10 Hyaline degeneration Cause: inadequacy of the blood supply Uniform, eosinophilic, ground-glass appearanceCystic degenration: secondly to hyaline degeneration
11 Red degeneration Frequent during pregnancy or puerperium A deep pink or red, softerThe ghosts of the musclecells and theirnuclear remain
12 Sarcomatous change 1.Margin not well defined, blurred, merging, irregular2. Loss of whorled pattern3. Yellow, tan, or gray color4. Heterogeneity5. Softer, less rubbery6. Absence of a bulgingsurface
13 Symptoms and physical signs 40~50% asymptomatic, discovered incidentally after routine examination
14 Menorrhagia Menostaxis Irregular mense Change of menseMenorrhagia Menostaxis Irregular menseIntramural myomaAnemiaShortness of breathPalpitationsWeaknessSubmucosal myoma
15 Pelvic mass and physical signs Depend on the size, location, numberand degeneration typeAsymmetric enlargement of uterusConsistencyFirm or rubberyHard or stony ( calcification)Soft ( cystic)
16 Pelvic mass and Physical signs A firm mass extruded from thecervical OS (submucosal)Distortion and elongation ofthe cervical canal (cervical )
17 Compressive symptoms Different location of the myoma Cervical or lower segmentCervical orbroad ligmentPosteriorUrethral obstructionUreteralobstructionRecto-sigmoidcompressionFrequency and retention of urineNephrohydrosisHydroureterConstipationDiscomfort
20 Pain Red degeneration Torsion of pendunculated myoma Extrusion of submucosal myoma from the cervix
21 Myoma and infertility infrequent primary cause of infertility 27% of women who received myomectomy had a history of infertilityUsually caused by submucosal and intramural myoma
22 Myoma and pregnancy Pregnancy loss , abortion Increased cesarean section ( Obstruction of labor)Question: Can myoma be removed during cesarean section?Postpartum hemorrhageRed degenerationGrowth of myomaMost patients have uncomplicated pregnancies and deliveries.
23 Diagnostic methods History Physical signs Ultrasound/ MRI 4. Cervical cytology5. Dilation &Curretage4,5 : To rule out cervical cancer and endometrial cancer23
31 principle Factors should be taken into consideration Age Desire of childbearingSymptomsLocation, size and numberMalignant change
32 observation Observation with close follow-up Indications: small and asymptomatic myoma especially for peri-menopausal women
33 Medications Indications: Size <= 2 months pregnant uterus Mild symptoms Peri-menopausal With contraindications for operation
34 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..
35 Indications of GnRH-aPreservation of fertility before attempting conceptionTreatment of anemia to allow recovery of Hb before surgery, minimizing the need for blood transfusionPreoperative treatment of large leiomyomas to make surgery more feasible.Treatment of women in menopausal period.
37 Surgery Indications: Menorrhagia with anemia, resistant to medication Markedly enlarged uterus with compression symptomsChronic pain, dyspareunia,Acute pain, as in torsion of a pedunculated myoma, or prolapsing submucosal fibroid4. Rapid enlargement of uterus-sarcomatous change?5. Infertility or spontaneous abortion with myoma as the only abnormal finding
39 MyomectomyIndications: young patients whodesire for childbearingRecurrence risk: as high as 50%,and up to 1/3 requiring repeatsurgery
40 HysterectomyIndications: no requirement of uterine preservationNote: : Cervical or endometrial cancer must be excluded before operation
41 Other treatments: Uterine artery embolization, UAE Endometrium ablation by hysteroscopy
42 Video 1: Laparoscopic myomectomy Advantages :Minimizes incision, quicker recoveryDisadvantages:Risks of convertion to a laparotomyImmature suture technique: uterine rupture during pregnancyVideo 2: Laparoscopic hysterectomy
44 General informationRare tumors of mesodermal origin (myometrium, connective tissue, stroma of endometrium, or secondly to myoma)2~4% of uterine malignanciesPoor prognosis ( death occurring within 1 to 2 years after diagnosis, except ESS)
45 Three commonest types Leiomyosarcoma (~45%) Endometrial stromal sarcoma (ESS) Undifferentiated endometrial sarcoma (15~25%)Mixed epithelial and mesenchymal tumorsAdenosarcomaCarcinosarcoma , or malignant mesodermal mixed tumor, MMMT
46 leiomyosarcoma Age: 45-55 yr, Usually arise de novo from uterine smooth muscle, rarely arise in a preexisting myomaDiagnosis usually is not made before surgery. D&C are diagnostic only for ~10% of tumors that are submucous.Poor prognosis
48 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 treatmentBehaviour : indolent, late recurrence and metastasis may occur. 5-yr survival >80%
49 ESS, low grade Originated from endometrial stromal cells, similar to proliferative phaseESS with invasive border
50 Undifferentiated endometrial sarcoma ( UES) UES: behave aggressively, with 5-year survival < 40%UES with severe atypiaMitosis>10/10HPF
52 Carcinosarcoma Malignant mesodermal mixed tumor, MMMT Both epithelial and mesenchymal elements are malignantIn FIGO 2009, carcinosarcoma was regarded as type II endometrial carcinoma, because the prognosis is mainly determined by epithelial elements.
