NCCN子宮內(nèi)膜癌療指南解讀

1、 *省腫瘤醫(yī)院2011.5.31概要l1.2009年子宮內(nèi)膜癌figo分期變更l2.2011年nccn指南解讀l 子宮內(nèi)膜樣腺癌的初始治療l 完備分期手術(shù)后的輔助治療l 不全手術(shù)分期后的處置懲罰l 復(fù)發(fā)的治療l 特殊類(lèi)型子宮內(nèi)膜癌的治療l 激素治療和化療23312312l正常子宮內(nèi)膜周期性再生、分化、剝脫，依賴女性激素作用。l無(wú)排卵、排卵不規(guī)則婦女因雌激素刺激，子宮內(nèi)膜持續(xù)增生this is the microscopic appearance of normal proliferative endometrium in the menstrual cycle. the proliferati

2、ve phase is the variable part of the cycle. in this phase, tubular glands with columnar cells and surrounding dense stroma are proliferating to build up the endometrium following shedding with previous menstruation.here is early secretory endometrium. the appearance with prominent subnuclear vacuole

3、s in cells forming the glands is consistent with post-ovulatory day 2. the histologic changes following ovulation are quite constant over the 14 days to menstruation and can be utilized to date the endometrium. 正常子宮內(nèi)膜正常子宮內(nèi)膜 增生期增生期 早期分泌期早期分泌期(proliferative endometrium) (early secretory endometrium)th

4、is is normal secretory phase endometrium. note the larger tortuous glands with secretions. the secretory phase follows a set 14 day course leading to either implantation of a fertilized ovum or menstruation.晚期分泌期（月經(jīng)前期）晚期分泌期（月經(jīng)前期）(secretory phase endometrium) this is endometrial cystic hyperplasia in

5、 which the amount of endometrium is abnormally increased and not cycling as it should. the glands are enlarged and irregular with columnar cells that have some atypia. simple endometrial hyperplasias can cause bleeding, but are not thought to be premalignant. however, adenomatous hyperplasia is prem

6、alignant.子宮內(nèi)膜非典型增生子宮內(nèi)膜非典型增生（40歲） 年代 例 癌變率 年限gusberg 1963 68 12 % 1.5-9chamlian 1970 97 14 % 1-14wentz 1974 22 81.8 % 2-8sheman 1978 91 57.1% 2-15蓋銘英 1981 41 9.7 % 3-15kurman 1985 48 23 % 1-11 l絕經(jīng)后5059歲婦女最多;l60%絕經(jīng)后, 30%絕經(jīng)前;l高發(fā)年齡58歲，中間年齡61歲;l40歲以下患者僅占2% 5%;l25歲以下患者極少 。 this adenocarcinoma of the endom

7、etrium is more obvious. irregular masses of white tumor are seen over the surface of this uterus that has been opened anteriorly. the cervix is at the bottom of the picture. this enlarged uterus was no doubt palpable on physical examination. such a neoplasm often present with abnormal bleeding.the e

8、ndometrial adenocarcinoma is present on the lumenal surface of this cross section of uterus. note that the neoplasm is superficially invasive. the cervix is at the right. 子宮內(nèi)膜癌子宮內(nèi)膜癌 iii 期期 侵肌全層、宮頸、附件侵肌全層、宮頸、附件 侵肌侵肌 this is endometrial adenocarcinoma which can be seen invading into the smooth muscle

9、bundles of the myometrial wall of the uterus. this neoplasm has a higher stage than a neoplasm that is just confined to the endometrium or is superficially invasive.子宮內(nèi)膜癌侵肌子宮內(nèi)膜癌侵肌the endometrial adenocarcinoma in the polyp at the left is moderately differentiated, as a glandular structure can still

10、be discerned. note the hyperchromatism and pleomorphism of the cells, compared to the underlying endometrium with cystic atrophy at the right. 子宮內(nèi)膜增生子宮內(nèi)膜增生子宮內(nèi)膜子宮內(nèi)膜 癌（息肉樣）癌（息肉樣） 子宮內(nèi)膜增生子宮內(nèi)膜增生 。 normal cavityhysteroscopypolyp 陰道流血、排液或?qū)m腔積膿、積液者陰道流血、排液或?qū)m腔積膿、積液者 婦科檢查婦科檢查 細(xì)胞學(xué)檢查細(xì)胞學(xué)檢查 腹部或陰道腹部或陰道b b超檢查超檢查 宮腔鏡檢

11、查宮腔鏡檢查 分段刮宮分段刮宮 病理組織學(xué)檢查確診病理組織學(xué)檢查確診 圖圖 子宮內(nèi)膜癌的診斷步驟子宮內(nèi)膜癌的診斷步驟 全子宮切除全子宮切除筋膜外子宮切除筋膜外子宮切除次廣泛子宮切除次廣泛子宮切除廣泛子宮切除廣泛子宮切除。組織學(xué)形態(tài)l常見(jiàn)的形態(tài)依次為乳頭狀、腺樣、實(shí)性、管狀l通常至少由上述兩種形態(tài)組成l可見(jiàn)嗜酸性細(xì)胞，“鞋釘”樣細(xì)胞l核多形性通常很明顯透明細(xì)胞癌、組織類(lèi)型、治療 臨床分期：l局部復(fù)發(fā)與分期無(wú)關(guān)。l遠(yuǎn)處復(fù)發(fā)則與淋巴結(jié)受累（iii期）密切相關(guān)。l有無(wú)淋巴血管浸潤(rùn)是唯一預(yù)測(cè)子宮內(nèi)膜癌復(fù)發(fā)的因素。 組織類(lèi)型：l局部復(fù)發(fā)以腺癌為多。l近年來(lái)未見(jiàn)組織類(lèi)型與復(fù)發(fā)關(guān)系研究的報(bào)道。 治療方式：l 術(shù)后放療可降低局部復(fù)發(fā)率，l 但增加遠(yuǎn)距離復(fù)發(fā)。l 其遠(yuǎn)距離復(fù)發(fā)率高的原因： 可能與接受放療患者的高危因素有關(guān)， 而與治療方式無(wú)關(guān)。l我院早期子宮內(nèi)膜癌中復(fù)發(fā)病例11/112例（9.82%）。l臨床分期：ib期2例，ic期7例，ii a期1例，iib期1例；l病理類(lèi)型：子宮內(nèi)膜腺癌9例，腺棘癌1例，漿液性乳頭狀腺癌1例；l組織分級(jí)： g1：4例 ， g2：5例， g3：2例；l肌層浸潤(rùn)：2例侵犯淺肌層，9例至少侵肌1/2。l首次治療：l復(fù)發(fā)組8例(72.73%)行分期手術(shù)，l3例未行淋巴結(jié)切除術(shù)或活檢術(shù)；l術(shù)后放療9例；l在發(fā)現(xiàn)復(fù)發(fā)前均未行術(shù)后輔助化療；l2例術(shù)后應(yīng)用