子宫平滑肌瘤课件

Leiomyoma of UterusZhong gang Department of Gynecology and ObstetricTongji HospitalLeiomyomaofUterusZhonggang1IntroductionvUterine enlargement as a result of leiomyoma is common in clinical practice.vMyoma are the commonest new growths of the uterus and one of the most common tumors of the human body.vThese occur in approximately,20%of women over 30,25%of women over 40.IntroductionUterineenlargeme2Aetiological factorsvFemale Hormones Estrogens Progestrons vGrowth Factors Basic fibroblast growth factor(BFGF).Insulinlike growth factor(IGF)-I.Epidermal growth factor(EGF).AetiologicalfactorsFemaleHor3Anatomy of uterusAnatomyofuterus4ClassificationClassification5ClassificationvAccording to location of uterine myomata have been divided in vCorporeal fibromyomata(90%)vCervical myomata(10%).ClassificationAccordingtoloc6ClassificationvAnd corporeal myomata have been divided:vIntramural fibromymata 60-70%vSubserous fibromymata 20%vSubmucous fibromymata 10-15%ClassificationAndcorporealmy7子宫平滑肌瘤课件8ClassificationvIntramural fibromymata with intramural fibromyomata enlargement of the uterine body usually occurs,often with elongation of its cavity so that there is increased menstrual loss.ClassificationIntramuralfibro9Classification Subserous fibromymata vSize:from small nodules to enormous masses of 20 kg or more in weight.vPedunculated myoma:they tend to grow up into the abdomen and the broad ligament,vRarely torsion may occur,resulting in interference with the blood supply to the tumor.ClassificationSubserousfib10ClassificationvSubmucous fibromyoma.Some intramural tumors are extruded towards the uterine cavity.vThe uterus contracts in an attempt to expel the tumor and it may be extruded until it is only attached to the uterine wall by a stalk and is known as a fibro-myomatous polyp ClassificationSubmucousfibrom11PathologyvNacked eye appearance.on section the fibromyoma is paler,harder and more fibrous than the uterine wall.vOn comparing an intramural tumor with the surrounding false capsule of uterine wall the difference is well marked.PathologyNackedeyeappearance12Nacked eye appearanceNackedeyeappearance13Smooth muscle tumors of the uterus are often multiple.Seen here are submucosal,intramural,and subserosal leiomyomata of the uterus.Smoothmuscletumorsoftheut14PathologyvMicroscopical structure.These growths are composed of unstriped muscle and fibrous tissuePathologyMicroscopicalstructu15Here is the microscopic appearance of a benign leiomyoma.Normal myometrium is at the left,and the neoplasm is well-differentiated so that the leiomyoma at the right hardly appears different.Bundles of smooth muscle are interlacing in the tumor mass.Hereisthemicroscopicappear16DegenerationvThese tumors grow slowly;in some cases there may be no evident change in size for many years.vIn a few cases growth is more rapid and secondary changes may also cause swelling of the tumor.DegenerationThesetumorsgrow17DegenerationvHyaline degeneration is the commonest change seen in fibromyomata.It is caused by a gradual inadequacy of the blood supply.vCystic degeneration is not uncommon,especially after the menopause,and is due to liquefaction of the areas of hyaline change.DegenerationHyalinedegenerati18DegenerationvRed degeneration.In this variety of degeneration the affected area is stained red and resembles raw meat.It is most freguently seen during the pregnancy and in postpartum.DegenerationReddegeneration.19Degeneration Malignant change vIn 0.1to 1%of cases,malignancy as leiomyosarcoma may develop.It is most likely to be seen in large tumors.vMalignancy is more typical in older patients,especially postmenopausal patients vPresention with rapidly enlarging uterine mass and postmenopausal bleeding.vMetastasis occurs rapidlly in these cases.DegenerationMalignantchang20This is a leiomyosarcoma protruding from myometrium into the endometrial cavity of this uterus that has been opened laterally so that the halves of the cervix appear at right and left.Fallopian tubes and ovaries project from top and bottom.The irregular nature of this mass suggests that is not just an ordinary leiomyoma.Thisisaleiomyosarcomaprotr21SymptomsvBleeding is the most common presenting symptom in uterine fibroids.vMenorrhagia is freguent reason for patients to seek advice.vThe periods increase in amount and duration.SymptomsBleedingisthemostc22SymptomsvBleeding vSubmucous fibromyomata menorrhagia is nearly always present,and quite small tumors can lead to severe anaemia.vIntramural tumors may increase the lossvSubserous growths do not affect the menstrual loss.SymptomsBleeding23SymptomsvBleeding vMechanisms for increased bleeding:vAlteration of normal myometrial contractile functionvInability of the overlying endometrium to respond to the normal E/P menstrual phases.vPressure necrosis of the overlying endometrial bed.SymptomsBleeding24SymptomsvAn abdominal tumour