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精品子宫内膜增生_7课件

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子宫内膜增生 子宫内膜增厚
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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * * 1 1 子宫内膜增生 与 子宫内膜癌前病变 l北京医科大学人民医院妇产科 l魏丽惠 This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜增生 (endometrial hyperplasia,EH) l正常子宫内膜周期性再生、分化、剥脱, 依赖女性激素作用。 l无排卵、排卵不规则妇女因雌激素刺激, 子宫内膜持续增生 l与长期受雌激素刺激、缺乏孕激素有关: 单用雌激素一年,20%子宫内膜增生; l以腺体病变为主、伴有少量间质病变,少 数内膜增生可以发展成癌 2 2 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 国际妇科病理协会分期(ISGP,1987) (International Society of Gynecology Pathology) l单纯增生(simple hyperplasia)良性病变, 原腺囊性增生(cysitic hyperplasia ) l复合增生(complex hyperplasia)良性病变 原腺瘤性增生(adenomatous hyperplasia) l非典型增生(atypical hyperplasia) 癌前病变 3 3 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee This is the microscopic appearance of normal proliferative endometrium in the menstrual cycle. The proliferative phase is the variable part of the cycle. In this phase, tubular glands with columnar cells and surrounding dense stroma are proliferating to build up the endometrium following shedding with previous menstruation. Here is early secretory endometrium. The appearance with prominent subnuclear vacuoles in cells forming the glands is consistent with post-ovulatory day 2. The histologic changes following ovulation are quite constant over the 14 days to menstruation and can be utilized to date the endometrium. 正常子宫内膜 增生期 早期分泌期 (proliferative endometrium) (early secretory endometrium) 4 4 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee This is normal secretory phase endometrium. Note the larger tortuous glands with secretions. The secretory phase follows a set 14 day course leading to either implantation of a fertilized ovum or menstruation. 晚期分泌期(月经前期) (secretory phase endometrium) 5 5 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 单纯增生 (simple hyperplasia) l子宫内膜腺体和间质增生 , l腺体不规则, 可扩张呈囊性并有群集间 质致密 l无细胞异型性 6 6 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 复合增生 (complex hyperplasia) l腺体高度增生,成芽状 或乳头状, 腺体不规则,呈现结构 复杂和背靠背的群集, 细胞呈复层或假复层 l 无细胞异型性 7 7 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生(atypical hyperplasia ) l细胞极性消失,大小不一,核深染, 腺上皮细胞异行型; l无间质浸润。 l根据腺上皮增生程度分为轻、中、重。 8 8 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee This is endometrial cystic hyperplasia in which the amount of endometrium is abnormally increased and not cycling as it should. The glands are enlarged and irregular with columnar cells that have some atypia. Simple endometrial hyperplasias can cause bleeding, but are not thought to be premalignant. However, adenomatous hyperplasia is premalignant. 子宫内膜非典型增生 9 9 Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生(atypical hyperplasia) 轻度非典型增生: l腺体轮廓稍不规则, l腺上皮细胞轻度异 行型, l无间质浸润。 1010Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生(atypical hyperplasia) 中度非典型增生: l腺体轮廓不规则, 呈分支或乳头状, l腺上皮细胞异行型 较明显。 l有细胞异型性,无 间质浸润 1111Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生(atypical hyperplasia) 重度非典型增生: l腺体轮廓明显不规则,呈 不规则分支状,有腺腔内 出芽和乳头状结构, l腺上皮细胞异行型明显。 