子宫肌瘤 Myoma of uterus
-
Upload
eleanor-dennis -
Category
Documents
-
view
478 -
download
1
description
Transcript of 子宫肌瘤 Myoma of uterus
子宫肌瘤子宫肌瘤Myoma of uterus Myoma of uterus
王世宣 ( Shixuan Wang )
Department of OB/GYN
Tongji Hospital
Tongji Medical College of HUST
Topics today
发病相关高危因素 High risk factors 分类 Classification 病理 Pathology 肌瘤变性 Degeneration of uterine myoma 临床表现 Clinical manifestation 诊断及鉴别诊断 Diagnosis and differential
diagnosis 治疗 Management
Female Internal genitalia
Myoma of uterus
Most common Most common benign tumor benign tumor in female in female genitalia!genitalia!
MYOMA OF THE UTRUS--
in various region of uterus
General consideration
Terms: Myoma, leiomyoma, fibroid, fibroid tumor
Consists of: smooth muscle tissue + connective tissue
The most common benign tumor in female genital organs
20% of women over 30; 25% of women over 40
Commonly seen in women of age: 30-50; 40- 50 yrs old with peak incidence
Rare in girls under 20; shrink after menopause
High risk factors (1)
Cytogenetic factors Female Hormones Growth Factors Molecular factors
The exact causes remain unclear
High risk factors (2)
Cytogenetic factors:
20%- 50%, cytogenetic abnormalities
(chromosome) family history
Female Hormones:
Estrogens ↑, ER ↑
Hypersensitivity to estrogen
Progestin ?
High risk factors (3) Growth Factors:
Epidermal growth factor (EGF)
Insulin-like growth factor (IGF)-I
Basic fibroblast growth factor (BFGF)
Cellular and Molecular factors:
Hypothesis:Hypothesis: stem cells
monoclonal → single myoma
polyclonal → multiple myomas
Pathogenesis of uterine myomaPathogenesis of uterine myoma
Cytogenetic background
Growth factors
EstrogenHigh ER
hypersensitivity
Myoma of uterus
Smooth muscle cells Stem cell(s) of myoma
Classification of myoma of uterus
Originate in the myometrium of uterus
按肌瘤生长部位 Classified by
anatomic location
按肌瘤与肌层关系 Classified by
relationship with myometrium
Anatomy of uterus
Classification- by the location:
宫体肌瘤 Corporeal
myoma: 90%
宫颈肌瘤 Cervical
myoma: 10%
Classification- by the relationship with myometrium
肌壁间 Intramural myoma: 60 % -70 %
浆膜下 Subserous myoma : 20%
粘膜下 Submucous myoma : 10 % -15%
Classification-
by the relationship with myometrium
Subserous
Submucous ( / intracavitary)
Subserous
Submucous + intramural
Submucous + Intramural + Subserous
Pathology
Gross view (Naked eye appearance)
Microscopic features
Pathology – gross view
Mass: Spherical, solid, hard; grey-white; pseudocapsule; often multiple
Section: paler, harder and more fibrous than the normal uterine myometrium (wall)
Pathology - Microscopic features
Smooth muscle cells arising from mostly Smooth muscle cells arising from mostly
myometrium, or endometrium of blood myometrium, or endometrium of blood
vesselsvessels
Composed of unstriped, interlaced bundles of Composed of unstriped, interlaced bundles of
smooth muscle and fibrous tissuesmooth muscle and fibrous tissue
Condensed nuclei, mitotic activity Condensed nuclei, mitotic activity
Fig. 1 100× left : normal ;right : myoma with interlaced bundles of smooth muscle tissue
fig. 2 100× Uterine myoma
fig. 3 200×Uterine myoma
Atrophic
hyaline degeneration
cystic degeneration
red degeneration
malignant transformation: mainly
sarcomatous change
Others: myxomatous (fatty), septic,
calcific (calcareous)
肌瘤变性 Degeneration of myoma
Hyaline degeneration
•The commonest change
seen in myoma.
•caused by a gradual
inadequacy of the blood
supply.
Cystic degeneration
not uncommon,
especially after the
menopause
due to liquefaction of the
areas of hyaline change.
Red degeneration
The affected area resembles
raw meat and is stained red.
most freguently seen during
the pregnancy and in
postpartum.
Malignant change
0.1%- 1% of cases
Most likely to be seen in large tumors.
More typical in older patients, especially postmenopausal patients
Presented with rapidly enlarging uterine mass and postmenopausal bleeding.
Metastasis occurs rapidly
症状 Symptoms
Abnormal vaginal bleedingAbnormal vaginal bleeding:: the most common presenting
symptom; hypermenorrhea(经量过多及经期延长)
Lower abdominal mass:Lower abdominal mass: usually asymptomatic
Vaginal discharge ↑Vaginal discharge ↑
Pressure effects:Pressure effects:
Others:Others: abdominal pain, infertility, secondary anemia
Symptoms – Abnormal vaginal bleeding (1)
Submucous myoma:
almost 100%, quite small tumors can lead to severe anemia.