is sometimes the first thing that the patient notices.The tumor is not tender and rarely gives rise to pain.vDischarge is rarely a prominent symptom except during the extrusion of fibromyomatos polyp through the cervical canal.SymptomsAnabdominaltumouris25SymptomsvPain is not a common symptom.vwhen it occur it is generally an indication that there is associated vendometriosis vor pelvic inflammatory disease,vor some complication of the tumor such as red degeneration or torsion.SymptomsPainisnotacommons26SymptomsvPelvic pressure:pressure on the bladder leading to frequency and retention of urine.SymptomsPelvicpressure:press27Physical signsvThe physical signs vary with the size,position and number of the tumors.vA symmetrical enlargement of the uterus is found with a submucos growth.vMore often the enlargement is asymmetrical;it is often nodular on the surface because there are multiple tumor.vSubserous tumors with little myometrial covering often fell particularly hard.PhysicalsignsThephysicalsig28Physical signsvOn pelvic examination the cervix may be found to be pushed down or displaced to one side.If it is expanded by an intracervical tumor,or it may be dilated with the lower pole of a tumor left within it.PhysicalsignsOnpelvicexamin29DiagnosisvThe diagnosis of these tumors is usually made vby clinical examination,include abdominal and bimanual palpation,vor imaging studies.vIn addition,irregularities of the uterine cavity can be detected at the time of endometrial currettage.DiagnosisThediagnosisofthes30DiagnosisvPelvic ultrasound is the most commonly used for confirmation of uterine myomas.vDilation and curettage may provide relevant information,because larger tissue specimens,including small submucous myomas,may be obtained.DiagnosisPelvicultrasoundis31Pelvic ultrasoundPelvicultrasound32Pelvic ultrasoundPelvicultrasound33HysteroscopyvHysteroscopy may also be used to evaluate the enlarged uterus by directly visualizing the endometrial cavity.HysteroscopyHysteroscopymaya34Differential diagnosisvOther conditions which cause menorrhagiavDysfunctional uterine bleedingvCarcinoma of the uterusvEndometrial polyp of uterusvOther conditions which give rise to a swelling in the pelvisvAdenomyoma,ovarian tumors,inflammatory swelling in the pelvis,pregnancy DifferentialdiagnosisOtherco35This uterus has been opened anteriorly through cervix and into the endometrial cavity.High in the fundus and projecting into the endometrial cavity is a small endometrial polyp.Such benign polyps may cause uterine bleeding.Thisuterushasbeenopenedan36The thickened and spongy appearing myometrial wall of this sectioned uterus is typical of adenomyosis.There is also a small white leiomyoma at the lower left.Thethickenedandspongyappea37子宫平滑肌瘤课件38This adenocarcinoma of the endometrium is more obvious.Irregular masses of white tumor are seen over the surface of this uterus that has been opened anteriorly.The cervix is at the bottom of the picture.This enlarged uterus was no doubt palpable on physical examination.Thisadenocarcinomaoftheend39Abnormality of uterusAbnormalityofuterus40TreatmentvFollow up vhormonal treatment vfibroid embolisation vSurgical management 1.hysterectomy 2.myomectomyvmyolysisTreatmentFollowup41TreatmentvFollow up:the majority of patients with uterine myomas do not require surgical treatment.vSmall tumors and not causing symptomsvPatients in the late reproductive or perimenopausal years.vManagement:repeat pelvic exminations and assisted by serial pelvic ultrasound measurements vEvery 3-6 months.TreatmentFollowup:themajori42TreatmentvDrug therapy:bleeding is not heavy enough to cause anemia and small myoma.vMechanisms:vPharmacologic inhibition of estrogen secretionvAn attempt may be made to minimize uterine bleeding vThis treatment is commonly used for 3 to 6 months.TreatmentDrugtherapy:43TreatmentvDrugsvandrogen vGnRH-a supplementation.vGestrinonevMifepristonevChinese medicineTreatmentDrugs44TreatmentSurgical treatment is indicated in cases with:1.Heavy or prolonged bleeding2.Tumors of large size over 2.5 gestation months,even if these are not causing symptoms.3.Possible malignant change,such as a tumor which grows after the menopause.4.Pressure symptoms,pressure against bladder,bowel,and pelvic floor.5.Tumors which have undergone torsionTreatmentSurgicaltreatmentis45TreatmentvSurgical forms:vMyomectomy is occasionally warranted in younger patients whose fertility is compromised by the presence of myomas.vHysterectomy:although hysterectomy is commonly performed for uterine myomas,it should be considered as definitive treatment only in symptomatic women who have completed childbearing.TreatmentSurgicalforms:46子宫平滑肌瘤课件47子宫平滑肌瘤课件48子宫平滑肌瘤课件49UterineFibroidEmbolization(UterineArteryEmbolization)UterineFibroidEmbolization50UterineFibroidEmbolization(UterineArteryEmbolization)UterineFibroidEmbolization51子宫平滑肌瘤课件52子宫平滑肌瘤课件53