1
BAB I PENDAHULUAN
Kanker endometrium merupakan salah satu kanker ginekologi dengan angka kejad kejadia ian n terti terting nggi gi,, teru terutam tamaa di nega negara ra-ne -nega gara ra maju maju.. Sela Selama ma tahu tahun n 2005 2005,, diperkirakan di Amerika terdapat sekitar 40.880 kasus baru dengan sekitar 7.100 kematian terjadi karena kanker endometrium 1. Kanker endometrium paling sering terdiagnosis pada usia pasca menopause, dima dimana na 75% 75% kasu kasuss terja terjadi di pada pada wani wanita ta usia usia pasca pasca meno menopa paus usee2. Meskipu Meskipun n demiki demikian an sekitar sekitar 20% kasus kasus terdia terdiagno gnosis sis pada pada saat saat premen premenopa opause use3. Seca Secara ra epidem epidemiol iologi ogi terdapa terdapatt bebera beberapa pa faktor faktor risiko risiko yang yang berkai berkaitan tan dengan dengan kanker kanker endometrium endometrium yaitu hormon hormon replacement replacement theraphy theraphy,, terapi Tamoxifen , obesitas, wanita wanita pasca pasca menopa menopause use,, nullip nullipara ara atau atau dengan dengan parita paritass rendah rendah,, dan keadaa keadaan n anovulasi. Hal-hal tersebut berkaitan dengan keadaan upopposed estrogen yang meni mening ngka katk tkan an risik risiko o terjad terjadiny inyaa mem mempeng pengar aruh uhii
pema pemapa para ran n
kank kanker er endo endome metri trium um..
terh terhad adap ap
estr estrog ogen en
atau atau
Fakt Faktor or-f -fak akto torr meni mening ngka katk tkan an
yang yang kada kadar r
progesteron, seperti penggunaann kontrasepsi oral dan merokok, merupakan faktor yang bersifat protektif 3. Kanker endometrium stadium awal memiliki prognosis yang cukup baik. Kanker endometrium terdiagnosis saat masih terlokalisir memiliki survival memiliki survival rate 5 tahunnya mencapai 96%, dan menurun sampai ke 44% pada stadium lanjut 4. Dengan Dengan penget pengetahu ahuan an yang yang baik baik tentan tentang g perdar perdaraha ahan n pervag pervagina inam m pasca pasca menopause di dunia Barat, sebagian besar kasus ini, sekitar 77% terdiagnosis pada stadium dini4. Teknik skrining yang dapat digunakan adalah skrining non-invasif, seperti USG dan teknik invasif seperti pemeriksaan D&C dan biopsi endometrium yang ang
meru merupa paka kan n
tehn tehnik ik
yang ang
digu diguna naka kan n
untu untuk k
meng mengev eval alua uasi si
jari jaring ngan an
endome endometri trium um dan menjad menjadii bakuan bakuan dalam dalam menilai menilai status status endom endometri etrium. um. Biopsi Biopsi endometrium mempunyai sensitifitas yang baik dengan negatif palsu yang rendah dan sebagi sebagian an besar besar disebab disebabkan kan karena karena kesalah kesalahan an dalam dalam pengam pengambil bilan. an. Namun Namun demikian penentuan stadium karsinoma endometrium yang akurat adalah melalui prosedur pembedahan.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
2
BAB II TINJAUAN PUSTAKA
2.1 Endometr Endometrium ium
Korpus uteri dibagi atas tiga bagian yaitu endometrium, myometrium, dan perimetrium. Perimetrium ke arah lateral melanjut sebagai ligamentum, ke anterior melanjut ke vesica urinaria, dan ke posterior melanjut ke rectum. Endometrium merupakan bagian dari korpus uteri yang membatasi cavum uteri dengan myometrium. Endometrium ini mempunyai tiga fungsi penting, yaitu sebagai: •
Tempat nidasi
•
Tempat terjadinya proses haid
•
Petunjuk gangguan fungsional dari steroid seks.
