宫颈肿瘤治疗ppt课件

Cervical Tumor 宫颈肿瘤 Xin LU Obstetrics and Gynecology Hospital Fudan University Contents uuCIN CIN t t HPVHPV t t HistologyHistology t t PathologyPathology t t DiagnosisDiagnosis t t TreatmentTreatment uuCervical Cancer Cervical Cancer uuGeneral informationGeneral information uuPathologyPathology uuSpread pattern Spread pattern uuFIGO staging FIGO staging uuClinical signsClinical signs uuDiagnosis and Diagnosis and differential diagnosis differential diagnosis uuPrinciple for Principle for treatmenttreatment uuPreventionPrevention Key words n n Human Papillomavirus (Human Papillomavirus (HPV)HPV) n n Radical Hysterectomy (RHRadical Hysterectomy (RH) ) n n Radiotherapy (RT)Radiotherapy (RT) n n Chemotherapy (CT)Chemotherapy (CT) n n NNeoadjuvant chemotherapyeoadjuvant chemotherapy (NACT) (NACT) n n Concurrent chemo-radiotherapy Concurrent chemo-radiotherapy (CCCR) (CCCR) n n Radical TrachelectomyRadical Trachelectomy 人乳头瘤状病毒人乳头瘤状病毒 广泛全子宫切除术广泛全子宫切除术 放射治疗放射治疗 化学治疗化学治疗 新辅助化疗新辅助化疗 同步放化疗同步放化疗 宫颈根治术宫颈根治术 Female Reproductive Anatomy Transformation Zone Cervical Cancer 子宫颈癌 uuWorld report: World report: t t Account forAccount for 1/3 1/3 female malignancies female malignancies t t New cases: New cases: 529 800529 800 t t Death: Death: 275 100275 100 t85% developing country uuThe The 4th4th most common cause of death most common cause of death from malignancy in women.from malignancy in women. 流行病学 新发病例数 死亡病例数 Cervical cancer progression HPV infection HPV infection CINs CINs 10-15yrs10-15yrs Carcinoma in situ Carcinoma in situ Cervical cancer Cervical cancer Cervical tumorigenesis n n ProgressionProgression uuHost immunityHost immunity uuEnvironmental factorsEnvironmental factors uuGenetics: Genetics: t t oncogeneoncogene E6, E7 E6, E7 tumor tumor suppresorsuppresor gnengnen p53, p53, RbRb n n RegressionRegression High Risk Factors uuHR-HPVHR-HPV uuUse of oral contraceptivesUse of oral contraceptives uuSmoking Smoking uuMultiple sexual partnersMultiple sexual partners uuHistory of herpes infection History of herpes infection uuHistory of STDHistory of STD Human Papillomavirus , HPV 人乳头瘤状病毒 n1972： Harald zur Hausen n1995： High-risk HPV by International Agency for Research on Cancer，IARC n90% cervical cancer with HPV infection HPV High risk HPV（HR-HPV） oncogenic HPV HPV 16,18,31,33,35,39,45,51,52,56,58,59,68,73,82 HSIL, Cervical cancer nLow risk HPV（LR-HPV） nnon-carcinogenic HPV nHPV 6,11,42,43,44,54,61,70,72,81 nLSIL Precursors CIN: CIN: 宫颈上皮内瘤样病变宫颈上皮内瘤样病变 n n CIN ICIN I：mild dysplasiamild dysplasia，1/31/3 n n CIN IICIN II：moderate dysplasiamoderate dysplasia，1/3-2/3 1/3-2/3 n n CIN IIICIN III：severe dysplasia severe dysplasia n n CIS(carcinoma in situ) CIS(carcinoma in situ) 原位癌原位癌 CIN Histological Types Squamous carcinoma 80-85%Squamous carcinoma 80-85% Adenocaricinoma 15-20%Adenocaricinoma 15-20% Endometrial carcinomaEndometrial carcinoma Clear cell carcinomaClear cell carcinoma Adenosquamous 3-5%Adenosquamous 3-5% Undifferentiated carcinomaUndifferentiated carcinoma From From：20032003年年WHOWHO女性生殖器官肿瘤女性生殖器官肿瘤 Spread pattern n n Local tumor extension Local tumor