婦科培訓課件-Endometrial Cancer

EndometrialCancerAimsTomasterThepathogenesisandriskfactorsoftypeIEndometrialCancer(EC)TheclinicalandpathologicalcharacteristicsofECThediagnosisofECThe

surgicalstagingofECBefamiliarwithTheprincipleoftreatmentofECThepreventionofECToknowTheLynchSyndrome（hereditarynonpolyposiscolorectalcancer）ThestagingsurgeryandtheadjuvanttherapyofECPage

2ContentsPage

3OverviewPathogenesisRiskFactorsPatternsofSpread

SurgicalStaging

ClinicalManifestationDiagnosisDifferentialDiagnosisTreatmentPrognosisFollow-upSummaryOverviewPage

4CorpusuteriCervixStructureofUterusEndometriumMyometriumSerouslayerPage

6PeriodicchangeandsheddingoftheendometriumWhatIsEndometrialCancer？AcancerthatarisesfromtheendometriumIssometimescalleduterinecancerOccursmostcommonlyafter

menopauseIsoftendetectedatanearlystage

GYNmalignancies：mostcommoninUS,2ndinChina3rdmostcommoncauseofGYNcanerdeathsKnownriskfactorsPage

8HowCommonIsThisCancer?Page

9CancerstatisticsinChina,2017Page

10WhoGetsThisCancer?Page

11HowManyPeopleSurvive5YearsOrMoreafterBeingDiagnosedwithEndometrialCancer?PathogenesisPage

12TypeIEndometrioidcancer:G1andG2Mostcommon:80%,preorperimenopausalEstrogen-dependentStartasatypicalhyperplasiaandprogresstocancerBetterprognosisPTENmutation,ER+,PR+Page

13TypeIIEndometrioidcancerG3,nonendometrioidhistology:serous,clearcell…10-20%,postmenopausalwomenEstrogenunrelatedWithoutprecancerousdiseasesHighgradewithpoorprognosisP53mutation,ER-,PR-上皮性腫瘤及前驅病變