Pada Pada usia usia repr reprod oduk uksi si dan dan dalam dalam kead keadaan aan tida tidak k hami hamil, l, endo endome metri trium um mengalami berbagai perubahan siklik yang berkaitan dengan aktivitas ovarium. Endometrium terdiri dari dua lapisan , yaitu lapisan basal dan lapisan fungsional. Di bawa bawah h peng pengaru aruh h horm hormon on estro estroge gen n dan dan prog progest ester eron on,, endo endome metri trium um akan akan dimatangkan dan kemudian akan terlepas secara teratur setiap bulannya sebagai menstruasi. Perubahan kandungan salah satu hormon tersebut di dalam darah akan memberi memberikan kan peruba perubahan han pada pada endom endometri etrium. um. Dikata Dikatakan kan endom endometri etrium um sangat sangat sensitif terhadap perubahan kadar estrogen ataupun progesteron. Hal ini yang menyebabkan endometrium dapat digunakan untuk menilai kualitas kandungan kadar kedua hormon tersebut, secara tidak langsung. Penilaian kadar estrogen dan atau progesteron dilakukan dengan memeriksa struktur histologik endometrium. Penilaian tersebut dilakukan pada kasus-kasus infer inferti till dalam dalam upay upayaa mene menemu muka kan n salah salah satu satu peny penyeb ebab ab kema kemand ndul ulan an.. Untu Untuk k penilaiannya maka kerokan endometrium dilakukan beberapa jam sebelum menstru menstruasi. asi. Di sampin samping g menetap menetapkan kan waktu waktu tersebu tersebutt cukup cukup sulit sulit serta serta untuk untuk ghinda ghindari ri keroka keroka
pad
telu
telah telah nidasi, nidasi, mak
keroka keroka
dilaku dilakukan kan
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
3
lengkap, sesuai dengan hari ke-14 setelah ovulasi. Perlu diingat bahwa patokan siklus menstruasi adalah 28 hari. Apabila struktur histologik endometrium tidak sesuai dengan yang diharapkan, misalnya menunjukkan fase sekresi pertengahan, maka dikatakan bahwa penderita penderita mempuny mempunyai ai kadar progesteron progesteron yang kurang. Makin Makin jauh jauh kenya kenyataan taan gambar gambaran an histol histologi ogikny knyaa diband dibanding ingkan kan gambara gambaran n yang yang diharapkan, maka makin sulit kemungkinan hamilnya. Secara umum struktur histologik endometrium dibagi atas fase proliferatif (permulaan, pertengahan, dan akhir), ovulasi yang kemudian langsung masuk ke fase sekresi sekresi (permu (permulaan laan,, perten pertengah gahan, an, dan akhir), akhir), dan diakhi diakhiri ri dengan dengan fase menstruasi. menstruasi. Jarak waktu yang dipakai sebagai pegangan pegangan untuk penilaian ini ialah 28 hari antara dua menstruasi. Begitu pelepasan endometrium berhenti pada akhir menstruasi dan sebelum proliferasi terjadi maka terjadi proses regenerasi. Penilaian fase endometrium didasarkan atas beberapa kriteria, yaitu: 1.
Bany Banyak akny nyaa mito mitosis sis sel sel epit epitel el kel kelen enjar jar;;
2.
Banya Banyakny knyaa susun susunan an semu semu berlap berlapis is sel sel epite epitell kelen kelenjar; jar;
3.
Banya Banyakny knyaa vaku vakuoli olisasi sasi basalis basalis epitel epitel kelenj kelenjar; ar;
4.
Bany Banyak akny nyaa sekr sekres esii kel kelen enja jar; r;
5.
Kesem Kesemba baba ban n stro stroma ma endo endome metri trium um;;
6.
Terjad Terjadiny inyaa reaksi reaksi pseudo pseudo atau atau pre-de pre-desid sidua ua stroma stroma endo endomet metriu rium; m;
7.
Banya Banyakny knyaa mito mitosis sis sel stroma stroma endom endometri etrium; um; dan
8.
