子宮內(nèi)膜癌治療相問題-婦產(chǎn)科課件

1、子宮內(nèi)膜癌治療相關(guān)問題n子宮內(nèi)膜癌新分期n子宮內(nèi)膜癌淋巴結(jié)切除必要性n子宮內(nèi)膜癌子宮切除的范圍 IA腫瘤局限于子宮內(nèi)膜 IB腫瘤浸潤(rùn)深度1/2肌層0909分期把累及宮頸內(nèi)膜腺體歸入分期把累及宮頸內(nèi)膜腺體歸入期期 n腹水或腹腔沖洗液細(xì)胞學(xué)陽性88分期為A期n多項(xiàng)大樣本病例對(duì)照研究結(jié)果，腹水細(xì)胞學(xué)陽性和腹腔或淋巴結(jié)的轉(zhuǎn)移不相關(guān)，不影響預(yù)后n沒有足夠的證據(jù)說明腹水細(xì)胞學(xué)陽性與復(fù)發(fā)風(fēng)險(xiǎn)和治療效果有何關(guān)系n針對(duì)腹水細(xì)胞學(xué)陽性的治療尚有爭(zhēng)議：不處理？化療？放療？激素治療？0909分期刪去細(xì)胞學(xué)檢查結(jié)果分期刪去細(xì)胞學(xué)檢查結(jié)果 婦科常見腫瘤診治指南 中華醫(yī)學(xué)會(huì)婦科腫瘤分會(huì) p49I期子宮內(nèi)膜癌應(yīng)行手術(shù)分期術(shù)式

2、為筋膜外子宮切除術(shù)及雙附件切除術(shù) 盆腔及腹主動(dòng)脈旁淋巴結(jié)切除和（或）取樣術(shù)術(shù)中如無明顯淋巴結(jié)腫大，應(yīng)系統(tǒng)切除淋巴結(jié)術(shù)中有可疑淋巴結(jié)腫大，取樣明確有無轉(zhuǎn)移即可腹主動(dòng)脈旁淋巴結(jié)切除/取樣指征： 可疑淋巴結(jié)轉(zhuǎn)移 特殊組織類型 CA125顯著升高 宮頸受累深肌層受累 低分化子宮內(nèi)膜癌淋巴結(jié)切除的必要性？全國高等院校教材 婦產(chǎn)科學(xué) 樂杰主編 林仲秋編寫 p275I期子宮內(nèi)膜癌應(yīng)行筋膜外子宮切除術(shù)及雙附件切除術(shù) 盆腔及腹主動(dòng)脈旁淋巴結(jié)切除和（或）取樣術(shù)下列情況之一，應(yīng)行盆腔及腹主動(dòng)脈旁淋巴結(jié)切除和（或）取樣術(shù)可疑淋巴結(jié)增大 宮頸受累 CA125顯著升高特殊組織類型 癌灶累及宮腔面積超過50% 低分化 深肌

3、層受累 Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007585.Lymphadenectomy for the management of endometrial cancer.May K, Bryant A, Dickinson HO, Kehoe S, Morrison J University of Oxford, Womens Centre No evidence that lymphadenectomy decreases the risk of death or disease recurrence compared with no

4、 lymphadenectomy in women with presumed stage I disease. The evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgically related systemic morbidity or lymphoedema/lymphocyst formation.J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16. Epub

5、 2008 Nov 25Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.Rome, Italy CONCLUSION: Although systematic pelvic lymphadenectomy statistically significantly improved surgical staging, it did not improve disease-free or overall su

6、rvival.Lancet. 2009 Jan 10;373(9658):125-36. Epub 2008 Dec 16.Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.Collaborators (180) Amos C, Blake P, Branson A, Buckley CH, Redman CW, Shepherd J, Dunn G, Heintz P, Yarnold J, Johnson P, Mason M,

7、Rudd R, Badman P, Begum S, Chadwick N, Collins S, Goodall K, Jenkins J, Law K, Mook P, Sandercock J, Goldstein C, Uscinska B, Cruickshank M, Parkin DE, Crawford RA, Latimer J, Michel M, Clarke J, Dobbs S, McClelland RJ, Price JH, Chan KK, Mann C, Rand R, Fish A, Lamb M, Goodfellow C, Tahir S, Smith

8、JR, Gornall R, Kerr-Wilson R, Swingler GR, Lavery BA, Chan KK, Kehoe S, Flavin A, Eddy J, Davies-Humphries J, Hocking M, Sant-Cassia LJ, Pearson S, Chapman RL, Hodgkins J, Scott I, Guthrie D, Persic M, Daniel FN, Yiannakis D, Alloub MI, Gilbert L, Heslip MR, Nordin A, Smart G, Cowie V, Katesmark M,