分割性（絨毛葉狀）平滑肌瘤0前驅病變

彌散性平滑肌瘤病1

增生過長不伴不典型脈管內平滑肌瘤病1

不典型增生過長/子宮內膜上皮內瘤變EIN2

轉移性平滑肌瘤1子宮內膜癌惡性潛能未定平滑肌腫瘤1

內膜樣腺癌3平滑肌肉瘤3

鱗狀上皮分化3

上皮樣平滑肌肉瘤3

絨毛管狀3

粘液樣平滑肌肉瘤3

分泌性3子宮內膜間質和相關腫瘤

粘液性癌3

內膜間質結節(jié)0漿液性子宮內膜上皮內癌2

低級別子宮內膜間質肉瘤3

漿液性癌3

高級別子宮內膜間質肉瘤3

透明細胞癌3

未分化子宮肉瘤3

神經內分泌腫瘤

類似于卵巢性索腫瘤的子宮腫瘤1

低級別神經內分泌腫瘤雜類間葉源性腫瘤

類癌3

橫紋肌肉瘤3

高級別神經內分泌癌

血管周上皮樣細胞腫瘤

小細胞神經分泌分癌3

良性0

大細胞神經內分泌癌3

惡性3

混合細胞腺癌3其他

未分化癌3

去分化癌混合性上皮和間葉腫瘤腺肌瘤0腫瘤樣病變不典型息肉狀腺肌瘤0

息肉腺纖維瘤0

化生腺肉瘤3A-S反應癌肉瘤3

淋巴瘤樣病變雜類腫瘤間葉源性腫瘤腺瘤樣瘤0平滑肌瘤0神經外胚層腫瘤

富細胞平滑肌瘤0生殖細胞腫瘤

伴奇異核的平滑肌瘤0

核分裂活躍的平滑肌瘤0淋巴樣和髓樣腫瘤

水腫變性平滑肌瘤0淋巴瘤

卒中性平滑肌瘤0髓樣腫瘤

脂肪瘤性平滑肌瘤（脂肪平滑肌瘤）0

上皮樣平滑肌瘤0繼發(fā)性腫瘤

粘液樣平滑肌瘤0DisorderedproliferativeendometriumNormalproliferativeendometriumTypeIendometrialcancerSimplehyperplasiaComplexhyperplasiaAtypicalhyperplasia/EIN(EndometrialIntraepithelialneoplaisa)TypeIEndometrialcancerEndometrioidcancerG1,G2Hyperplasia17ClassificationoftheendometrialhyperplasiaandprogressiontoECArchitecturalTypeCytologicAtypiaProfressiontoEC(in%)SimplehyperplasiaAbsent1ComplexhyperplasiaAbsent3AtypicalsimplehyperplasiaPresent10AtypicalcomplexhyperplasiaPresent30DegreeofDifferentiationGrade3Grade1Grade2Lessthan5%ofthetumorhasasolidgrowthpattern6-50%ofthetumorisarrangedinsolidnestsMorethan50%ofthetumorisarrangedassolidsheetsofneoplasticcellsTypeIITypeISerousadenocarcinomaClearcelladenocarcinomaMucinousSquamousTransitionalcellMesonephricUndifferentiatedPostmenopausalwomenRiskfactorunknownMightberelatedtoFSHstimulationTypeIIEndometrialcancerSerousClearcellRiskFactorsPage

20RiskFactorsOnlyfortypeIendometrialcancerTwomajoraspects:UnopposedestrogenexposureHereditaryPage

21EndogenousestrogenPolycysticovarysyndromeAnovulationFunctioningovariantumorsInfertility,NulliparityLatemenopauseHereditaryLynchSyndromeExogenousestrogenTamoxifenEstrogenreplacementtherapyInsulinresistanceDiabetesmellitusHypertensionOverweightobesityRiskFactorsRiskfactorRelativerisk(RR)(otherstatisticsarenotedwhenused)IncreasingageWomen50-to70-years-oldhavea1.4percentriskofendometrialcancerUnopposedestrogentherapy2to10Tamoxifentherapy2EarlymenarcheNALatemenopause(afterage55)2Nulliparity2Polycysticovarysyndrome(chronicanovulation)3Obesity2to4Diabetesmellitus2Estrogen-secretingtumorNA

Lynchsyndrome(hereditarynonpolyposiscolorectalcancer)22to50percentlifetimeriskFamilyhistoryofendometrial,ovarian,breast,orcoloncancerNALynchsyndromeAn

dominant

geneticdisorderMainlycausescolorectalcancer

andendometrialcancerEspeciallybeforemenopauseMutationofmismatchrepairgenes：MLH1,MSH2,

MSH6,

PMS2Endometrialcancerrisk：

MLH1mutations,54%;MSH2,21%;MSH6,16%Page

23RiskFactors:GeneticsEEC:EndometroidendometrialcancerLH:LaparoscopichysterectomyBSO:bilateralsalpingooophorectomyCT:ChemotherapyRT:RadiotherapyBilateralinguinallymphnodedissection+25RT+6CTMetastaticserousadenocarcinomaRectalcancerEEC,IA,G12011.42015.22015.72015.9Dixon’ssurgery+6roundsofCTFollowupFollowupLH+BSORightinguinallymphnodebiopsyMetastaticadenocarcinomaformEECFigure1Theschematicdiagramofdiseaseprogressionandmanagement.4IIIIII32143218765432110111298765109CCHCCCCCHCHCHCCC+EC+SACCCHCFigure2Pedigreestructureofthepatient’sfamily.Squareandcirclesdenotedmalesandfemalesrespectively.Romannumeralsindicategenerations.Arrowindicatestheproband(III5).CC:coloncancer;EC:endometrialcancer;HC:hepaticcancer;SAC:serousadenocarcinoma.Figure4Aheterozygousgermlinemutation(c.2089_2090delCT)inMLH1gene(NM_000249)detectedinthepatient.ABProtectiveFactorsSmoking:reducesriskby20%TheuseoftheprogestinOCPsHormonalIUD(Mirena,LevonorgestrelIntrauterineSystem)Multiparity:morethan5childrenBreastfeeding:morethan18monthsreducesriskby23%Page