Banya Banyak k sebuk sebukan an lekosi lekositt dalam dalam stroma stroma endome endometriu trium. m.
Perubahan-p Perubahan-perubah erubahan an endometrium endometrium setiap kriteria kriteria tersebut, tersebut, berkaitan berkaitan dengan dengan fase-fase endometrium dapat dilihat pada grafik 3.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
4
Gambar 2.1 Struktur Lapisan Endometrium
2.1. 2.1.1 1
Fase Fase Haid Haid atau atau Desk Deskua uama masi si End Endom omet etri rium um
Pada Pada fase ini endome endometri trium um dilepa dilepaskan skan dari dari uterus uterus yang yang diserta disertaii dengan dengan perdarahan. Lapisan basalis tetap utuh. Fase ini berlangsung 3-4 hari.
2.1.2 2.1.2
Fase Pascahaid Pascahaid atau atau Fase Fase Regenera Regenerasi si Endometr Endometrium ium
Pada fase ini endometrium yang terlepas tadi berangsur-angsur sembuh dan dilapisi kempali oleh selaput lendir yang baru. Fase ini telah dimulai sejak fase haid dan berlangsung sekitar 4 hari.
2.1.3
Fase Proliferatif atau Fase Antarhaid
Fase ini dimulai dari hari ke-5 hingga hari ke-14 siklus haid. Dalam fase ini endometrium tumbuh menjadi setebal kurang lebih 3,5 mm. Pada fase yang awal
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
5
yang padat. Pengaruh estrogen mulai tampak pada fase pertengahan (sampai hari ke-10). Endometrium tampak menebal karena stroma yang edema. Kelenjar mulai tumb tumbuh uh berk berkel elok ok-ke -kelo lok, k, bere berepi pitel tel torak torak selap selapis is deng dengan an bagi bagian an yang yang mulai mulai berlapis. Pada fase akhir proliferatif stroma mulai berkurang edemanya, sedang kelenjar terus tumbuh, sehingga bentuknya lebih berkelok-kelok. Karena tebal endometrium endometrium terbatas dan kelenjar kelenjar tumbuh tumbuh terus, maka sel epitel menjadi seperti bertumpuk-tumpuk di mana setiap sel masih melekat pada membran basal ( pseudostratified pseudostratified ). ).
2.1.4
Fase Sekresi atau Fase Prahaid
Adanya ovulasi baru bisa dilihat pada endometrium setelah 36 jam dari saat ovulasi terjadi, kira-kira hari kedua setelah ovulasi. Terlihat vakuolisasi basalis pada epitel kelenjar. kelenj ar. Di samping s amping itu bentuk kelenjar lebih berkelok-kelok. Mitosis mulai bisa ditemukan pada beberapa sel. Pada hari kelima setelah ovulasi, inti sel epitel kelenjar akan turun, sampai ke bagian bawah sel. Pada waktu ini sekresi dimulai, sehingga lumen menjadi membesar. Pada Pada fase fase perte perteng ngah ahan an,, stro stroma ma mula mulaii edem edemaa lagi lagi,, menc mencap apai ai kond kondisi isi maksimum pada hari kedelapan. Sehari kemudian arteriol menjadi lebih nyata. Dari fase proliferatif sampai sekresi akhir, pembuluh darah tumbuh menjadi 3 kali besarnya dan 5 kali panjangnya. Dengan lebih nyatanya arteriol, maka sel stroma disekeliling disekelilingnya nya berubah menjadi lebih besar. Pada hari kesepuluh sel tersebut tersebut menjadi menjadi sel pseudo pseudodesi desidua dua,, di antaran antaranya ya mulai mulai terliha terlihatt sebuka sebukan n sel radang radang.. Pseudo Pseudodes desidu iduaa bertam bertambah bah banyak banyak ditemu ditemukan kan pada pada hari hari beriku berikutny tnya. a. Sedang Sedang kelenjar mulai kolaps. Kondisi ini berlanjut sampai menstruasi terjadi pada hari ke-14 setelah menstruasi3. Stru Strukt ktur ur histo histolo logi gik k fase-f fase-fase ase di atas atas kada kadang ng-k -kad adan ang g tida tidak k selur seluruh uhny nyaa ditemukan dalam seluruh endometrium. Pada keadaan ini maka penentuan hari dari fase endometrium diambil berdasarkan struktur kelenjar yang paling lanjut atau matang.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
6
tersebut sering tidak jelas sebabnya. Untuk menegakkan diagnosis, klinikus perlu melakukan kerokan endometrium yang kemudian penentuan diagnosis dilakukan secara pemeriksaan histopatologik histopatologik.. Dengan materi kerokan kerokan yang cukup, maka diag diagno nosis sis
perd perdara araha han n
dapa dapatt
dite ditega gakk kkan an..