53 most patients being postmenopausal Enlarged or irregular uterus Tumor protrudes throughthe cervical OS like a polyp (50%)Behaviour: aggressiveRecurrence rate: 53%5 year survival 11~35%Carcinosarcoma
56 Diagnosis Symptoms ( Uterine bleeding ) and signs Ultrasound / MRI D & CPathological diagnosis
57 Staging New staging systems ( FIGO 2009) Three different staging systems for1. Leiomyosarcoma2. ESS and adenosarcoma3. Carcinosarcoma
58 Staging FIGO 2009 leiomyosarcoma I Tumor limited to uterusIA<5CMIB ≥ 5CMII Tumor grows outside of uterus but not outside the pelvisIIA tumor is growing into adnexaIIB tumor is growing to the tissue of pelvis other than adnexaIII tumor grows into tissue of abdomen ( not just intruding into abdomen)IIIA in one placeIIIB in 2 or more placesIIIC tumor has spread to pelvic/ para-aortic lymph nodesIV The tumorr has spread to the urinary bladder or the rectum, and/or to distant organs, such as the bones or lungIVA spread to bladder or the rectumIVB distant metastasis
59 Staging FIGO 2009 ESS and adenosarcoma I Tumor limited to uterusIA limited to endometriumIB <1/2 myometriumIC ≥ 1/2 myometriumII Tumor grows outside of uterus but not outside the pelvisIIA tumor is growing into adnexaIIB tumor is growing to the tissue of pelvis other than adnexaIII tumor grows into tissue of abdomen ( not just intruding into abdomen)IIIA in one placeIIIB in 2 or more placesIIIC tumor has spread to pelvic/ parpaotic lymphnodesIV The tumor has spread to the urinary bladder or the rectum, and/or to distant organs, such as the bones or lungIVA spread to bladder or the rectumIVB distant metastasis
60 Carcinosarcomathe same as FIGO Staging for endometrial cancer
61 Treatment1. Surgery: only treatment of proven curative value Stage I and II : hysterectomy + bilateral oorphorectomy Pelvic and or para-aortic lymphnectomy: ESS/UES and Carcinosarcoma: required Leiomyosarcoma: not certain
62 cytoreductive surgery for advanced stage ( III or IV) patients 2. Adjunvant therapy: Chemotherapy +/- radiotherapyRadiotherapy improves tumor control in the pelvis without influencing final outcomechemotherapy : response rate (~20%)Drugs: doxorubicin, cisplatin,ifosfamide, palitaxel
63 3. Hormone therapy ( only used in ESS, low grade) progesterone, letrozol GnRH antagonist
64 Prognosis Generally poor, 5-year survival 20%~30% Stage is the most important prognostic factor. Cell type, grade, metastasis, and treatmentIf the leiomyosarcoma arises in a benign myoma, the prognosis is improvedESS: 5-yr survival >80%.
65 Case discussionHistory : A 33 year old woman complains heavy bleeding during period for 1 year. The duration of bleeding usually lasts 9 days. Sometimes she has blotting.Physical examination : shows pale and short of breath. Pelvic examination revealed enlarged uterus with a size of two-month pregnancy.
66 Case discussionUltrasound: A 65/55/50 mm low-echoes mass with clear margin in myometrium was seen by ultrasound.In addition, a 23/20/19mm low echoes mass protrudes from uterus cavity.Lab test: Hb: 80g/L.
67 Questions What ‘s the diagnosis ? ( give the evidence) Which diseases should be excluded?What is the suitable treatment?Does this treatment affect fertility?
68 Take home message About the myoma The symptoms are related to the types of location and degenerations. Half of the patients are asymptomatic. The commonest symptom is change of mense.Ultrasound is the common and accurate diagnostic tool.
69 Take home message About the myoma No treatment is required for asymptomatic patients. Medications are suitable for peri-menopausal patients with mild symptoms.Surgery is the effective way to treat symptomatic patients or suspicious for sarcomatous change.
70 Take home message About the sarcoma Rare tumors with poor prognosis The commonest symptom is irregular vaginal bleeding with pain. Diagnosis is by pathology results.Surgical treatment is the main option. Adjunvant therapy depends on stage and type.