l腺体搭桥、共壁,但无间 质浸润。 1212Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 临床表现 l发生于年龄较轻患者,常伴有多囊卵巢、 无排卵性月经、不孕症。 l发生在绝经前妇女,患者常伴有肥胖、 子宫 肌瘤、更年期症状,或有较长期服用外源性雌 激素,而未同时服用孕激素史。 1313Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 临床表现 l年龄:可发生在任何年龄妇女 l青春期患者: 在月经出潮后,常出现无排卵功血,此种 内膜多为单纯性增生,以后随卵巢发育成 熟,内膜增生消失。 l生育年龄患者: 常伴有多囊卵巢、无排卵性月经、不孕症 。此类患者长期卵巢功能异常,应用促排 卵药物治疗无效时,应注意有无内膜病变 ,特别是有无癌前病变。 1414Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 临床表现 l绝经前妇女: 由于卵巢功能减退,无排卵,长期受雌激素刺激 ,患者可有阴道出血或经量增多,临床表现为无 排卵功血,并常伴有子宫肌瘤、更年期症状,对 此类患者应注意有无内膜病变。 l绝经后妇女: 表现为阴道出血,较绝经前妇女发生癌的危险性 更大。另外对应用激素替代,有较长期服用外源 性雌激素,而未同时服用孕激素,也成为引起内 膜增生的高危因素。 1515Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 临床表现 l肥胖妇女: 增加雌激素储存,缺乏孕激素对抗; 在脂肪内可将雄烯二酮转化为雌激素,致 使体内雌激素过高。 l具有分泌功能的卵巢肿瘤,如卵巢性索间 质肿瘤,由于雌激素水平增高,也常伴有 子宫内膜增生。 1616Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 临床表现 l出血 是最常见的症状,也有少数患者呈月经 稀发或闭经后出现阴道大量出血。 l因内分泌功能失调,不排卵常伴有不孕。 l妇科检查 子宫可稍大、稍软 l特别要注意有无非典型增生或内膜癌存在 1717Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 诊断 l主要辅助诊断 (1)分段诊断性刮宫 (2)B超检查:常见子宫内膜明显增厚, 常≥5mm(绝经后)、≥10mm(绝经前), 有时呈弥漫状或息肉状。 (3)宫腔镜检查:可直视下观察到病变情况, 并取活体组织行病理学检查。 l活体组织病理学检查是确诊的依据 1818Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 分段诊断性刮宫 l分段诊刮应先遍刮宫颈管,再探宫腔 l刮宫时应注意宫壁四周的情况,不必强求刮至 闻肌声,当有刮不净的感觉时,取够送病理检 查之组织即可。 l刮出组织应肉眼进行观察,注意组织量及组织 是否新鲜,有无组织糟脆似豆腐渣样,然后按 宫颈、宫体刮出物分别送病理学检查。 1919Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 鉴别诊断 l功能失调性子宫出血:患者有阴道不规则出血,诊断 性刮宫组织病理学检查可见单纯或复合增生,但无腺 上皮细胞异型性。 l子宫内膜息肉:患者有阴道不规则出血,但刮宫组织 病理学检查可无异常,B超检查对鉴别有一定帮助。 l子宫内膜癌:主要依靠刮宫组织病理学检查可见腺上 皮细胞异型性,腺体共壁伴有间质浸润。 2020Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 治疗 l治疗子宫内膜增生 遵循个体化(individualize)原则 l根据患者 年龄、 生育情况 有无子宫内膜癌发生的高危因素 采取不同的治疗方案 2121Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜单纯增生或复合增生的治疗 生育年龄 者(≤40岁) l外源性雌激素引起的子宫内膜单纯增生或复合增生: 保守治疗 停用雌激素,如仍需用雌激素,则加用孕激 素采取周期疗法 l内源性雌激素引起的子宫内膜单纯增生或复合增生: 孕激素治疗:甲羟孕酮 10mg /d 共10天、 甲地孕酮 40mg/d 共10天; 炔诺酮(妇康片)8-10#/d(0.625mg/#); 密切观察子宫内膜情况,进行内膜活检或诊刮 l对希望妊娠者可用氯底酚促排卵治疗 2222Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜单纯增生或复合增生的治疗 围绝经或绝经者(40岁) l孕激素治疗 治疗后3~6月取内膜观察其发展 l子宫全切 保守治疗无效 有家族史、肥胖、高血压等高危因素者 2323Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生的治疗 (生育年龄者) l大剂量孕激素治疗: 甲羟孕酮250mg~500mg/d、甲地孕酮160mg/d, 用药3月后诊刮追踪 l促排卵治疗 有生育要求者,子宫内膜转为正常后停用孕激素 ,改为氯底酚于月经5~9天或3~7天50mg~150mg/ 日促排卵 l子宫全切:治疗无效者手术治疗 2424Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生的治疗 (围绝经或绝经者) l因潜在恶变率高,特别是重度非典型增生不易与 高分化腺癌鉴别,原则应手术。 l手术治疗 行子宫及双附件切除 l只能试用大剂量孕激素保守治疗、于治疗后周期 性取内膜, l用孕激素治疗后又复发者 不能耐受孕激素副作用者行子宫切除 l对高龄、严重内科合并症不能手术者 用孕激素治疗,定期刮宫取内膜 2525Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 预后 单纯增生、复合增生 良性病变,绝大部分预后好 仅有少部分可在10 年左右发展为癌 l单纯增生 随访15年1%可发展为癌 80%病变可自然消退 l复合增生 随访13年,3%可发展为癌, 83% 消退,经孕激素治疗85% 可逆转 2626Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生与癌变率 年代 例 癌变率 年限 Gusberg 1963 68 12 % 1.5-9 Chamlian 1970 97 14 % 1-14 Wentz 1974 22 81.8 % 2-8 Sheman 1978 91 57.1% 2-15 盖铭英 1981 41 9.7 % 3-15 Kurman 1985 48 23 % 1-11 2727Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 非典型增生癌变的相关因素 l年龄 l非典型增生的病理分级: 轻:15%;中:24%;重:45% l对孕激素治疗反应 lDNA含量,异倍体增加 2828Endometral CaEndometral Ca 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * * 2929 子宫内膜癌 This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜癌( endometrial carcinoma ) l是女性生殖道常见三大恶性肿瘤之一。 