Untu Untuk k
meng mengev eval alua uasi si
peru peruba baha han n
endome endometri trium um perlu perlu dilaku dilakukan kan keroka kerokan. n. Berbag Berbagai ai penye penyebab bab perdar perdaraha ahan n dapat dapat dikelompokkan menjadi 3 kelompok, yaitu perdarahan karena penyakit sistemik, kelain kelainan an fungsi fungsiona onal, l, kelain kelainan an lokal. lokal. Dua kelain kelainan an terakh terakhir, ir, biasan biasanya ya dapat dapat dite ditega gakk kkan an
diag diagno nosi sisn sny ya
deng dengan an
peme pemeri riks ksaa aan n
hist histop opat atol olog ogik ik
kero keroka kan n
endometrium. Kelainan fungsional yang berkaitan dengan perubahan hormonal, banyak ditemukan. Kelaina Kelainan n fungsi fungsiona onall misaln misalnya: ya: disfun disfungsi gsi ovariu ovarium, m, tumor tumor ovariu ovarium m yang yang memproduksi hormon, dan pemberian hormon dari luar (pil KB). Kelainan lokal misalny misalnyaa pada pada endom endometri etrium: um: radang radang,, abortu abortus, s, polip, polip, tumor, tumor, dan benda benda dalam dalam cavum uteri (IUD). Pada miometrium: myoma, radang, dan adenomiosis 4.
2.2 2.2
Neop Neopla lasm sma a Endo Endome metr triu ium m
2.2.1
Neoplasma Ji Jinak
Neoplasma
jinak endometrium yang sering
ditemukan ialah
polip
endometrium. Sedangkan yang berasal dari pembuluh darahnya jarang ditemukan. Bent Bentuk uk poli polip p send sendir irii dapa dapatt pula pula dite ditemu muka kan n pada pada hyperplasia hyperplasia glandularis glandularis endometrii ataupun adenocarsinoma endometrium. Keluhan Keluhan biasany biasanyaa adalah adalah perdar perdaraha ahan n melalu melaluii vagina vagina,, sehing sehingga ga kadang kadang-kadang klinikus mendiagnosis sebagai perdarahan disfungsi. Tumor dapat tunggal atau multiple bertonjol-tonjol mengisi cavum uteri. Lokasi biasanya dekat fundus dan kornu uterus 2,3.