Intramural tumors:
increasing of blood loss; prolonged period
Subserous growths:
do not affect the menstrual loss.
Symptoms – Abnormal vaginal bleeding (2)
Mechanisms for increased bleeding:
Alteration of normal myometrial contractile function
Inability of the overlying endometrium to respond to the normal E/P menstrual phases.
Pressure necrosis of the overlying endometrial bed.
Symptoms – abdominal mass
Sometimes the first thing that the patient notices.
Asymptomatic: not tender and rarely gives rise to pain.
Symptoms – Pelvic pressure
Against bladder (frequency and retention of urine)
Against rectum ( constipation )
Against parauterine tissues: pain or discomfort
Symptoms – abnormal Vaginal discharge
42%
↑Area of uterine cavity
Pelvic congestion
Complications of submucous myoma
Symptoms – pelvic Pain
not a common symptom, when it occurs:
Some complication of myoma such as, degeneration or torsion
Endometriosis
Pelvic inflammatory disease
Symptoms – others
Infertility:Infertility: 3030 %% patients with myomapatients with myoma
Spontaneous abortion:Spontaneous abortion: 4 4 :: 11
Secondary Anemia:Secondary Anemia:
体征 Signs
Vary with the size , site (region/ location),
number, and complication of myomas.
abdominal examination
pelvic examination
Signs - Abdominal mass
﹤3 months gestational age : not palpable
> 3 months gestational age : In the middle
of the lower abdomen, irregular, hard, nodular
Signs - Pelvic mass
Intramural : enlargement of uterus; irregular,
single or multiple nodules on the surface
Subserous : spherical, nodular masses
Submucous : symmetrical enlargement of the
uterus , extrusion of myoma into cervical
canal even vagina
诊断 Diagnosis
History: reproductive age Symtoms: Signs: Ancillary tests:
Ultrasonography
Hysteroscopy
Laparoscopy
Dilation and curettage
HSG
Essentials for diagnosis
Bleeding: hypermenorrhea, metrorrhagia,
dysmenorrhea
Mass: irregular enlargement of the uterus (usually
asymptomatic); solid, spherical, and nodular
Pain: from torsion or degeneration
Pressue symptoms: from neighboring organs (large
tumors)
Diagnosis- ancillary test
Pelvic ultrasound
the most commonly used for confirmation of uterine myomas
Subserous myoma
Submucous myoma
Ancillary test - Laparoscopy
Ancillary test - Hysteroscopy
Differential diagnosis (1)
Other conditions which give rise to a mass in the pelvis (盆腔包块)
Adenomyoma
Ovarian tumors
Inflammatory mass in the pelvis
Pregnancy
Abnormality of uterus
Differential diagnosis (2)
Other conditions which cause metrorrhagia(子宫出血)
Adenomyoma
Endometrial polyp of uterus
Carcinoma of the uterus: endometrial, cervical
Dysfunctional uterine bleeding
Endometrial polyp
Adenomyosis
Adenocarcinoma of the endometrium
Abnormality of uterus
治疗 Management
Follow up Drug therapy Surgical management:
hysterectomy;myomectomy Others: Embolisation of myoma ;
myolysis
Treatment - Follow up
The majority of patients with uterine myomas do not require surgical treatment.
Age: Patients in the late reproductive or perimenopausal years.
Small and asymptomatic
Management: repeat pelvic examinations and assisted by serial pelvic ultrasound measurements
Every 3 - 6 months.
Management - Drug therapy
Indications: Perimenopausal women small myoma ( 2 months﹤ ) Asymptomatic, or with mild symptoms Couldn’t tolerate surgery
Management - Drug therapy
Mechanisms:
Pharmacologic inhibition of effects of estrogen
Inhibit the function of H-P-O axis
Commonly used for 3 to 6 months.
Management - Drug therapy
Drugs: Androgen GnRH-a: down regulation Mifepristone Gestrinone: nemestran Chinese herb medicines
Management - surgery
Surgical treatment is indicated in cases with:
1. Heavy or prolonged bleeding
2. Tumors of large size over 2.5 gestation months, ( 10 weeks ) even if these are not causing symptoms.
3. Possible malignant change, such as a tumor which grows after the menopause
4. Pressure symptoms ( against bladder, bowel, and pelvic floor)
5. Tumors which have undergone torsion or degeneration
Management - surgery
肌瘤切除术 Myomectomy:
Occasionally warranted in younger patients whose
fertility is compromised by the presence of myomas.
子宫切除术 Hysterectomy:
Should be considered as definitive treatment only in
symptomatic women who have completed childbearing.
Laparoscopic Myomectomy
Laparoscopic myomectomy
Management - Uterine myoma Embolization (Uterine Artery Embolization)
Uterine myoma Embolization (Uterine Artery Embolization)
Women at age of 30 ~ 50
Abnormal vaginal bleeding
Enlargement of uterus with smooth, spherical, s
olid mass
Pelvic ultrasonography generally assists in esta
blishing diagnosis
Medical and surgical treatment
What we have talked about?