宫颈癌标准治疗选择.ppt

9/29/2019,Dr.Xiaohua Wu,1,Standard Treatment Options for Cervical Cancer,FIGO: Staging classifications and clinical practice guidelines of Cervical cancer National Cancer Institute M.D. Anderson Cancer Center Practical Gynecologic Oncology 4th Edition,9/29/2019,Dr.Xiaohua Wu,2,Cancers of the Female Reproductive Tract: Worldwide Statistics1,Ferlay et al. GLOBOCAN 2000 IARC, WHO 2001 (www.dep.iarc.fr),9/29/2019,Dr.Xiaohua Wu,3,1974-2000上海市居民妇科肿瘤发病率 上海市肿瘤研究流行病研究室年报告,9/29/2019,Dr.Xiaohua Wu,4,9/29/2019,Dr.Xiaohua Wu,5,9/29/2019,Dr.Xiaohua Wu,6,Treatment Option Overview,Five randomized phase III trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy,1-6 while 1 trial examining this regimen demonstrated no benefit.7 The risk of death from cervical cancer was decreased by 30% to 50% by concurrent chemoradiation. Based on these results, strong consideration should be given to the incorporation of concurrent cisplatin- based chemotherapy with radiation therapy in women who require radiation therapy for treatment of cervical cancer.1-8,9/29/2019,Dr.Xiaohua Wu,7,Treatment Option Overview,Surgery and radiation therapy are equally effective for early-stage small-volume disease.9 Younger patients may benefit from surgery in regard to ovarian preservation and avoidance of vaginal atrophy and stenosis. Patterns of care studies clearly demonstrate the negative prognostic effect of increasing tumor volume. Therefore, treatment may vary within each stage as currently defined by FIGO, and will depend on tumor bulk and spread pattern.10,9/29/2019,Dr.Xiaohua Wu,8,Treatment Option Overview,Therapy of patients with cancer of the cervical stump is effective, yielding results comparable to those seen in patients with an intact uterus.11 During pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert colposcopy is recommended to exclude invasive cancer. Treatment of invasive cervical cancer during pregnancy depends on the stage of the cancer and gestational age at diagnosis.,9/29/2019,Dr.Xiaohua Wu,9,宫颈癌分期:临床诊断分期,有经验的医师、在麻醉下进行检查 后来的发现不能改变已经确定的期别 触诊、视诊、阴道镜、宫颈管诊刮术(ECC)、宫腔镜、膀胱镜、直肠镜、静脉尿路造影、以及骨骼和肺部x线检查 膀胱和直肠怀疑病灶须经活检并有组织学证实 淋巴管造影、动脉造影、静脉造影、剖腹探查术、超声探查、CT扫描和磁共振（MRI）等，故不能作为改变期别的根据 对扫描检查怀疑的淋巴结行细针穿刺，能帮助制定治疗计划,9/29/2019,Dr.Xiaohua Wu,10,宫颈癌分期:手术治疗后病理分期,手术-病理检查切除的标本结果，是最确切诊断肿瘤侵犯范围 这些结果不能改变临床分期，但可将这些结果记录在疾病的病理分期法则中，TNM分期正是符合情况 首次诊断时确定分期，而且不能更改，即使在复发时也是如此 只有在临床分期的准则严格执行时，才有可能比较各个临床单位和不同治疗方式的结果,9/29/2019,Dr.Xiaohua Wu,11,9/29/2019,Dr.Xiaohua Wu,12,临床分期检查方法,临床分期 非损伤性诊断检查 双足淋巴管X线照片（Bipedal lymphangiogram） 计算机断层X线扫描术（CT, Computed Tomography） 超声波扫描术（Ultrasonography） 磁共振成像（MRI, Magnetic Resonance Imaging） 正电子发射断层扫描（PET, Positron Emission Tomography） 细针吸取细胞学检查 手术分期： 治疗前，腹主动脉旁LN，延伸放射野? 剖腹探查术的方法 腹腔镜分期,9/29/2019,Dr.Xiaohua Wu,13,Surgical Staging,Pretreatment surgical staging is the most accurate method to determine extent of disease. Because there is little evidence to demonstrate overall improved survival with routine surgical staging, it usually should be performed only as part of a clinical trial. Pretreatment surgical staging in bulky, but locally curable, disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. If abnormal nodes are detected by CT scan or lymphangiography, fine needle aspiration should be negative before a surgical staging procedure is performed.,9/29/2019,Dr.Xiaohua Wu,14,腹主动脉旁淋巴结CT阴性患者中生存率曲线与PET扫描结果的关系 J Clin Oncol 2001;19: 37453749.),9/29/2019,Dr.Xiaohua Wu,15,IB期宫颈癌盆腔淋巴结转移率,9/29/2019,Dr.Xiaohua Wu,16,II 和 III期宫颈癌腹主动脉旁淋巴结转移率,9/29/2019,Dr.Xiaohua Wu,17,宫颈癌治疗：根据期别选择,0期 微小浸润癌 B1期和早A癌 B至A期宫颈癌,9/29/2019,Dr.Xiaohua Wu,18,Stage 0 Cervical Cancer,Standard treatment options: Methods to treat ectocervical lesions include: Loop electrosurgical excision procedure (LEEP).7,8 Laser therapy.9 Conization. Cryotherapy.10 When the endocervical canal is involved, laser or cold-knife conization may be used for selected patients to preserve the uterus and avoid radiation therapy and/or more extensive surgery. Total abdominal or vaginal hysterectomy is an accepted therapy for the postreproductive age group and is particularly indicated when the neoplastic process extends to the inner cone margin. For medically inoperable patients, a single intracavitary insertion with tandem and ovoids for 5,000 milligram hours (8,000 cGy vaginal surface dose) may be used.11,9/29/2019,Dr.Xiaohua Wu,19,对异常Pap 涂片或活检示微小浸润癌处理步骤,9/29/2019,Dr.Xiaohua Wu,20,Stage IA Cervical Cancer Equivalent treatment options:,Intracavitary radiation alone: If the depth of invasion is less than 3 millimeters and no capillary lymphatic space invasion is noted, the frequency of lymph node involvement is sufficiently low that external beam radiation is not required. One or 2 insertions with tandem and ovoids for 6,500 to 8,000 milligram hours (10,000-12,500 cGy vaginal surface dose) are recommended.4 Radiation should be reserved for women who are not surgical candidates.,9/29/2019,Dr.Xiaohua Wu,21,IB 和早 IIA期宫颈癌的治疗步骤,9/29/2019,Dr.Xiaohua Wu,22,Stage IIB Cervical Cancer Stage III Cervical Cancer Stage IVA Cervical Cancer,Radiation therapy plus chemotherapy: Intracavitary radiation and external-beam pelvic irradiation combined with cisplatin or cisplatin/fluorouracil.7-12,9/29/2019,Dr.Xiaohua Wu,23,晚期宫颈癌的诊治步骤,9/29/2019,Dr.Xiaohua Wu,24,Recurrent Cervical Cancer,Standard treatment options: For recurrence in the pelvis following radical surgery, radiation in combination with chemotherapy (fluorouracil with or without mitomycin) may cure 40% to 50% of patients.3 Chemotherapy can be used for palliation. Tested drugs include: Cisplatin (15%-25% response rate).4 Ifosfamide (15%-30% respo