Mikroskopik
Memberi Memberi gambaran gambaran sebagai sebagai pertumbuhan pertumbuhan polipoid polipoid mukosa mukosa endometrium endometrium dengan dengan stroma stroma oedema oedema pembul pembuluh uh darah darah bertam bertambah bah dan meleba melebar. r. Kelenj Kelenjar ar
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
7
Hiperplasia endometrium endometrium
Tanpa atipia – 1% menjadi Ca, 80% regresi spontan
Dengan atipia
Simpleks – 8% menjadi Ca
Kompleks – 29% menjadi Ca
Ca in situ – “borderline – “borderline diagnosis”, diagnosis”, kontroversial
Saran: histerektomi Pemberian progestin: 50-94% relaps
2.2.2
Neoplasma Ga Ganas
Tumor ganas endometrium, pada dekade terakhir ini menunjukkan kenaikan insid insiden ensin siny ya, terut terutam amaa di nega negara ra-ne -nega gara ra yang tela telah h menca mencapa paii kema kemaju juan an.. Peningkatan program penanggulangan kanker serviks uteri (misalnya program pap smear), smear), disertai disertai makin makin tingginya tingginya umur harapan harapan hidup, hidup, maka kanker serviks akan mengurang mengurang jumlahnya jumlahnya dan kanker kanker endometrium endometrium akan naik. Perbandingan Perbandingan age standardized cancer incidence rate (kanker serviks uteri dibanding endometrium) iala ialah h 8,2: 8,2:1. 1. Umur Umur yang yang ditem ditemuk ukan an sebag sebagia ian n besar besar setel setelah ah umur umur 45 tahu tahun. n. Adenokarsinoma merupakan tumor ganas yang paling banyak ditemukan diantara berbagai jenis tumor ganas endometrium3.
2.3 2.3
Carc Carcin inom oma a Endo Endome metr triu ium m
Ditemukan paling banyak pada wanita berusia di atas 45 tahun. Keluhan
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
8
2.3.2
Definisi
Keg Keganas anasan an
selsel-se sell
epit epithe heli lial al
pada ada
korpu orpuss
uteri teri
(ter (teru utama tama
bagia agian n
endome endometri trium), um), satu di antara antara kanker kanker gineko ginekolog logii yang yang paling paling sering, sering, teruta terutama ma menyerang wanita pascamenopause; gejala yang sering terjadi adalah perdarahan per vaginam abnormal. Karsinoma ini terdiri dari berbagai tipe keganasan dari yang menginvasi lokal sampai yang bermetastasis 1.
2.3.3
Batasan
Tumor ganas primer dari lapisan endometrium.
2.3.4 2.3. 2.3.4. 4.1 1 •
Klasifikasi Klas Klasif ifik ikas asii Ber Berda dasa sark rkan an Mor Morfolo fologi gi
Endometrioid adenocarcinoma o
Usual type
o
Variant
Villoglandular or papillary
Secretory
With squamous differentiation5
•
Mucinous carcinoma
•
Papillary serous carcinoma
•
Clear cell carcinoma
•
Squamous carcinoma
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
9
carcinoma dan prognosisnya baik. Hal ini penting untuk membedakan mucinous carcinoma dari endometrium dengan endocervical adenocarcinoma6. Gambaran carcinoma endometrium primer terdiri dari jaringan endometrium normal, normal, adanya adanya foamy endometrial stromal cell , adanya metaplasia squamosa, atau atau adany adanyaa typica typicall endome endometri trioid oid carcino carcinoma ma area area. Hasil Hasil posit positif if pewa pewarn rnaa aan n perinuclear immunohistochemical dengan vimentin menandakan tumor berasal dari endometrium.
2.3.4.1.2
Papillary Se Serous Ca Carcinoma
Sekitar Sekitar 3%-4% carcinoma endometrium endometrium merupakan merupakan carcinoma carcinoma ovarium ovarium serosa dan carcinoma carcinoma tuba fallopii fallopii serosa. serosa. Kebanyakan tumor ini terdiri dari fibrovascular stalks lined yang tersusun dari sel atipikal tingkat tinggi dengan susunan susunan bertingkat. bertingkat. Psammoma bodies sering ditemukan. ditemukan. Uterine Uterine papillary papillary serous carcinoma car cinoma (UPSC) secara keseluruhan disadari sebagai high-grade lesion. lesion . Biasany Biasanyaa gambara gambaran n histol histolog ogikn iknya ya campur campuran, an, tetapi tetapi tumor tumor campur campur memilik memilikii tingkat agresivitas setara dengan carcinoma serosa murni6,7. Carcinoma serosa sering berhubungan dengan invasi lymph-vascular space dan invasi myometrium myometrium profunda. Bahkan saat tampak tumor pada endometrium endometrium atau polyp endometrium tanpa invasi myometrium atau invasi vaskular, tumor dapat dapat menjadi menjadi lebih lebih agresif agresif daripa daripada da endom endometri etrioid oid carcin carcinoma oma dan memilik memilikii kecend kecenderu erunga ngan n untuk untuk menye menyebar bar ke intraab intraabdom domina inal, l, seperti seperti pada pada carcino carcinoma ma ovariu ovarium. m. Pasien Pasien dengan dengan tumor tumor stadium stadium I, lebih lebih dari dari setenga setengahny hnyaa didapa didapatka tkan n terkena invasi myometrium profunda, tiga perempatnya menunjukkan manifestasi
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
10
bukti penyebaran, rekurensi terjadi pada lebih dari setengah penderita. Adanya metast metastasis asis ke nodus nodus limfati limfatikus kus,, hasil hasil positi positiff sitolog sitologii perito peritonea neal, l, dan tumor tumor intraperitoneal tidak berhubungan dengan peningkatan invasi myometrium 7.
