子宫内膜癌治疗相关问题妇产科课件

子宫内膜癌治疗相关问题 北京大学人民医院妇产科 王建六 n子宫内膜癌新分期 n子宫内膜癌淋巴结切除必要性 n子宫内膜癌子宫切除的范围 子宫内膜癌子宫内膜癌0909分期修订分期修订1 1 I I 肿瘤局限于子宫体肿瘤局限于子宫体 IA肿瘤局限于子宫内膜 IB肿瘤浸润深度1/21/2肌层肌层 肿瘤局限于子宫体肿瘤局限于子宫体 a a 肿瘤浸润深度肿瘤浸润深度 2cm 15% 2cm 15% entire uterine cavity 35% entire uterine cavity 35% n n 5-y survival: 5-y survival: 2cm - 98% 2cm - 98% 2cm - 84% 2cm - 84% entire uterine cavity - 64% entire uterine cavity - 64% 建议有指征的行腹膜后淋巴结切除术建议有指征的行腹膜后淋巴结切除术 腹膜后淋巴结切除指征腹膜后淋巴结切除指征 1.术前B超、MRI等估计深肌层受侵 2.术前病理分级为G3 3.术前临床分期II期以上 4.术中探查腹膜后淋巴结可疑转移 5.术中发现侵肌1/2 6.术中发现宫腔50%以上有病灶累及 7.子宫内膜浆乳癌、透明细胞癌等 一定要切除腹主动脉旁淋巴结吗？ nEur J Gynaecol Oncol. 2007;28(2):98-102. n Prince 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 lymphadenectomy n35 (21.5%) nodal metastases npositive pelvic 26 (16.0%) npositive aortic 24 (27.3%) nIsolated aortic metastases 17 cases (19.3%) n35 patients with nodal metastases n recurrence developed in 15 (42.9%) nand all except one died within five to 50 months nThe recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases nall those who recurred died of disease within seven to 28 months. CONCLUSIONS naortic 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 analysis. Lancet. 2010 Apr 3;375(9721):1165-72 n 671 patients with endometrial carcinoma nsystematic 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 carcinoma of intermediate or high risk of recurrence. 期子宫内膜癌子宫切除范围期子宫内膜癌子宫切除范围 33 I期子宫内膜癌 子宫切除范围： 全子宫切除术？筋膜外子宫切除术？二者异同？ 次广泛子宫切除术？ FIGO 2009 子宫内膜癌分期改变 影响子宫内膜癌子宫切除范围的选择吗？ 局限于子宫的内膜癌手术选择 争议：局限于子宫，宫颈累及？广泛子宫切除术？ 子宫切除范围值得探讨子宫切除范围值得探讨 内膜癌病变局限于子宫-手术方式 Disease limited to uterus Medically inoperable operable Tumor directed RT Total hysterectomy and bilateral salpingo- oophorectomy Lympho nodes dissection pelvic+para aortic The current NCCN Clinical Practice Guideline recommends practicing radical hysterectomy only when cervical infiltration is suspected on MRI or when confirmed by cervical biopsy. 2009NCCN nFIGO: 筋膜外子宫切除术 nGOG2010:Women with endometrial cancers should undergo total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO), pelvic/paraaortic dissection n妇科常见恶性肿瘤治疗指南：筋膜外子宫切除术 n林巧稚妇科肿瘤学：全子宫切除术 n中国妇产科学（曹泽毅主编）：筋膜外子宫切除术 I 期子宫内膜癌-手术方式 I 期子宫内膜癌-手术方式 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 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. 为什么不行广泛或次广泛子宫切除术 Mauro Signorelli, et al. Gynecologic Oncology 2009 Modified Radical Hysterectomy Versus Extrafascial Hysterectomy 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) (0.55 1.51) OS HR (95% CI)88.9% (1.0 ref) 92.2%(0.77) (0.44 1.33) 筋膜外子宫切除术 n目的 to ensure that the cervix is entirely removed n适应症：子宫内 膜癌，早期宫颈 癌 n与全子宫切除术 异同？ n定义？ n手术中要点？ 筋膜外子宫切除术 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, keeping 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. 病变累及宫颈手术范围的选择 nII期子宫内膜癌子宫切除范围首选 广泛子宫切除术（IIIII型子宫根 治术） n累及宫颈粘膜，现在归为I期，子 宫切除范围？ n累及粘膜和间质如果应该选择不同 的手术范围，如何术前鉴别诊断之 ？ n宫颈是否累及？是否间质浸润？术 前诊断困难 40 分期 改变 带来 的新 问题 累及宫颈粘膜（I期）？ nOLD：IC差 于IIA nNEW：II差 于所有I期 nIIA期宫旁 累及？ 宫颈癌早期 手术范围 n如何识别粘 膜累及还是 间质浸润 FIGO1988FIGO 2009 I期 IA IB IC (56757) 91% 89% 77% 90% 78% IIIA IIIB IIIC IIIC1 IIIC2 59% 36% 54%(3120) 56% 36% - 57% 49% 累及宫颈粘膜（ 一期）？ 诊断和鉴别宫颈粘膜累及还是间质浸润 分段诊刮或宫腔镜检查 宫颈管阴性 宫颈上皮浸润 I 型子宫切除术 MR 局限于颈管内膜 侵犯宫颈间质 II或III型子宫切除术 宫颈间质浸润 宫颈累及时子宫切除范围选择 n n 指指 南：广泛子宫切除术南：广泛子宫切除术 n局限于子宫归为一类 nII期子宫内膜癌: 筋膜外或广泛子宫切除术 nKOREA， JAPAN： Choose the surgical extent of hysterectomy through their own disposition and do not strictly adhere the results of pre operative evaluation. nJAPANESE group more than 70% of institutes never perform RH without regarding the preoperative status of cervical involvement (Watanabe) nNORTH AMERICAN：20-30% center II期子宫内膜癌RH 手术的必要性 II期子宫内 膜癌手术方 式的选择 II期子宫内膜癌RH 手术的必要性 nDepth of myometrial invasion and pelvic or par