子宮內膜癌

endometrialcarcinoma

overview3rdcommonestcancerinwomeninChinaThediseasenormallyoccursinpostmenopausalwomenMedianage61yearsold2-5%diagnosed<40yearold75%diagnosedatStageⅠ

確切病因尚不清，可能與下列因素有關：1.雌激素依賴型(Estrogen-dependent)（I型）：

一、發病相關因素Theestrogen-dependentdisease,unopposedestrogenstimulationisconsideredthemajorriskfactorforendometrialcancer(EC).Riskfactorsofestrogen-dependentECChronicEstrogenExposure:oralcontraceptiveswithoutprogestins,estrogen-secretingtumors,andthelong-termuseoftamoxifen;Obesity:2-5foldgreaterrisk.Thisislikelyduetothefactthatfatcellsproduceestrogen;DiabetesMellitusandHypertension;anovulationassociated:PCOS,anovulatoryAUBMenopausalunopposedestrogenreplacement:increasetheriskforECby4-8timescharactersoftypeIECyoungerwell-differentiatedPRandERpositivebetterprognosis2.非雌激素依賴型（II型）：與雌激素無明顯關系，與基因突變有關（P53，P16等）。多見于年老體瘦女性，病理類型是少見的子宮內膜漿液性腺癌、透明細胞癌、黏液腺癌等。惡性程度高、分化差、雌孕激素受體多陰性。

1．巨檢(grossobservation)：(1)彌漫型：侵及大部分內膜或全部內膜，呈菜花狀、灰白色，豆腐渣樣。少有肌層侵犯。(2)局灶型：

局限內膜的一個區域，多見于宮底或宮角部。呈小菜花或結節狀，易侵犯肌層。Pathology彌漫型局灶型PathologyHistology(1)Endometrialadenocarcinoma(內膜樣腺癌)：about80~90%themostcommoncarcinomasfoundintheendometriumHistology(2)Adenocarcinomawithsquamousdifferentiation(3)Adenosquamouscarcinoma(4)UterinePapillarySerousCarcinoma,UPSC(5)Clearcelladenocarcinomauncommon,1-9%,highlyaggressive,foundinadvancedstages,earlyspreadrare,4%,olderpostmenopausalwomen,poorpronosis,earlyspread(6)MucinousadenocarcinomadirectextensiontoadjacentsiteslymphaticspreadhematogenousspreadtranstubalpassageofexfoliatedcellsPatternsofSpread以直接蔓延和淋巴轉移為主,晚期有血行轉移。1.直接蔓延：

①宮角→輸卵管、卵巢→盆腹膜②肌層→漿膜→輸卵管、卵巢→盆腹膜→子宮直腸窩→大網膜。③宮頸→陰道PatternsofSpread2.淋巴轉移

為主要轉移途徑,癌累及宮頸、深肌層或癌組織分化不良時，容易淋巴轉移。與部位有關。宮底→闊韌帶淋巴網→骨盆漏斗韌帶→卵巢→腹主動脈旁淋巴結宮角→圓韌帶→腹股溝淋巴結子宮下段、宮頸管→宮旁→髂內、外→髂總淋巴結子宮后壁→宮骶韌帶→直腸淋巴結；前壁→膀胱→陰道前壁PatternsofSpread3.HematogenousspreadThisoccurslate,withthemostcommonsitebeingthelungs.Otherpotentialsitesincludetheliver,brian,orosseous(骨的)

metastases.

PatternsofSpread

Ⅰ期癌局限在子宮體Ia期侵犯肌層<1/2Ib期侵犯肌層≧1/2

四、手術病理分期(FIGO,2009)IbIaII期腫瘤侵犯宮頸間質，但無宮體外蔓延

II期Ⅲ期腫瘤局部和（或）區域擴散Ⅲa期腫瘤累及漿膜和(或)附件Ⅲb期陰道和（或）宮旁轉移Ⅲc期盆腔和(或)腹主動脈旁淋巴結轉移Ⅲc1盆腔淋巴結陽性Ⅲc2腹主動脈旁淋巴結轉移伴或不伴盆腔淋巴結陽性IIIaIIIbIIIcⅣ期：腫瘤侵及膀胱和（或）直腸粘膜，和（或）遠處轉移

Ⅳa期腫瘤侵犯膀胱和（或）直腸粘膜Ⅳb期遠處轉移，包括腹腔內和（或）腹股溝淋巴結轉移Clinicalfindingssigns

（1）Theuterusmaybesoftandenlargedslightlyintheearlystages.（2）Signsofadvancedcasesincludepelvicpressureorpain,increasedurinaryfrequency,conspitation,thepresenceofapalpablemass,orascites.

