UterineCancerXi-ShiLiu

ObstetricsandGynecologyHospital

FudanuniversityGeneralDescriptionAlsocalledendometrialcancerEndometrialcancerisoneofthemostcommonmalignancyoffemalegenitaltract.GeneralDescriptionAmalignantepithelialdiseasethatoccursinendometrialglandofuterusTheincidenceofendometrialcancerisincreasingworldwideinrecentyears.

RiskFactors1.Medicalconditionsa.Diabetesmellitus,hypertension.b.Overweight---obesity(excessestrogenasaresultofperipheralconversionofadrenallyderivedandrostenedionebyaromatizationinfat).c.Latemenopause.RiskFactors2.Somegynecologicdiseases(Long-termendogenousestrogenexposure)-polycysticovarysyndrome-functioningovariantumors-anovulatingdysfunctionalbleeding-Infertility,Nulliparity.RiskFactors3.ProlongedUseofestrogena.Prolongedmenopausalestrogenreplacementtherapywithoutprogestogen.b.Prolongeduseoftheantiestrogen

tamoxifenforbreastcancer.RiskFactors4.Geneticfactorsandotherfactorsa.Endometrialandovariancancerarethesimultaneouslyoccurringwithothergenitalmalignancy,reportedincidence(1.4~3.8%).b.Familyhistoryoftumorishigher.(12-28%)

ClassificationEstrogendependentandestrogen

independentaretwodifferentpathogenetictypes:--Onewithhistoryofexposuretounopposedestrogen(eitherendogenousorexogenous).--Othertypewithnosourceofestrogenstimulationofendometrium.FivehistologicalsubtypesEndometrioid

adenocarcinomaMucinouscarcinomaSerousadenocarcinomaClearcellcarcinomaOtherraresubtypesFivehistologicalsubtypes

--Endometrioid

AdenocarcinomaAccountforabout80~90%.Welldifferentiated.Prognosisisbetter.Fivehistologicalsubtypes

--MucinouscarcinomaRare(about5%)a.Mostofthemisawelldifferentiated.b.Behaviorissimilartothatofcommonendometrialcarcinoma.

Fivehistologicalsubtypes

--Serousadenocarcinoma

a.Architectureisidenticalwithcomplexpapillary.b.Moreaggressivelywithdeepmyometrialandlymphaticinvasion.c.Simulatingthebehaviorofovariancarcinoma.Fivehistologicalsubtypes

--Clearcellcarcinomaa.Araresubtypeb.Ishighgradeandaggressivec.Prognosisissimilartoorworsethanthatofpapillaryserouscarcinomad.Survivalrateislower33%~64%Fivehistologicalsubtypes

--otherraresubtypesSquamous

adenocarcinomaUndifferentiatedcarcinomaMixedadenocarcinomaMetastasisRoute

DirectextensionLymphaticmetastasis:importantrouteHematogenousmetastasisClinicalFeatures--SymptomsAbnormalvaginalbleeding(premenopausalorpostmenopausal,minimalornonpersistant)Abnormalvaginaldischarge(25%infectionofuterinecontents)Pelvicpressureordiscomfort(uterineenlargementorextrauterinediseasespread)ClinicalFeatures--SignsNoevidenceinearlystageonphysicalexaminationSlightenlargementofuterinesizeandsoftUterusfixed,immobile,adenexalmessinadvancedstageSpecialExaminationDilationandfractionalcurettage(D.C)Mosteffective,definitiveprocedureandcommonlyusedSignificance-Establishedcorrectdiagnosis,clinicalstage-differentiatedfromcervicalcancerorcervicalinvolvementUltrasonographyUsefuladjuvantmethodSignificancesSizeoflesionInvasionofendometriumorcervixResistantindexofnewvesselsEndometrialcarcinomaina58-year-oldwomanwithsubstantialpostmenopausalbleeding.(A)Sagittal

transvaginalUSscanshowstheendometriumwithathicknessof44mmandalargeareaofmixedechogenicitysuggestiveofamass.(B)Transversesonohysterogramshowsa50-mm-diameterpolypoidmassprotrudingintotheendometrialcavity(calipersindicatethestalkofthemass).Histopathologicfindingsindicatedpoorlydifferentiatedendometrialcarcinoma.

