子宮內膜癌診治關注幾個問題-婦產科課件

1、王建六北京大學人民醫(yī)院婦產科子宮內膜癌診治關注幾個問題OUTLINEFIGO 2009新分期的臨床意義子宮切除范圍淋巴結切除指征子宮內膜癌09分期修訂（1）如何判斷侵肌深度？TVS：準確率84.6%，淺肌層為82.4% 深肌層為77.9%，無侵肌100%MRI:90%術者肉眼剖視準確性89.7%病理醫(yī)生肉眼觀察 86.2%冰凍切片 91.4% 建議TVS+MRI，注重術中剖視子宮內膜癌09分期修訂（2）累及宮頸內膜腺體的預后和期無差異如何判定宮頸間質受侵？DC或HS宮頸管陰性宮頸上皮浸潤子宮切除術MRI TVS局限于頸管內膜侵犯宮頸間質廣泛子宮切除術宮頸間質浸潤子宮內膜癌09分期修訂(3)09

2、分期刪去細胞學檢查結果 163 case 35 (21.5%) nodal metastases positive pelvic 26 (16.0%) aortic 24 (27.3%) Isolated aortic 17 (19.3%) The recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastasesall those who recurred died of disease within seven to 28 months. Eur J Gynaecol Oncol

3、. 2007;28(2):98-102Is aortic lymphadenectomy necessary?子宮內膜癌標準術式I期筋膜外子宮切除術？II期廣泛（改良的）子宮切除術？子宮內膜癌如何切除子宮？筋膜內子宮切除術全宮切除術筋膜外子宮切除術？ I期子宮內膜癌GOG2010:Women with endometrial cancers should undergo total abdominal hysterectomy and BSO), pelvic/paraaortic dissection婦科常見惡性腫瘤治療指南：筋膜外子宮切除術林巧稚婦科腫瘤學：全子宮切除術婦產科學第七版（林仲

4、秋）：筋膜外子宮切除術 筋膜外子宮切除術？ 標準全子宮切除術？ 仁者見仁，智者見智 下推膀胱至宮頸外口水平下較低水平 主韌帶：宮頸旁切除（貼而略離開） 宮骶韌帶：單獨處理 陰道切除1cm17廣泛子宮切除術必要性？改良廣泛（根治）子宮切除術縮小的廣泛子宮切除術？（II型子宮切除術）廣泛子宮切除術目的：切除宮旁可能的轉移文獻：樣本例數較多的回顧性研究Sartori E, et al. Int J Gynecol Cancer 2001;11(6):430437 203 cases：10-Y OS 74% (TAH) vs 94%(RH)Boente MP,et al. Gynecol Oncol

5、1993;51(3):316322. 202 cases：5-Y OS 77% (TAH) vs 86%(RH)Cornelison TL, Gynecol Oncol 1999;74(3):350355. 932 cases：5-Y OS 84% (TAH) vs 93%(RH) OP alone 5-Y OS 83% (TAH) vs 88%(RH) OP+RT THIS IS AN AREA OF CONTINUED DEBATE！ 21J Korean Med Sci 2010; 25: 552-6原因：Current pre-operative evaluation method i

6、s not sensitive enough to detect cervical invasionMedical statuscervical stromal invasion should be followed by adjuvant radiotherapy and thus, the prognosis would not be changed by performing a high morbidity producing surgery considering the low incidence of PMI原因：4.Metastasis characteristics: dif

7、ferent from cervical cancerPMI: low incidence 6%PMI(+): LN(+) 80%LN(+): PMI(+)45%Metastasis patterns: direct invasion of cancer cells to the parametrial connective tissues parametrial lymphvascular space invasion frequently seen in patients with deep myometrial involvement without cervical involveme

