子宮平滑肌瘤：鐘剛-課件

LeiomyomaofUterusZhonggangDepartmentofGynecologyandObstetricTongjiHospitalLeiomyomaofUterusZhonggang1Introduction

Uterineenlargementasaresultofleiomyomaiscommoninclinicalpractice.Myomaarethecommonestnewgrowthsoftheuterusandoneofthemostcommontumorsofthehumanbody.Theseoccurinapproximately,20%ofwomenover30,25%ofwomenover40.IntroductionUterineenlargeme2AetiologicalfactorsFemaleHormonesEstrogensProgestronsGrowthFactorsBasicfibroblastgrowthfactor(BFGF).Insulinlikegrowthfactor(IGF)-I.Epidermalgrowthfactor(EGF).AetiologicalfactorsFemaleHor3AnatomyofuterusAnatomyofuterus4ClassificationClassification5ClassificationAccordingtolocationofuterinemyomatahavebeendividedinCorporealfibromyomata(90%)Cervicalmyomata(10%).ClassificationAccordingtoloc6ClassificationAndcorporealmyomatahavebeendivided:Intramuralfibromymata60-70%Subserousfibromymata20%Submucousfibromymata10-15%ClassificationAndcorporealmy7子宮平滑肌瘤：鐘剛-課件8ClassificationIntramuralfibromymata

withintramuralfibromyomataenlargementoftheuterinebodyusuallyoccurs,oftenwithelongationofitscavitysothatthereisincreasedmenstrualloss.ClassificationIntramuralfibro9Classification

Subserousfibromymata

Size:fromsmallnodulestoenormousmassesof20kgormoreinweight.Pedunculatedmyoma:theytendtogrowupintotheabdomenandthebroadligament,Rarelytorsionmayoccur,resultingininterferencewiththebloodsupplytothetumor.ClassificationSubserousfib10ClassificationSubmucousfibromyoma.Someintramuraltumorsareextrudedtowardstheuterinecavity.Theuteruscontractsinanattempttoexpelthetumoranditmaybeextrudeduntilitisonlyattachedtotheuterinewallbyastalkandisknownasafibro-myomatouspolypClassificationSubmucousfibrom11PathologyNackedeyeappearance.onsectionthefibromyomaispaler,harderandmorefibrousthantheuterinewall.Oncomparinganintramuraltumorwiththesurroundingfalsecapsuleofuterinewallthedifferenceiswellmarked.PathologyNackedeyeappearance12NackedeyeappearanceNackedeyeappearance13Smoothmuscletumorsoftheuterusareoftenmultiple.Seenherearesubmucosal,intramural,andsubserosalleiomyomataoftheuterus.Smoothmuscletumorsoftheut14PathologyMicroscopicalstructure.ThesegrowthsarecomposedofunstripedmuscleandfibroustissuePathologyMicroscopicalstructu15Hereisthemicroscopicappearanceofabenignleiomyoma.Normalmyometriumisattheleft,andtheneoplasmiswell-differentiatedsothattheleiomyomaattherighthardlyappearsdifferent.Bundlesofsmoothmuscleareinterlacinginthetumormass.Hereisthemicroscopicappear16DegenerationThesetumorsgrowslowly;insomecasestheremaybenoevidentchangeinsizeformanyyears.Inafewcasesgrowthismorerapidandsecondarychangesmayalsocauseswellingofthetumor.DegenerationThesetumorsgrow17DegenerationHyalinedegenerationisthecommonestchangeseeninfibromyomata.Itiscausedbyagradualinadequacyofthebloodsupply.Cysticdegenerationisnotuncommon,especiallyafterthemenopause,andisduetoliquefactionoftheareasofhyalinechange.DegenerationHyalinedegenerati18DegenerationReddegeneration.Inthisvarietyofdegenerationtheaffectedareaisstainedredandresemblesrawmeat.Itismostfreguentlyseenduringthepregnancyandinpostpartum.DegenerationReddegeneration.19Degeneration

Malignantchange

In0.1to1%ofcases,malignancyasleiomyosarcomamaydevelop.Itismostlikelytobeseeninlargetumors.Malignancyismoretypicalinolderpatients,especiallypostmenopausalpatientsPresentionwithrapidlyenlarginguterinemassandpostmenopausalbleeding.Metastasisoccursrapidllyinthesecases.DegenerationMalignantchang20Thisisaleiomyosarcomaprotrudingfrommyometriumintotheendometrialcavityofthisuterusthathasbeenopenedlaterallysothatthehalvesofthecervixappearatrightandleft.Fallopiantubesandovariesprojectfromtopandbottom.Theirregularnatureofthismasssuggeststhatisnotjustanordinaryleiomyoma.Thisisaleiomyosarcomaprotr21SymptomsBleedingisthemostcommonpresentingsymptominuterinefibroids.Menorrhagiaisfreguentreasonforpatientstoseekadvice.Theperiodsincreaseinamountandduration.SymptomsBleedingisthemostc22SymptomsBleeding