Clinicalfindings

1.historyandclinicalfindings2.tranvaginalUltrasoundorMR3.fractionalcurettage4.hysteroscopy5.endometrialaspirationbiopsy6.serumCA125Diagnosis病史及臨床表現對于絕經后陰道出血、絕經過渡期月經紊亂，均應排除子宮內膜癌。對于有子宮內膜癌高危相關因素者應高度警惕。（1）肥胖、不育、絕經延遲（2）長期應用雌激素、tamoxifen或雌激素增高病史（3）有乳腺癌、內膜癌家族史者影像學檢查陰道超聲:異常陰道出血時初篩，子宮大小、宮腔形態、內膜厚度、宮腔贅生物有無、肌層浸潤與否...MRI：治療前評估，對于肌層浸潤深度和宮頸間質浸潤判斷較準確；CT協助判斷有無子宮外轉移診斷性刮宮（diagnosticcurettage）：

最常用最可靠的確診方法。先用小刮匙刮頸管，再進宮腔搔刮內膜，刮出物分瓶標記送檢。分段診刮

能直視宮腔及宮頸管內病灶并可定位活檢，對較小病灶更

有價值。宮腔鏡檢查(1)子宮內膜抽吸活檢(endometrialaspirationbiopsy)：子宮內膜活檢的專用吸管和刮匙，國內尚未開展。(2)血清CA125

：有宮外轉移者升高，監測手段。其他診斷方法1、功能失調性子宮出血：主要表現為月經紊亂，如經量增多、經期延長、經間出血或不規則流血，診刮活檢可明確。2、老年性陰道炎：主要表現為血性白帶。抗炎后復查，必要時診刮。3、子宮粘膜下肌瘤或息肉：多表現為月經增多及經期延長。4、內生型宮頸癌、子宮肉瘤及原發性輸卵管癌：表現為陰道排液、不規則陰道流血和下腹疼痛。診刮和影像學幫助鑒別。鑒別診斷(differentialdiagnosis)TreatmentOperation,radiotherapy,chemiotherapy,andhormonaltherapycanbeusedinthemanagementofEC,accordingtotheage,healthstatusandtheorgansinvolvedofthepatients.SurgicalprocedureshouldbethefirstchoicefortheearlystageofEC.高危因素：非子宮內膜樣腺癌或低分化腺癌，深肌層浸潤、脈管間隙受侵、腫瘤體積大、宮頸轉移、淋巴轉移和子宮外轉移。surgeryThestandardtreatmentforECisandremainsatotalabdominalhysterectomyandbilateralsalpingo-oophorectomy.Theoperationcommenceswithanadequateabdominalincision,allowingforathoroughabdominalexplorationaswellaspossiblelymphadenectomy.Apelvicwashingisobtainedusingsaline,orifascitesispresent,thisisaspiratedandsentforcytology.Anysuspiciousorobviousareasofextrauterinediseasearebiopsied.surgicalstagingprocedurelaparoscopicprocedureforECisconsideredtobethestandardoptionatpresenttimeOmentumorectomyshouldbeperformedforsomerarehistologiesandthecaseswiththeovaryinvolved.Lymphadenectomymyometrialinvasionmorethan1/2myometriallayercervicalextensionextrauterinespreadserous,clearcell,orundifferetiatedhistologiesanyenlargedlymphnodesGrade3endometrialadenocarcinomamorethan50%oftheuterinecavityisinvolvedSurgeryforstageIIofECradicalhysterectomyandbilateralsalpingo-oophorectomyandpelviclymhpadenectomyandparaaorticlymphanodesampling放療單純放療：有手術禁忌證或無法手術切除的晚期患者。放療聯合手術及化療：術后放療是I期高危和II期子宮內膜癌最主要的術后輔助治療。降低局部復發和改善無瘤生存期。化療晚期或復發子宮內膜癌綜合治療措施之一，也可用于術后有復發高危因素患者的治療以期減少盆腔外轉移。子宮漿液性癌術后均予以化療，方案同卵巢上皮性癌。孕激素治療主要用于晚期或復發癌，極早期要求保留生育功能的年輕患者。孕激素以高效、大劑量、長期為宜，12周以上評估效果。孕激素受體陽性者有效率80%。常用藥物：醋酸甲羥孕酮200-400mg/d；己酸孕酮500mg,每周兩次。注意藥物副作用。隨訪術后2-3年內重要。隨訪內容：病史、盆腔檢查、陰道細胞學涂片、胸部x-ray、CA125等，必要時CT、MRI檢查。方法：術后2-3年內，每3個月1次，3年后每6個月1