8、nt婦科常見腫瘤診治指南 中華醫(yī)學會婦科腫瘤分會 p49I期子宮內膜癌應行手術分期術式為筋膜外子宮切除術及雙附件切除術 盆腔及腹主動脈旁淋巴結切除和（或）取樣術腹主動脈旁淋巴結切除/取樣指征： 可疑淋巴結轉移 特殊組織類型 CA125顯著升高 宮頸受累 深肌層受累 低分化I期子宮內膜癌淋巴結切除必要性？全國高等院校教材 婦產科學 樂杰主編 林仲秋編寫 p275I期子宮內膜癌應行筋膜外子宮切除術及雙附件切除術 盆腔及腹主動脈旁淋巴結切除和（或）取樣術下列情況之一，應行盆腔及腹主動脈旁淋巴結切除和（或）取樣術可疑淋巴結增大 宮頸受累 CA125顯著升高特殊組織類型 低分化 深肌層受累 癌灶累及宮腔

9、面積超過50%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

10、 no 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.國外近2年的文獻報道Lancet. 2009 Jan 10;373(9658):125-36. E

11、pub 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, Rudd R, Badman P, Begum S, Chadwick N, Collins

12、 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 JR, Gornall R, Kerr-Wilson R, Swingler GR, Lav

13、ery 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, Murray P, Eddy J, Gornall R, Swingler GR, Finn

14、 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, Head AC, Lynch CB, Browning AJ, Cox C, Murphy

15、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, Paterson ME, Tidy J, Ind T, Lane J, Oates S, Red

16、ford 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 PA, Kerr-Wilson R, Chin K, Flynn P, Freites O

17、, 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, McConnell D. median follow-up of 37 months (IQR 24-58)

18、 191 women had died: 88/704 standard surgery group 103/704 lymphadenectomy group251Recurrent disease 107/704 standard surgery group 144/704 lymphadenectomy group)no evidence of benefit：OR or DFS for pelvic lymphadenectomy in early endometrial cancer.Pelvic lymphadenectomy cannot be recommended as ro

19、utine procedure for therapeutic purposes outside of clinical trials.早期：LND并未降低復發(fā) 改善生存1996年10月到2006年3月意大利多個中心的514例術前FIGO分期為期子宮內膜癌患者隨機分配接受盆腔淋巴結切除術（n=264）或者不進行此手術（n=250） 意大利研究生存上沒有差異 5年DFS 5年OS未接受淋巴結切除術 81.7% 90.0%接受淋巴結切除術 81% 85.9%復發(fā)時間和復發(fā)率相似 復發(fā)時間 復發(fā)率 （mth） （49mth）未進行淋巴結切除 13mth 33例（13.2%）淋巴結切除術者為 14mt

20、h 34例（12.9%）復發(fā)部位相似LND手術并發(fā)癥明顯增加在手術時間和住院時間上，兩組有顯著的統(tǒng)計學差異接受盆腔淋巴結切除術的患者有較高的早期和晚期術后并發(fā)癥率，兩組出現并發(fā)癥的患者分別為81例和34例。子宮內膜癌淋巴結切除利與弊爭論“由來已久”！I期患者真的可以不切除淋巴結嗎？Lesion sites and regionDepth of myometrial invasionCervical invasionExtrauterine invasion or not, single or multiple Pathological grade and classificationLymph

21、 vascular invasion(LVI)淋巴轉移相關因素有指征行腹膜后淋巴結切除術術前B超、MRI等估計深肌層受侵術前病理分級為G3術前臨床分期II期以上術中探查腹膜后淋巴結可疑轉移術中發(fā)現侵肌1/2術中發(fā)現宮腔50%以上有病灶累及子宮內膜漿乳癌、透明細胞癌等TodoY et al. Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet. 2010 Apr 3;375(9721):1165-72

22、Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. 一定要切除腹主動脈旁淋巴結嗎？ESMO2009Intermediate-risk group: aged 60 yrs deeply invasive G1 or G2 superficially invasive G3High-risk group: deeply invasiveG3 StageII LVSI+ Rare pathological types(UPSC CCC)內分泌治療必要性？內分泌治療主要為大劑量孕激素治療： 晚期、復發(fā)子宮內膜癌患者；要求保留生育