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Uterine myoma and sarcoma Fudan University Weiwei Feng, MD,Ph.D Email:jingsakura@gmail

Uterine myoma and sarcoma Fudan University Weiwei Feng, MD,Ph.D Email:jingsakura@gmail.com. Terms: Myoma Leiomyoma Fibroid The commonest benign conditions of the uterus. Incidence. True incidence--- uncertain Common in women between 20~50y

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Uterine myoma and sarcoma Fudan University Weiwei Feng, MD,Ph.D Email:jingsakura@gmail

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  1. Uterine myomaand sarcomaFudan UniversityWeiwei Feng, MD,Ph.DEmail:jingsakura@gmail.com

  2. Terms: Myoma Leiomyoma Fibroid The commonest benign conditions of the uterus

  3. Incidence • True incidence--- uncertain • Common in women between 20~50y • Clinically evident in 20%~30% of the women over 30 years old. an exceedingly frequent event

  4. Etiology Related to hormones ( estrogen and progesterone) Elevated ER expression in myoma Abnormal cytogenetics Arise during the period of menstrual activity, shrink after menopause

  5. Classification Location Corpus ( 90%) Cervix ( 10%) Growth pattern Intramural( 60~70%) Subserosal (20%) Submucosal (10~15%) Multiple (>=2)

  6. Pathology- grossly examination Pseudo capsule Margins : blunt, non-infiltrating, pushing Cut surface Whorled, spiral patterns of fibers

  7. Microscopic features Elongated smooth muscle cells and fibrous tissue. No nuclear atypia, mitotic figures are absent or sparse.

  8. Degenerations Cause: gradually inadequacy of blood supply Hyaline degeneration : commonest Cystic degeneration Red degeneration Degeneration with calcification Benign Malignant Sarcomatous degeneration ( 0.4~0.8%)

  9. Hyaline degeneration Cause: inadequacy of the blood supply Uniform, eosinophilic, ground-glass appearance Cystic degenration: secondly to hyaline degeneration

  10. Red degeneration Frequent during pregnancy or puerperium A deep pink or red, softer The ghosts of the muscle cells and their nuclear remain

  11. Sarcomatous change • 1.Margin not well defined, • blurred, merging, irregular • 2. Loss of whorled pattern • 3. Yellow, tan, or gray color • 4. Heterogeneity • 5. Softer, less rubbery • 6. Absence of a bulging • surface

  12. Symptoms and physical signs 40~50% asymptomatic, discovered incidentally after routine examination

  13. Menorrhagia Menostaxis Irregular mense Change of mense Intramural myoma Anemia Shortness of breath Palpitations Weakness Submucosal myoma

  14. Pelvic mass and physical signs • Depend on the size, location, number • and degeneration type • Asymmetric enlargement of uterus • Consistency • Firm or rubbery • Hard or stony ( calcification) • Soft ( cystic)

  15. Pelvic mass and Physical signs • A firm mass extruded from the • cervical OS (submucosal) • Distortion and elongation of • the cervical canal (cervical )

  16. Compressive symptoms Different location of the myoma Cervical or lower segment Cervical or broad ligment Posterior Urethral obstruction Ureteral obstruction Recto-sigmoid compression Frequency and retention of urine Nephrohydrosis Hydroureter Constipation Discomfort

  17. Increasing of discharge Intramural myoma—increased uterus cavity area Submucosal myoma— purulent discharge ( infection) lower abdominal discomfort

  18. Pain Red degeneration Torsion of pendunculated myoma Extrusion of submucosal myoma from the cervix

  19. Myoma and infertility • infrequent primary cause of infertility • 27% of women who received myomectomy had a history of infertility • Usually caused by submucosal and intramural myoma

  20. Myoma and pregnancy • Pregnancy loss , abortion • Increased cesarean section ( Obstruction of labor) • Question: Can myoma be removed during cesarean section? • Postpartum hemorrhage • Red degeneration • Growth of myoma • Most patients have uncomplicated pregnancies and deliveries.