27PatternsofSpreadPage

28ThreeprimaryroutesofspreadDirectextensionLymphaticsystemHematogenousSurgicalStagingPage

30The2009FIGOstagingsystemSurgicalStagingFIGO,

2009StageIAandIBendometrialcancerStage

II

endometrial

cancerStageIIIendometrialcancerStageIVendometrialcancerⅢC1ⅢC2ClinicalManifestationsPage

33SignsandsymptomsVaginalbleedingor

discharge

notrelatedtomenstruation(periods).VaginalbleedingaftermenopauseVaginaldischarge~10%Asymptomatic:foundincidentallyinhysterectomyorhysteroscopePainfulsexualintercoursePelvicpainPelvicmassWeightloss90%PhysicalexaminationObesityHypertensionSignsformetastaticdisease:peripherallymphnodes,mass,ascites……Pelvicexamination:alwaysnormalPage

35DiagnosisPage

36DiagnosticevaluationHistoryAgeRiskfactorsPostmenopausalbleedingAbnormaluterinebleedingPhysicalexaminationThesourceofbleedingDiagnosticevaluationLaboratorytestingUrineHCGCA125，HE4….TSH,PRL,FSH….TCT，HPVImagingexaminationTransvaginalultrasoundEndometrialthickness(morethan4mm),

homogeneityofthetissuePolypoidendometrialmassUterineeffusionCT/MRI:PreoperativeimagingoftumorsInvestigateextrapelvicdiseaseNearbylymphnodesDiagnosticevaluationEndometrialsamplingOfficeendometrialbiopsy:accuracyof90%-98%DiagnosticevaluationEndometrialsamplingDilationandcurettage(D&C)SuspiciousofficeendometrialbiopsyContinuestohavesymptomsafternegativeofficeendometrialbiopsyHeavybleedingHysteroscopyDifferentialDiagnosisPage

41PostmenopausalbleedingCauseofBleedingFrequency（%）Endometrialatrophy60-80Exogenousestrogen/

HRT15-25Endometrialcancer10-15Endometrialorcervicalpolyps2-12Endometrialhyperplasia5-10Miscellaneous10Confirmthesourceofbleeding:uterus,virginal,anus,urinarytractTheamountofbleedingdoesnotcorrelatewithriskofmalignancybCervicalcancerPreorperimenopausalbleeding

Abnormaluterinebleeding(AUB)ComplicationsofpregnancymustbehighonthelistTreatmentPage

44TreatmentOptionsSurgeryLaparoscopic/robotPelvicwashingTH+BSOLymphnoderesectionRadiotherapy：AdjuvanttreatmentChemotherapyProgestins：fertilitypreservingTargetedtherapyMonoclonalantibodymTORinhibitorsSignaltransductioninhibitorsClinicaltrialsStageIIIndicationsforparaaorticlymphnodedissectionSuspectedpelvicorparaaorticLNmetastasisAlltypeIIEC:serous,clearcell,squamouscell,carcinosarcoma,undifferentiated,andG3EECMorethan?myometriuminvasion(IB)Lesioncovermorethan50%oftheuterinecavity(≥3cmindiameter)46EndometrialcanceroperableTotalhysterectomy+bilateralsalpingo-oophorectomyandsurgicalstagingAdjuvanttherapyforsurgicallystaged(radiotherapy/chemotherapy)PatientdesiresfertilitysparingoptionHormonetherapyMedicallyinoperableTumordirectedRTOrConsiderhormonetherapyinselectedpatientsTreatment子宮內膜癌手術視頻Page

48PrognosisPage

495-yearrelativesurvivalratesPage

50MajorindependentprognosticfactorsAge>60ysDepthofthemyometrialinvasion>50%myometrialinvasionHistologictype:serous,clearcell…Histologicgrade:G3tumorsTumorsize:lagertumors>2cmSurgicalstage:stageIIIandIVLymphovascularinvolvementPeritonealcytologyPage

51Follow-upPage

5275-95%diseasewillrecurwithin2-3yearsafteroperationEvery3monsfor3ysEvery6monsfor2ysAnnuallyPage

53RectovaginalexaminationTCTX-ra