extension uumost commonmost common n n Lymphatic Lymphatic uupelvic and pelvic and parapara- -aortic aortic n n HematogenousHematogenous disseminationdissemination uuuncommonuncommon FIGOFIGO stagestage Symptoms n n AsymptomaticAsymptomatic n n Abnormal pap smearAbnormal pap smear n n Watery, blood-tinged vaginal dischargeWatery, blood-tinged vaginal discharge n n Post-coital bleedingPost-coital bleeding n n Pelvic painPelvic pain Diagnosis uuHistoryHistory uuPhysical examinationPhysical examination uuCytology (pap smear, TCT, HPV)Cytology (pap smear, TCT, HPV) uuBiopsy (Biopsy (colposcopycolposcopy) ) uuConizationConization uuImagingImaging Platform of diagnosis for cervical diseases vvPap smear TBS classificationPap smear TBS classification vvTCTTCT vvHPVHPV vvColposcopy-biopsyColposcopy-biopsy vvLEEPLEEP Colposcopy 阴道镜 Conization 宫颈锥切 Differential Diagnosis uuCervicitisCervicitis uuCervical polypsCervical polyps uuBenign cervical Benign cervical tumor:myomatumor:myoma 宫颈糜烂分度 n n 轻轻 度度 n n 中中 度度 n n 重重 度度 宫颈糜烂分型 单纯型 颗粒型 乳突型 Cervical polyps 宫颈息肉 Principle for cervical cancer treatment n n Evidence based medicineEvidence based medicine uuFIGO FIGO ( ( International Federation of Gynecology and International Federation of Gynecology and Obstetrics) Obstetrics) uuNCCN NCCN ( (National Comprehensive Cancer Network)National Comprehensive Cancer Network) n n Individualized therapyIndividualized therapy； TREATMENT n n Precursor- Precursor- CINsCINs n n Micro-invasive cancerMicro-invasive cancer n n Invasive cancerInvasive cancer CINs n n CIN I: follow up 3CIN I: follow up 36months6months n n CIN II: CIN II: uulocal therapy local therapy uuconizationconization n n CIN III: CIN III: uuconization conization uuhysterectomyhysterectomy n n Stage Ia1: hysterectomyStage Ia1: hysterectomy n n Stage Ia2: modified hysterectomyStage Ia2: modified hysterectomy n n Stage Ia with positive margin (Ia Stage Ia with positive margin (Ia or CIS): radical hysterectomyor CIS): radical hysterectomy Micro-invasive cervical cancerMicro-invasive cervical cancer n n Surgical treatment Ib-IIaSurgical treatment Ib-IIa n n RadiotherapyRadiotherapy n n Chemotherapy Chemotherapy n n Combined therapyCombined therapy Treatment for invasive Treatment for invasive cervical cancercervical cancer Cervical cacner（b-a) RH+PLND+/- PAD 1. 1. 标准的手术方式：广泛全子宫切除标准的手术方式：广泛全子宫切除+ +盆腔淋巴清扫术盆腔淋巴清扫术; ; 2.2.盆腔淋巴结清扫术盆腔淋巴结清扫术 腹股沟深淋巴结腹股沟深淋巴结 髂淋巴结髂淋巴结 闭孔淋巴结闭孔淋巴结 3.3.腹主动脉旁淋巴结取样的指征：腹主动脉旁淋巴结取样的指征： 可疑的腹主动脉旁及髂总淋巴结可疑的腹主动脉旁及髂总淋巴结 大块附件病灶及增大的盆腔淋巴结大块附件病灶及增大的盆腔淋巴结 浸润肌层全层的低分化肿瘤浸润肌层全层的低分化肿瘤 Post-surgical treatment (high risk factors) poor differentiated poor differentiated deep myometrial invasiondeep myometrial invasion LVSILVSI LN positiveLN positive positive marginpositive margin Advanced stage（b，) n n Radiotherapy (RT)Radiotherapy (RT) n n NACT + RadiotherapyNACT + Radiotherapy n n Concurrent chemo-radiotherapyConcurrent chemo-radiotherapy； n n Combined RT and CTCombined RT and CT Trachelectomy n n Fertility sparing Fertility sparing n n Ib 4cmIb 4cm n n Evaluation of infertility factorEvaluation of infertility factor n n Procedure of trach