ABHysteroscopySignificance-Directobservation-Takingsamplecorrectly-Identifyingpolypsandsubmucous

myomaPaptest-Unreliablediagnostictest-30%-50%abnormalpaptestresultsOthers-MRI,CT,chestx-ray,IVurography,cystoscopy,sigmoidoscopy,

DiagnosisHistory,symptoms,relatedriskfactorsDiagnosticmethodsDifferentialDiagnosisSenileendometritis/vaginitisDysfunctionaluterinebleedingSubmucous

myoma/EndometrialpolypsCervixcancer/Sarcomaofuterus/PrimarycarcinomaoffallopiantubeClinicalStage

(FIGO1971)StageI

Ia

Thecarcinomaisconfinedtothecorpusandthelengthoftheuterinecavityis≤8cm

Ib

Thecarcinomaisconfinedtothecorpusandthelengthoftheuterinecavityis>8cmStageII

Thecarcinomahasinvolvedthecorpusandthecervix,buthasnotextendedoutsidetheuterusClinicalStage

(FIGO1971)StageIII

Thecarcinomahasextendedoutsidetheuterus,butnotoutsidethetruepelvisStageIV

IVa

Thecarcinomahasextendedoutsidetheuterusandinvolvesthemucosaofthebladderorrectum(abullous

oedemaassuchdoesnotpermitthecasetobeallottedtoStageIV)

IVb

ThecarcinomahasextendedoutsidethetruepelvisandspreadtodistantorgansSurgicalpathologicstaging

(FIGO1988)StageI

Ia*Tumourlimitedtotheendometrium

Ib*Invasiontolessthanhalfofthemyometrium

Ic*InvasionequaltoormorethanhalfofthemyometriumStageII

IIa*Endocervicalglandularinvolvementonly

IIb*CervicalstromalinvasionSurgicalpathologicstaging

(FIGO1988)StageIII

IIIa*Tumourinvadestheserosaofthecorpusuteriand/oradnexaeand/orpositivecytologicalfindings

IIIb*Vaginalmetastases

IIIc*Metastasestopelvicand/orpara-aorticlymphnodesStageIV

IVa*Tumourinvasionofbladderand/orbowelmucosa

IVb*Distantmetastases,includingintra-abdominalmetastasisand/oringuinallymphnodesStageIa*

Tumorlimitedtotheendometrium

StageIb*

Invasiontolessthanhalfofthemyometrium

StageIc*

InvasionequaltoormorethanhalfofthemyometriumStageIIa*

Endocervicalglandularinvolvementonly

StageIIb*

Cervicalstromalinvasion

StageIIIa*

Tumorinvadestheserosaofthecorpusuteriand/oradnexaeand/orpositivecytologicalfindings

StageIIIb*

Vaginalmetastases

StageIIIc*

Metastasestopelvicand/orpara-aorticlymphnodesStageIVa*

Tumorinvasionofbladderand/orbowelmucosa

StageIVb*

Distantmetastases,includingintra-abdominalmetastasisand/oringuinallymphnodes

TreatmentSurgeryRadiationChemotherapyHormonetherapySurgeryStageI:-Abdorminalhysterectomy+bilateralsalpingoophorectomy+selectivelymphadenectomyStageIIRadicalhysterectomy+pelviclymphadenectomy+

paraortic

lymphadenectomyIndicationsofpelviclymphadenectomySpecialpathogeneticpatternEndometrialcancer,grade3Myo-invasionmorethan?Sizeoflesionmorethan50%ofuterinecavityInvolvementinisthmusofuterusRadiationtherapyRadiationaloneRadiationwithsurgeryIndicationsforradiationaloneElderlyorobesityMultiplechronicoracutemedicalillness(hypertension,cardialdisease,diabetes,pulmonary,renal)AdvancedstageunsuitableforsurgeryRadiationcombinedsurgery

--RadiationaftersurgeryAdenexal/serosal/parametrialspreadVaginalmetastasisLymphnodemetastasisIntraperitonealspreadBladder/rectalinvasionMyoinvasion>50%G3<50%myoinvasionChemotherapyDrugs:DDP(cisplatin),CTX(cyclophosphamide),ADM(doxoru