2.3.4.1.3
Clear Cell Carcinoma
Jeni Jeniss clea clearr cell cell carc carcin inom omaa terh terhit itun ung g <5% <5% dari dari selu seluru ruh h carc carcin inom omaa endome endometri trium. um. Clear Clear cell cell carcino carcinoma ma biasany biasanyaa memilik memilikii gambar gambaran an histol histologi ogik k campuran, meliputi gambaran papiler, tubulokistik, glandular, dan tipe solid. Sel memiliki inti atipikal dan sitoplasma yang jernih atau eosinofilik. Clear cell carcinoma carcinoma terjadi pada wanita dengan usia lanjut dan merupakan merupakan jenis carcinoma endometrium yang sangat agresif; prognosisnya sama atau lebih buruk daripada papillary serous s erous carcinoma. Invasi myometrium dan LVSI penting sebagai indicator untuk menentukan prognosis 8.
2.3.4.1.4
Squamous Carcinoma
Squamo Squamous us carcin carcinoma oma pada pada endome endometri trium um jarang jarang terjadi terjadi.. Beberap Beberapaa tumor tumor merupakan tumor sejati, tetapi kebanyakan memiliki beberapa kelenjar. Squamous carcinoma sering disertai dengan cervical stenosis, inflamasi kronik, dan pyometra saat didiagnosis. Tumor ini memiliki diagnosis yang buruk dengan perkiraan 36% survival rate pada pasien dengan stadium I 9.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
11
2.3. 2.3.4. 4.2 2
Klas Klasif ifik ikas asii Berd Berdas asar arka kan n Stad Stadiu ium m Klin Klinik ik
Tabel 2.1 Stadium klinik karsinoma endometrium endometrium (FIGO 1971)7 Stadium Keterangan Stadium 0 Stadium I
Stadium II Stadium III Stadium IV
Karsinoma insitu Karsinoma terbatas pada korpus Stadium IA Panjang kavum uteri <8 cm Stadium IB Panjang kavum uteri > 8 cm Karsinoma mengenai korpus dan servik Karsinoma meluas keluar uterus tetapi belum keluar dari panggul kecil Karsinoma Karsinoma meluas meluas keluar keluar dari panggul panggul kecil atau sudah mengenai mukosa kandung kemih atau rektum Stad Stadium ium IVA IVA Proses Proses suda sudah h meng mengen enai ai mucosa rectum atau mucosa vesica urinaria Stadium IVB Proses sudah metastase jauh.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
12
Tabel 2.2 Stadium pembedahan karsinoma endometrium endometrium (FIGO 7 1988) Stadium Keterangan Stadium IA Stadium IB Stadium IC Stadium IIA Sadium IIB Stadium IIIA
Stadium IIIB Stadium IIIC Stadium IVA Stadium IVB G1
G2
G3
Tumor terbatas pada endometrium Invasi kurang dari ½ bagian miometrium Invasi lebih dari ½ bagian miometrium Tumor hanya menginvasi kelenjar endoserviks Tumor menginvasi stroma serviks Tumor menginvasi lapisan serosa dan atau ke adne adneks ksaa dan dan atau atau ditem ditemuk ukan anny nyaa sel sel gana ganass pada bilasan peritoneum Tumor menginvasi ke vagina Tumor bermetastasis pada ke k elenjar getah bening pelvik dan atau paraaorta Tumor menginvasi mukosa vesika urinaria dan atau rektum Tumor dengan metastasis jauh Gambaran pertumbuhan nonskuamosa atau nonmorular padat 5% atau kurang, diferensiasi baik Gambar Gambaran an pertum pertumbuh buhan an nonsku nonskuamo amosa sa atau atau nonm nonmor orul ular ar pada padatt 6%-50 6%-50%, %, dife difere rens nsias iasii sedang Gambar Gambaran an pertum pertumbuh buhan an nonsku nonskuamo amosa sa atau atau