Submucousfibromyomatamenorrhagiaisnearlyalwayspresent,andquitesmalltumorscanleadtosevereanaemia.IntramuraltumorsmayincreasethelossSubserousgrowthsdonotaffectthemenstrualloss.SymptomsBleeding23SymptomsBleeding

Mechanismsforincreasedbleeding:AlterationofnormalmyometrialcontractilefunctionInabilityoftheoverlyingendometriumtorespondtothenormalE/Pmenstrualphases.Pressurenecrosisoftheoverlyingendometrialbed.SymptomsBleeding24SymptomsAnabdominaltumourissometimesthefirstthingthatthepatientnotices.Thetumorisnottenderandrarelygivesrisetopain.Dischargeisrarelyaprominentsymptomexceptduringtheextrusionoffibromyomatospolypthroughthecervicalcanal.SymptomsAnabdominaltumouris25SymptomsPainisnotacommonsymptom.whenitoccuritisgenerallyanindicationthatthereisassociatedendometriosisorpelvicinflammatorydisease,orsomecomplicationofthetumorsuchasreddegenerationortorsion.SymptomsPainisnotacommons26SymptomsPelvicpressure:pressureonthebladderleadingtofrequencyandretentionofurine.SymptomsPelvicpressure:press27PhysicalsignsThephysicalsignsvarywiththesize,positionandnumberofthetumors.Asymmetricalenlargementoftheuterusisfoundwithasubmucosgrowth.Moreoftentheenlargementisasymmetrical;itisoftennodularonthesurfacebecausetherearemultipletumor.Subseroustumorswithlittlemyometrialcoveringoftenfellparticularlyhard.PhysicalsignsThephysicalsig28PhysicalsignsOnpelvicexaminationthecervixmaybefoundtobepusheddownordisplacedtooneside.Ifitisexpandedbyanintracervicaltumor,oritmaybedilatedwiththelowerpoleofatumorleftwithinit.PhysicalsignsOnpelvicexamin29DiagnosisThediagnosisofthesetumorsisusuallymadebyclinicalexamination,includeabdominalandbimanualpalpation,orimagingstudies.Inaddition,irregularitiesoftheuterinecavitycanbedetectedatthetimeofendometrialcurrettage.DiagnosisThediagnosisofthes30DiagnosisPelvicultrasoundisthemostcommonlyusedforconfirmationofuterinemyomas.Dilationandcurettagemayproviderelevantinformation,becauselargertissuespecimens,includingsmallsubmucousmyomas,maybeobtained.DiagnosisPelvicultrasoundis31PelvicultrasoundPelvicultrasound32PelvicultrasoundPelvicultrasound33HysteroscopyHysteroscopymayalsobeusedtoevaluatetheenlargeduterusbydirectlyvisualizingtheendometrialcavity.HysteroscopyHysteroscopymaya34DifferentialdiagnosisOtherconditionswhichcausemenorrhagiaDysfunctionaluterinebleedingCarcinomaoftheuterusEndometrialpolypofuterusOtherconditionswhichgiverisetoaswellinginthepelvisAdenomyoma,ovariantumors,inflammatoryswellinginthepelvis,pregnancyDifferentialdiagnosisOtherco35Thisuterushasbeenopenedanteriorlythroughcervixandintotheendometrialcavity.Highinthefundusandprojectingintotheendometrialcavityisasmallendometrialpolyp.Suchbenignpolypsmaycauseuterinebleeding.Thisuterushasbeenopenedan36Thethickenedandspongyappearingmyometrialwallofthissectioneduterusistypicalofadenomyosis.Thereisalsoasmallwhiteleiomyomaatthelowerleft.Thethickenedandspongyappea37子宮平滑肌瘤：鐘剛-課件38Thisadenocarcinomaoftheendometriumismoreobvious.Irregularmassesofwhitetumorareseenoverthesurfaceofthisuterusthathasbeenopenedanteriorly.Thecervixisatthebottomofthepicture.Thisenlargeduteruswasnodoubtpalpableonphysicalexamination.Thisadenocarcinomaoftheend39AbnormalityofuterusAbnormalityofuterus40TreatmentFollowuphormonaltreatmentfibroidembolisationSurgicalmanagementhysterectomymyomectomymyolysisTreatmentFollowup41TreatmentFollowup:themajorityofpatientswithuterinemyomasdonotrequiresurgicaltreatment.SmalltumorsandnotcausingsymptomsPatientsinthelatereproductiveorperimenopausalyears.Management:repeatpelvicexminationsandassistedbyserialpelvicultrasoundmeasurementsEvery3-6months.TreatmentFollowup:themajori42TreatmentDrugtherapy:bleedingisnotheavyenoughtocauseanemiaandsmallmyoma.Mechanisms:PharmacologicinhibitionofestrogensecretionAnattemptmaybemadetominimizeuterinebleedingThistreatmentiscommonlyusedfor3to6months.TreatmentDrugtherapy:43TreatmentDrugsandrogenGnRH-asupplementation.GestrinoneMifepristoneChinesemedicineTreatme