9、Murray P, Eddy J, Gornall R, Swingler GR, Finn CB, Moloney M, Farthing A, Hanoch J, Mason PW, McIndoe A, Soutter WP, Tebbutt H, Morgan JS, Vasey D, Cruickshank DJ, Nevin J, Kehoe S, McKenzie IZ, Gie C, Davies Q, Ireland D, Kirwan P, Davies Q, Lamb M, Kingston R, Kirwan J, Herod J, Fiander A, Lim K,

10、Head AC, Lynch CB, Browning AJ, Cox C, Murphy D, Duncan ID, Mckenzie C, Crocker S, Nieto J, Paterson ME, Tidy J, Duncan A, Chan S, Williamson KM, Weekes A, Adeyemi OA, Henry R, Laurence V, Dean S, Poole D, Lind MJ, Dealey R, Godfrey K, Hatem MM, Lopes A, Monaghan JM, Naik R, Evans J, Gillespie A, Pa

11、terson ME, Tidy J, Ind T, Lane J, Oates S, Redford D, Ford M, Fish A, Larsen-Disney P, Johnson N, Bolger A, Keating P, Martin-Hirsch P, Richardson L, Murdoch JB, Jeyarajah A, Lamb M, McWhinney N, Farthing A, Mason PW, Kitchener H, Beynon JL, Hogston P, Low EM, Woolas R, Anderson R, Murdoch JB, Niven

12、 PA, Kerr-Wilson R, Chin K, Flynn P, Freites O, Newman GH, McNally O, Cullimore J, Olaitan A, Mould T, Menon V, Redman CW, George M, Hatem MH, Evans A, Fiander A, Howells R, Lim K, Cawdell G, Warwick AP, Eustace D, Giles J, Leeson S, Nevin J, van Wijk AL, Karolewski K, Klimek M, Blecharz P, McConnel

13、l D. Hysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease and as a therapeutic procedure median follow-up of 37 months (IQR 24-58) 191 women h

14、ad died: 88/704 standard surgery group 103/704 lymphadenectomy group251Recurrent disease 107/704 standard surgery group 144/704 lymphadenectomy group) INTERPRETATIONno evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early endometrial cance

15、r.Pelvic lymphadenectomy cannot be recommended as routine procedure for therapeutic purposes outside of clinical trials.1.術(shù)前B超、MRI等估計(jì)深肌層受侵2.術(shù)前病理分級(jí)為G33.術(shù)前臨床分期II期以上4.術(shù)中探查腹膜后淋巴結(jié)可疑轉(zhuǎn)移5.術(shù)中發(fā)現(xiàn)侵肌1/26.術(shù)中發(fā)現(xiàn)宮腔50%以上有病灶累及7.子宮內(nèi)膜漿乳癌、透明細(xì)胞癌等一定要切除腹主動(dòng)脈旁淋巴結(jié)嗎？一定要切除腹主動(dòng)脈旁淋巴結(jié)嗎？nEur J Gynaecol Oncol. 2007;28(2):98-102.n Prin

16、ce of Wales Hospital, Shatin, Hong Kong nIs aortic lymphadenectomy necessary in the management of endometrial carcinoma?n75 (46.0%) pelvic lymphadenectomy alone n88 (54.0%) had both pelvic and aortic lymphadenectomyn35 (21.5%) nodal metastases npositive pelvic 26 (16.0%)npositive aortic 24 (27.3%) n

17、Isolated aortic metastases 17 cases (19.3%) n35 patients with nodal metastasesn recurrence developed in 15 (42.9%) nand all except one died within five to 50 monthsnThe recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastasesnall those who recurred died of disease wi

18、thin seven to 28 months. CONCLUSIONSnaortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metastatic risk. Todo Y et al.Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort ana

19、lysis. Lancet. 2010 Apr 3;375(9721):1165-72 n 671 patients with endometrial carcinomansystematic pelvic lymphadenectomy (n=325)npelvic and para-aortic lymphadenectomy (n=346) n INTERPRETATION: Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial c