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
13
U IC C T-1 T-2 T-3
Kriteria Karsinoma masih terbatas di korpus. Kars Karsin inom omaa tel telah ah melua eluass sam sampai di di ser servi vik ks, tapi tapi belum sampai keluar uterus. Kars Karsin inom omaa tel telah ah kelua eluarr dar darii ute uteru rus, s, term termas asu uk
FIGO I II III
penyebarannya ke vagina, namun namun masih tetap T-4
berada dalam panggul kecil. Kars Karsin inom omaa tel telah ah melib elibat atk kan mukos ukosaa rec rectu tum m ata atau u
IV
kandung kemih, dan atau telah meluas sampai di luar panggul kecil.
2.3.5
Insidensi
Umumnya Umumnya carcinoma carcinoma endometrium endometrium dijumpai dijumpai pada wanita yang berusia 5065 tahun dengan usia rata-rata 61 tahun. Kira-kira 5% dapat dijumpai pada usia sebelum 40 tahun dan sebesar 20-25% pada usia sebelum menopause. Di Amerika diperkiraka diperkirakan n 34.000 34.000 kasus baru dengan dengan angka angka kematian kematian sebesar 6000. Frekuensi adenocarcinoma corpus uteri lebih tinggi dari adenocarcinoma cervix uteri, tetapi lebih lebih kurang kurang dari dari epider epidermoi moid d carcino carcinoma ma cervix cervix uteri. uteri. Jika Jika carcin carcinoma oma cervix cervix
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
14
2-5% <40 tahun, pernah dilaporkan terjadi pada usia 20-30 tahun
75% kasus terbatas pd corpus uteri
Tabel 2.4 Insidensi Masing-masing Masing-masing Tipe Carcinoma Endometrium Tipe
Insidensi
(dari seluruh Ca endometrium, USA) Adenocarcinoma
(70-80%)
Adenocarcinoma
(5%)
w/ squamous differentiation Adenosquamous Ca
(10-20%)
Serous Ca
(50% dari yang relaps)
Clear Cell Ca
(usia + 67 tahun)
Miscellanous Subtypes
(9-10%)
(mucinous type, secretory type)
2.3.6
Penyebaran
Penyebaran Penyebaran adenokarsin adenokarsinoma oma endometrium endometrium biasanya lambat. lambat. Kecuali Kecuali pada
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
15
Penyebaran adenocarcinoma endometrium biasanya lambat terutama pada yang diferensiasi baik. Penyebarannya ke arah permukaan cavum uteri dan endo endoser servi viks ks.. Dari Dari cavu cavum m uter uterii menu menuju ju ke strom stromaa endo endome metri trium um ke myom myometr etriu ium m ke liga ligame mentu ntum m latu latum m dan dan orga organ n seki sekita tarny rnya. a. Jika Jika tela telah h menge engen nai
endo endose serv rvik iks, s,
peny enyebar ebaran an
sela selan njutn jutny ya
sepe sepert rtii
pada ada
adenocarcinoma cervix uteri. •
Melalui kelenjar limfe Penyebarannya melalui kelenjar limfe ovarium akan sampai ke kelenjar paraaorta dan melalui kelenjar limfe uterus akan menuju ke kelenjar iliaca inte intern rna, a, ekst ekstern erna, a, dan dan ilia iliaca ca comm commun unis is serta serta melal melalui ui kele kelenj njar ar limf limfee ligamentum rotundum akan sampai ke kelenjar limfe inguinal dan femoral.