l好发年龄较子宫颈癌晚,平均年龄60岁左 右。 l发病率近年来有增高趋势,在我国也明显 上升。 l为激素依赖型疾病,与高雌激素水平有关 。 3030Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 年龄分布 l绝经后50~59岁妇女最多; l60%绝经后, 30%绝经前; l高发年龄58岁,中间年龄61岁; l40岁以下患者仅占2% – 5%; l25岁以下患者极少 。 3131Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 年龄分布 3232Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜癌的高危因素 l常与雌激素水平相关疾病伴存: 无排卵性功血、多囊卵巢综合征、 功能性卵巢肿瘤 l子宫体癌综合征(内膜癌的高危因素) 肥胖、高血压、糖尿病、 未婚、不孕、少产、绝经延迟 l有近亲家族肿瘤史 3333Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜癌发病的高危因素 l肥胖 超过标准体重的10%~20% ↑ 2× 超过标准体重的21%~50% ↑ 3× 超过标准体重的 50% ↑10× l雌激素替代 ↑4.5 l口服避孕药 ↓0.5 l糖尿病 ↑2.0 l三苯氧胺 ↑7.5 l晚绝经 ↑2.4 l初潮早 ↑1.6~2.4 3434Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜癌的家族遗传 (遗传性子宫内膜癌)(1) l无家族史 l非特异性肿瘤聚集: 同代或两代亲属中有2~3人患不同类型肿瘤。 l家族性肿瘤(占1/2肌层 Ⅱ期 Ⅱa (G1、2、3)仅宫颈内膜腺体受累 Ⅱb (G1、2、3)宫颈间质受累 5858Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 子宫内膜癌手术病理分期(FIGO,1988) ( Surgical pathological staging ) Ⅲ期 Ⅲa(G1、2、3)癌累及浆膜和(或) 附件和(或)腹腔细胞学阳性 Ⅲb(G1、2、3)阴道转移 Ⅲc(G1、2、3)盆腔淋巴和(或) 腹主动脉旁淋巴结转移 Ⅳ期 Ⅳa(G1、2、3)癌瘤累及膀胱和(或) 直肠粘膜 Ⅳb(G1、2、3)远处转移,包括腹膜内 转移和(或)腹股沟淋巴结转移 5959Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 转移途径 –约75%子宫内膜癌患者为Ⅰ期,余25% 为其他各期。 –特殊组织类型及低分化癌(G3)易出 现转移, –主要转移途径为直接蔓延,淋巴转移 ,晚期可有血行转移。 6060Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 转移途径 直接蔓延:病灶沿子宫内膜蔓延。 (1)子宫上部及宫底部癌→宫角部→ 输卵管、卵巢→盆腹腔。 (2)子宫下部癌→宫颈、阴道→盆腔。 (3)癌侵犯肌层→子宫浆膜层 → 输卵管、卵巢→盆腹腔。 6161Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 转移途径 淋巴转移:是子宫内膜癌的主要转移途径。 转移途径与癌瘤生长部位有关 (1)子宫底部癌→阔韧带上部→骨盆漏斗韧 带→卵巢→腹主动脉旁淋巴结。 (2)子宫角部或前壁上部→圆韧带→腹股沟 淋巴结。 (3)子宫下段累及宫颈→宫旁→闭孔→ 髂内、外→髂总淋巴结。 6262Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 与子宫内膜癌淋巴结转移的有关因素 l腹腔冲洗液细胞学检查是否阳性, l癌灶在宫腔内的位置及病变范围的大小 l肌层浸润的深度 l是否侵犯宫颈, l附件、宫旁有无转移,是单处还是多处转移。 l癌细胞组织病理学分级。 6363Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 症状与体征 (1) l75% 均为早期患者,极早期可无症状。 l阴道流血:最常见症状 未绝经者经量增多、经期延长,或经间期出血 绝经后者阴道持续性出血或经歇性出血 个别也有闭经后出血 l阴道排液: 在阴道流血前有此症状 少数主诉白带增多 晚期合并感染可有脓血性白带伴臭味 6464Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 症状与体征 (2) l疼痛: 因宫腔积液、宫腔积脓可引起下腹痛; 腹腔转移时可有腹部胀痛; 晚期癌浸润周围组织时可引起相应部位 疼痛。 l全身症状 腹腔转移时可有腹部包块、腹胀、腹水; 晚期可引起贫血、消瘦、恶液质及全身 衰竭。 6565Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 诊断中应注意的问题 l手术前临床后分期与手术后病理分期不一致 lI、II期误差达25.3%~62.5% 升高 25.3%~30.4%, 下降13%~37%。 l术前B超可协助诊断侵肌; l术前诊断刮宫、宫腔镜可协助诊断宫颈有无 侵犯。 6666Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 诊断(1) 辅助检查 细胞学检查: l仅从宫颈口吸取分泌物涂片细胞学检查 阳性率不高, l用宫腔刮勺、宫颈管毛刷、宫腔吸管或 宫腔刷吸取分泌物涂片,可提高阳性率 ,准确率达90%~97%。 6767Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 巴氏涂片的恶性细胞团 6868Endometral CaEndometral Ca This year, my town construction work in the city, municipal government, municipal construction Bureau of the direct leadership and support, the Town party committee 诊断 (2) 分段刮宫:是诊断子宫内膜癌最常用的方 法,确诊率高,称为金标准。 l适应症: * 绝经后阴道流血; * 绝经后阴道B超子
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