20、arcinoma of intermediate or high risk of recurrence. 33I I期子宮內(nèi)膜癌期子宮內(nèi)膜癌子宮切除范圍：子宮切除范圍： 全子宮切除術(shù)？筋膜外子宮切除術(shù)？二者異同？全子宮切除術(shù)？筋膜外子宮切除術(shù)？二者異同？ 次廣泛子宮切除術(shù)？次廣泛子宮切除術(shù)？FIGO 2009 FIGO 2009 子宮內(nèi)膜癌分期改變子宮內(nèi)膜癌分期改變影響子宮內(nèi)膜癌子宮切除范圍的選擇嗎？影響子宮內(nèi)膜癌子宮切除范圍的選擇嗎？局限于子宮的內(nèi)膜癌手術(shù)選擇局限于子宮的內(nèi)膜癌手術(shù)選擇爭(zhēng)議：局限于子宮，宮頸累及？廣泛子宮切除術(shù)？爭(zhēng)議：局限于子宮，宮頸累及？廣泛子宮切除術(shù)？ 內(nèi)膜癌病變局限于子

21、宮內(nèi)膜癌病變局限于子宮-手術(shù)方式手術(shù)方式Disease limited to uterusMedically inoperable operableTumor directed RTTotal hysterectomy and bilateral salpingo-oophorectomyLympho nodes dissection pelvic+para aorticThe current NCCN Clinical Practice Guideline recommendspracticing radical hysterectomy only when cervical infiltr

22、ationis suspected on MRI or when confirmed by cervical biopsy.2009NCCNnFIGO: 筋膜外子宮切除術(shù)nGOG2010:Women with endometrial cancers should undergo total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO), pelvic/paraaortic dissectionn婦科常見惡性腫瘤治療指南：筋膜外子宮切除術(shù)n林巧稚婦科腫瘤學(xué)：全子宮切除術(shù)n中國婦產(chǎn)科學(xué)（曹澤毅主編）：筋膜外

23、子宮切除術(shù) I 期子宮內(nèi)膜癌期子宮內(nèi)膜癌-手術(shù)方式手術(shù)方式 I 期子宮內(nèi)膜癌-手術(shù)方式nGan To Kagaku Ryoho. 1995 Aug;22(9):1163-8. Total hysterectomy is done for cases of stage 0, modified radical hysterectomy for stage I, radical hysterectomy for stage II, and radical hysterectomy combined with resection of the metastatic lesions for stage

24、III and IV nZhonghua Fu Chan Ke Za Zhi. 2002 Feb;37(2):90-3. Surgical method is not the main factor influenced the survive of stage I endometrial carcinoma. 為什么不行廣泛或次廣泛子宮切除術(shù)為什么不行廣泛或次廣泛子宮切除術(shù) Mauro Signorelli, et al. Gynecologic Oncology 2009Modified Radical Hysterectomy Versus Extrafascial Hysterecto

25、my in the Treatment of Stage I Endometrial Cancer Recurrence Class I hysterectomy(n =263)Class II hysterectomy(n=257)NO recurrence231(87.8)228 (88.7)WIth recurrence32 (12.2)29 (11.3)DFS HR (95% CI) 87.7%(1.0 ref) 89.7%(0.91) (0.551.51) OS HR (95% CI)88.9% (1.0 ref) 92.2%(0.77) (0.441.33) 筋膜外子宮切除術(shù)筋膜外

26、子宮切除術(shù)n目的 to ensure that the cervix is entirely removedn適應(yīng)癥：子宮內(nèi)膜癌，早期宮頸癌n與全子宮切除術(shù)異同？n定義？n手術(shù)中要點(diǎn)？ 筋膜外子宮切除術(shù)筋膜外子宮切除術(shù)n方法：nThe position of the ureters is determined by palpation without freeing the ureters from their beds. nThe parametrium is transected medial to the ureter, but lateral to the cervix, keepin

27、g the paracervical ring intact. nThe uterosacral and vesicouterine ligaments are transected close to the uterus. nThere is no removal of paracolpos and a minimal part of vagina is resected at fornix level. 病變累及宮頸手術(shù)范圍的選擇 nII期子宮內(nèi)膜癌子宮切除范圍首選廣泛子宮切除術(shù)（IIIII型子宮根治術(shù)）n累及宮頸粘膜，現(xiàn)在歸為I期，子宮切除范圍？n累及粘膜和間質(zhì)如果應(yīng)該選擇不同的手術(shù)范圍，如何術(shù)前鑒別診斷之？n宮頸是否累及？是否間質(zhì)浸潤(rùn)？術(shù)前診斷困難40分期分期改變改變帶來帶來的新的新問題問題累及宮頸粘膜（I期）？nOLD：IC差于IIAnNEW：II差于所有I期nIIA期宮旁累及？ 宮頸癌早期手術(shù)范圍n如何識(shí)別粘膜累及還是間質(zhì)浸潤(rùn)FIGO1988FIGO 2009I期IAIBIC(56757)91%89%77% 90%78%IIIAIIIBIIICIIIC1IIIC259