•
Melalui aliran darah Biasany Biasanyaa proses proses penye penyebara baran n sangat sangat lambat lambat dan tempat tempat metast metastasen asenya ya adalah paru, hati, dan otak.
Daerah penyebaran: penyebaran:
Myometrium
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
16
berbenjol-benjol, dengan bagian nekrosis dan ulseratif. Cavum uteri terisi oleh oleh massa massa tumo tumor, r, sehin sehingg ggaa uteru uteruss memb membes esar, ar, tida tidak k simetr simetris is.. Pada Pada pertumbuhan lanjut, terjadi penembusan ke dalam miometrium sampai ke peritoneum dan akan memberikan tonjolan-tonjolan sampai di permukaan uterus4,5; b.
Polipoid/terbatas: tumor mengenai sebagian kecil dari endometrium dan terbatas, yang sering berbentuk polip. Tumor kadang-kadang sangat kecil tetapi tetapi sudah sudah diikut diikutii penemb penembusan usan ke dalam dalam miomet miometrium rium.. Karena Karena lokasi lokasi yang terbatas, maka pada waktu dilakukan kuretase, semua massa tumor terambil. terambil. Akibatny Akibatnyaa apabila apabila dilakukan dilakukan pemeriksaan pemeriksaan hasil histerektomi histerektomi,, maka tidak ditemukan lagi struktur tumor ganasnya. Dibanding dengan bentuk difus, maka jenis terbatas mempunyai prognosis yang yang lebih baik 6.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
17
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
18
o
Dediferensiasi
o
Hyperchromasi
o
Aktivitas mitosis
Pada adenokarsinoma berdiferensiasi baik, struktur kelenjar terlihat masih dalam kondisi yang baik, berisi sedikit mucus. Sel epitel tersusun berlapis semu atau berlapis-lapis disertai pertumbuhan papiliferum ke dalam lumen kelenjar. Inti besar,
pleiomorfik,
dengan beberapa
nucleoli,
hiperkromatik, sitoplasma
berkurang. Pada beberapa tempat kelenjar tersusun sangat berdekatan tanpa stroma di antaranya, yang sering diikuti membran basalis yang tidak utuh lagi. Pada yang berdiferensiasi jelek, terlihat sel tumor bentuk bulat lonjong tersusun padat. Di beberapa tempat membentuk struktur kelenjar
imatur sebagai
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
19
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
20
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
21
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
22
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
23
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
24
2.3.9
Etiologi
Penyeba Penyebab b carcin carcinoma oma endome endometri trium um belum belum diketa diketahui hui secara secara pasti pasti namun namun umumn umumnya ya disebab disebabkan kan oleh oleh perang perangsang sangan an estrog estrogen en pada pada endome endometri trium um tanpa tanpa halangan periodik dari progesteron.
Hiperestrogenisme: DM, HT, SOPK, obesitas, estrogen eksogen
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
25
endome endometri trium um berlan berlanjut jut oleh oleh estroge estrogen. n. Nullip Nulliparit aritas as merupa merupakan kan faktor faktor risiko risiko carcinoma endometrium. Tamoxifen adalah antiestrogen sintetik (estrogen antagonis) yang digunakan pada terapi carcinoma mammae. Di samping itu, tamoxifen juga memiliki efek estroge estrogenik nik (agoni (agonis) s) pada pada endom endometri etrium um dan mening meningkatk katkan an risiko risiko carcino carcinoma ma
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
26
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
27
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
28
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
29
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
30
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
31
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world's largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.