complication)Clinical stageTumour pathologic type,Surgery,ObjectOperative pathologic stage, finding prognosis risk factorsRemove uterus and metastasis tumourStage I :Abdorminal hysterectomy + bilateral sal
24、pingoophorectomy + selective lymphadenectomy clear cell or papillary carcinoma omentectomy+appenditectomy,Stage IIRadical hysterectomy + pelvic lymphadenectomy + paraortic lymphadenectomyStage III,IVCytoreductive surgery,Indications of pelvic lymphadenectomy,Special pathogenetic patternEndometrial c
25、ancer, grade 3 or no differentiationMyo-invasion more than Size of lesion more than 50% of uterine cavityInvolvement in isthmus of uterus,Radiation therapy,Radiation aloneRadiation with surgery,Radiation combined surgery-Radiation after surgery,Adenexal / serosal / parametrial spreadVaginal metastas
26、isLymph node metastasisIntraperitoneal spreadBladder / rectal invasionMyoinvasion 50%G3 50% myoinvasion,Indications for radiation alone,Elderly or obesityMultiple chronic or acute medical illness(hypertension, cardial disease, diabetes, pulmonary, renal)Advanced stage unsuitable for surgery,Hormone
27、Therapy,mechenismMost endometrial cancers have both ER & PR.(Estrogen dependent subtype)Indications: Advanced or recurrent stage Early stage and desire for fertilityUsed drugsMPA,Chemotherapy,Advanced stage or recurrent carcinomaPostoperative adjunctive treatment for high risk factorUsed drugs: DDP
28、(cisplatin), CTX (cyclophosphamide), ADM (doxorubicin ), 5-Fu,Taxal MMC, VP16.,Prognostic Factors,Tumour bilologic bihaviorCell type Histological grade Depth of myometrium infiltration lymph-node metastasisPresence of lymph vascular space involvement Positive peritoneal cytologyGeneral conditionOld
29、age Acute or chronic medical illnessChoice 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.ItemsMain complaintsPelvic examinationVaginal discharge smearChest X ray Serum CA125Blood routine testBlood biochemistry examinationCT/MRI,Questions,How to make diagnosis of uterine cancer?Whats the principle of treatment on patients with uterine cancer?Whatre associated with prognosis of uterine cancer?,?,THE END,THANKS,
