宫颈癌的诊断和治疗.ppt

CERVICALCANCER.,DiagnosisTreatment,CERVICALCANCER.,ThemostcommonmalignancyingynecologicaloncologyIncidence:7.8/100,000Mortality:2.7/100,000Diagnosis:biopsyMainmodalityoftreatment:surgeryandradiationGoaloftreatment:cure,exceptstage4b,SpecialCase,38yrs,G3/P1,nurseC/O:postcoitalbleedingfor2monthsMenstruationregularwith30dayscycleand5daysduration.Abnormaldischargewithbadsmell.LMP:12daysagoPapsmear:squamouscellcancerPV:Vulva:Normal,Vaginal:yellowishdischargewithbloodystained,Cervix:growthwithulcerationandcontactbleeding.Uterus:N/S,mobile.Parametrium:thickeningnottopelvicsidewallonbothside,CERVICALCANCER.,Howcanwemakeadiagnosis?Howcanweevaluatethepatient?Howcanwemanagethepatient?Howshouldweexplaintothepatient?Canwepreventcervicalcancer?,Howcanwemakeadiagnosis?,SYMPTOMSAbnormalvaginalbleedingpostcoitalbleeding*contactbleedingAbnormalvaginaldischargeAsymptomatic,justabnormalpapsmear,SYMPTOMS,Theclassicsymptomisintermittent,painlessmetrorragiaorspottingonlypostcoitallyorafterdouching.Probablythefirstsymptomofearlycancerofthecervixisathin,watery,blood-tingedvaginaldischargethatfrequentlygoesunrecognizedbythepatients.Asthemaligancyenlarges,thebleedingepisodesbecomeheavierandmorefrequent,andtheylastlonger.,SYMPTOMS,Latesymptomorindicatorsofmoreadvanceddiseaseincludethedevelopmentofpainreferredtotheflankorleg.Manypatientsc/odysuria,hematuriaorrectalbleedingorobstipationresultingfrombladderorrectalinvasion.Distantmetastasisandpersistentedemaofoneorbothlowerextremitiesasaresultoflymphaticandvenousblockagebyextensivepelvicwalldiseasearelatemanifestationofprimarydiseaseandfrequentmanifestationsofrecurrentdisease.,Howcanwemakeadiagnosis?,SIGNSVagina:mucous,fornixCervix:erosiongrowthulcerationbarrel-shapedUterus:size,mobilityParamet:thickening,Grossappearence,Threecategoriesofgrosslesionshavetraditionallybeendescribed.Themostcommonistheexophyticlesion,whichusuallyarisesontheectocervixandoftergrowstoformalarge,friable,polypoidmass,arisesontheendocervicalcanal,creatingbarrel-shapedlesion.Littlevisibleulcerationorexophyticmasslikeastone-hardcervixthatregressesslowlywithradiationtherapy.Ulcerativetumor,usuallyerodesaportionofthecervixorreplacingthecervix,erodesaportionoftheuppervaginalvaultwithalargecrate.,Howcanwemakeadiagnosis?,CLINICALTESTS:PapsmearColposcopyandtargetbiopsyEndocervicalcurettage(ECC)ConebiopsyBiopsy,Papsmear,Papsmearisthemostcommonandeffectivescreeningmethod.Exfoliatedcervicalcellsarescrapedfromthecervixbyspatula.TheentireTzonemustbesampled.Incompletesamplingcouldproduceafalse-negativesmear.Theendocervicalcanalisalsosampledwithaswaborcytobrush.Cellsarefixedimmediatelytoavoidair-dryingcytologicartifacts,PapSmearShowSquamousCellCarcinoma,Colposcopyanddirectedbiopsy,Apapsmearisonlyascreeningtest.Adefinitivediagnosisrequiresinspectionofawell-visualizedcervixwithacolposcope.Thecervixispaintedwith3%aceticacidsolutiontoenhancesurfacealterationsandvascularchanges.ThecolposcopeevaluationisconsideredadequateorsatisfactoryifthecompleteTzoneandfullextentofthelesionsisvisualized.Areasofabnormality(e.g.,Whiteepithelium,mosaicism,andpunctation)areselectivelypunchbiopsied.,ColposcopyExamination,Conebiopsy,Indicationsforconebiopsy1.Thelesioncannotbefullyvisualized.2.TheECCisposituve3.ThereissignificantdiscrepancybetweenthePapsmearandbiopsy.4.Abiopsyrevealsmicroinvasivesquamouscellcarcinoma5.Abiopsyrevealsadenocarcinomainsitu,Howcanwemakeadiagnosis?,Apapsmearisonlyascreeningtest!DefinitivediagnosisofcervicalcancerrequiresaBIOPSY!,Howcanweevaluatethepatient?,Histologictype:Squmouscellcarcinoma(SCC)80%Adenocacinoma10%-15%Others5%-10%,Routesofspread,Intothevaginalmucosa,extendingmicroscopicallydownbeyondvisibleorpalpabledisease;Intothemyometriumofthelowuterinesegmentandcorpus,particularllywithlesionsarisingfromtheendocervix.Intotheparacervicallymphaticsandfromtheretothemostcommoninvolvedlymphnbodes(theobturator;hypogastric,andexternaliliacnodes).Directextesionintoadjacentstructuresorparametria,reachingtotheobturatorfasciaandthewallofthetruepelvis,Howcanweevaluatethepatient?,Stage:Pelvicexamination,Rectovaginalexamination,Intravenouspyelography(IVP)UltrasonographyorCTStagingisclinical,butcanuseIVPandCTCervicalcanceristheonlygynecologicmalignancythatisnotsurgicallystaged,ClinicalStagingforCervicalCarcinoma,Stage0Carcinoma-insitu;Confinedtotheepitheliumonly,ClinicalStagingforCervicalCarcinoma,StageIInvasionisstrictlyconfinedtothecervixIa:Invasivecanceridentifiedonlymicroscopically.Ia1:Minimalmicroscopicallyevidentstromalinvasion=3mmindepthandnowiderthan7mm.Ia2:Microscopicinvasion50%PV:Vulvaandvaginal:normalCervix:erosionwithcontactbleeding,Uterus:N/S,mobile.Parametrium:clearWantstopreserveherreproductivefunction,TreatmentstrategyforCIN,Casediscussion,48yrs,G3/P1,midlifeC/O:postcoitalbleedingfor4monthsMenstruationirregularwith30-60dayscycleand5-20daysduration.Abnormaldischargewithbadsmell.LMP:2monthsagoPapsmear:squamouscellcancerPV:Vulva:Normal,vaginal:rightfornixinvolvedbycervicalgrowth.Cervix:growthwithulcerationandcontactbleeding.Uterus:N/S,mobile.Parametrium:nodularthickeningtopelvicsidewallonrightBiopsy:SCC.IVP:nonfunctionalkidney,TreatmentstrategyforInvasiveCervicalCancer,Howcanweexplaintothepatient?,Whatiscervicalcancer?Howmanytreatmentmodeforcervicalcancer?WhywechoosesurgeryorRTforthepatient?Whatistheside-effectofthetreatment?Whatistheprognosisandsurvivalrate?,Cervi