  21. Diagnostic methods History Physical signs Ultrasound/ MRI 4. Cervical cytology 5. Dilation &Curretage 4,5 : To rule out cervical cancer and endometrial cancer

  22. 6. Hysterosalpingography 7. Hysteroscopy 8. Laparoscopy 9. Other lab tests ( HCG, Hb)

  23. Differential diagnosis Pregnant uterus Ovarian tumor Uterine adenomyosis Malignant uterine neoplasms

  24. Pregnant uterus VS. Myoma

  25. Ovarian tumor VS. Myoma Solid ovarian tumor VS. Subserous leiomyoma Ovarian cyst VS. Cystic /hyaline degenerative myoma

  26. Adenomyosis VS. Myoma adenomyosis leiomyoma

  27. Endometrial cancer / Cervical Cancer VS. Submucous myoma Submucous myoma Cervical cancer Endometrial cancer

  28. Management

  29. principle Factors should be taken into consideration • Age • Desire of childbearing • Symptoms • Location, size and number • Malignant change

  30. observation • Observation with close follow-up Indications: small and asymptomatic myoma especially for peri-menopausal women

  31. Medications Indications: Size <= 2 months pregnant uterus Mild symptoms Peri-menopausal With contraindications for operation

  32. Gonadotropin-releasing hormone agonist (GnRH-a) Mechanism: Inhibit FSH, LH and Estrogen Efficacy : 40~60% decrease in uterine volume Side effects: hypoestrogenism reversible bone loss and hot flashes obvious for long use (>6 months) estrogen add-back therapy Regrowth : within a few months after stopping therapy.

  33. Indications of GnRH-a Preservation of fertility before attempting conception Treatment of anemia to allow recovery of Hb before surgery, minimizing the need for blood transfusion Preoperative treatment of large leiomyomas to make surgery more feasible. Treatment of women in menopausal period

  34. GnRH-a gesorelin ( 3.6mg q28d× 6) , leuprorelin: ( 3.75mg q28d × 6) • Mifepristone ( Ru486) : 12.5mg P.O. progesterone receptor antagonist

  35. Surgery Indications: Menorrhagia with anemia, resistant to medication Markedly enlarged uterus with compression symptoms Chronic pain, dyspareunia, Acute pain, as in torsion of a pedunculated myoma, or prolapsing submucosal fibroid 4. Rapid enlargement of uterus-sarcomatous change? 5. Infertility or spontaneous abortion with myoma as the only abnormal finding

  36. Surgical procedures Myomectomy Hysterectomy Abdominal / laparoscopic / hysteroscopic or vaginal

  37. Myomectomy Indications: young patients who desire for childbearing Recurrence risk: as high as 50%, and up to 1/3 requiring repeat surgery

  38. Hysterectomy Indications: no requirement of uterine preservation Note: : Cervical or endometrial cancer must be excluded before operation

  39. Other treatments: Uterine artery embolization, UAE Endometrium ablation by hysteroscopy

  40. Video 1: Laparoscopic myomectomy Advantages : Minimizes incision, quicker recovery Disadvantages: Risks of convertion to a laparotomy Immature suture technique: uterine rupture during pregnancy Video 2: Laparoscopic hysterectomy

  41. Uterine sarcoma

  42. General information Rare tumors of mesodermal origin (myometrium, connective tissue, stroma of endometrium, or secondly to myoma) 2~4% of uterine malignancies Poor prognosis ( death occurring within 1 to 2 years after diagnosis, except ESS)

  43. Three commonest types Leiomyosarcoma (~45%) Endometrial stromal sarcoma (ESS) Undifferentiated endometrial sarcoma (15~25%) Mixed epithelial and mesenchymal tumors Adenosarcoma Carcinosarcoma , or malignant mesodermal mixed tumor, MMMT

  44. leiomyosarcoma • Age: 45-55 yr, • Usually arise de novo from uterine smooth muscle, rarely arise in a preexisting myoma • Diagnosis usually is not made before surgery. D&C are diagnostic only for ~10% of tumors that are submucous. • Poor prognosis

  45. leiomyosarcoma mitotic figures>5/10HPF severe cytologic atypia coagulative tumor necrosis

  46. Endometrial stromal sarcoma • Before 2003, low grade ESS, low grade (低度恶性子宫内膜间质肉瘤) Most ESS involve endometrium, infiltrate muscles, sometimes protrude from the OS. D&C lead to diagnosis (about half). The only uterine sarcoma related to hormone, ER, PR (+), response to hormone treatment Behaviour : indolent, late recurrence and metastasis may occur. 5-yr survival >80%

  47. ESS, low grade Originated from endometrial stromal cells, similar to proliferative phase ESS with invasive border

  48. Undifferentiated endometrial sarcoma ( UES) UES: behave aggressively, with 5-year survival < 40% UES with severe atypia Mitosis>10/10HPF

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