子宫内膜癌治疗相关问题妇产科.ppt

,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,子宫内膜癌新分期子宫内膜癌淋巴结切除必要性子宫内膜癌子宫切除的范围,子宫内膜癌09分期修订1,和II期有关的新证据（修订2）,累及宫颈内膜腺体的预后和期无差异,09分期把累及宫颈内膜腺体归入期,和III期有关的新证据,腹水或腹腔冲洗液细胞学阳性88分期为A期多项大样本病例对照研究结果，腹水细胞学阳性和腹腔或淋巴结的转移不相关，不影响预后没有足够的证据说明腹水细胞学阳性与复发风险和治疗效果有何关系针对腹水细胞学阳性的治疗尚有争议：不处理？化疗？放疗？激素治疗？,子宫内膜癌09分期修订3,09分期删去细胞学检查结果,子宫内膜癌09分期修订4,资料表明主动脉旁淋巴结转移预后比盆腔淋巴结转移差。,妇科常见肿瘤诊治指南中华医学会妇科肿瘤分会p49I期子宫内膜癌应行手术分期术式为筋膜外子宫切除术及双附件切除术盆腔及腹主动脉旁淋巴结切除和（或）取样术术中如无明显淋巴结肿大，应系统切除淋巴结术中有可疑淋巴结肿大，取样明确有无转移即可腹主动脉旁淋巴结切除/取样指征：可疑淋巴结转移特殊组织类型CA125显著升高宫颈受累深肌层受累低分化,子宫内膜癌淋巴结切除的必要性？,全国高等院校教材妇产科学乐杰主编林仲秋编写p275I期子宫内膜癌应行筋膜外子宫切除术及双附件切除术盆腔及腹主动脉旁淋巴结切除和（或）取样术下列情况之一，应行盆腔及腹主动脉旁淋巴结切除和（或）取样术可疑淋巴结增大宫颈受累CA125显著升高特殊组织类型癌灶累及宫腔面积超过50%低分化深肌层受累,CochraneDatabaseSystRev.2019Jan20;(1):CD007585.Lymphadenectomyforthemanagementofendometrialcancer.MayK,BryantA,DickinsonHO,KehoeS,MorrisonJUniversityofOxford,WomensCentre,NoevidencethatlymphadenectomydecreasestheriskofdeathordiseaserecurrencecomparedwithnolymphadenectomyinwomenwithpresumedstageIdisease.Theevidenceonseriousadverseeventssuggeststhatwomenwhoreceivelymphadenectomyaremorelikelytoexperiencesurgicallyrelatedsystemicmorbidityorlymphoedema/lymphocystformation.,JNatlCancerInst.2019Dec3;100(23):1707-16.Epub2019Nov25Systematicpelviclymphadenectomyvs.nolymphadenectomyinearly-stageendometrialcarcinoma:randomizedclinicaltrial.Rome,Italy,CONCLUSION:Althoughsystematicpelviclymphadenectomystatisticallysignificantlyimprovedsurgicalstaging,itdidnotimprovedisease-freeoroverallsurvival.,Lancet.2009Jan10;373(9658):125-36.Epub2019Dec16.Efficacyofsystematicpelviclymphadenectomyinendometrialcancer(MRCASTECtrial):arandomisedstudy.,Collaborators(180)AmosC,BlakeP,BransonA,BuckleyCH,RedmanCW,ShepherdJ,DunnG,HeintzP,YarnoldJ,JohnsonP,MasonM,RuddR,BadmanP,BegumS,ChadwickN,CollinsS,GoodallK,JenkinsJ,LawK,MookP,SandercockJ,GoldsteinC,UscinskaB,CruickshankM,ParkinDE,CrawfordRA,LatimerJ,MichelM,ClarkeJ,DobbsS,McClellandRJ,PriceJH,ChanKK,MannC,RandR,FishA,LambM,GoodfellowC,TahirS,SmithJR,GornallR,Kerr-WilsonR,SwinglerGR,LaveryBA,ChanKK,KehoeS,FlavinA,EddyJ,Davies-HumphriesJ,HockingM,Sant-CassiaLJ,PearsonS,ChapmanRL,HodgkinsJ,ScottI,GuthrieD,PersicM,DanielFN,YiannakisD,AlloubMI,GilbertL,HeslipMR,NordinA,SmartG,CowieV,KatesmarkM,MurrayP,EddyJ,GornallR,SwinglerGR,FinnCB,MoloneyM,FarthingA,HanochJ,MasonPW,McIndoeA,SoutterWP,TebbuttH,MorganJS,VaseyD,CruickshankDJ,NevinJ,KehoeS,McKenzieIZ,GieC,DaviesQ,IrelandD,KirwanP,DaviesQ,LambM,KingstonR,KirwanJ,HerodJ,FianderA,LimK,HeadAC,LynchCB,BrowningAJ,CoxC,MurphyD,DuncanID,MckenzieC,CrockerS,NietoJ,PatersonME,TidyJ,DuncanA,ChanS,WilliamsonKM,WeekesA,AdeyemiOA,HenryR,LaurenceV,DeanS,PooleD,LindMJ,DealeyR,GodfreyK,HatemMM,LopesA,MonaghanJM,NaikR,EvansJ,GillespieA,PatersonME,TidyJ,IndT,LaneJ,OatesS,RedfordD,FordM,FishA,Larsen-DisneyP,JohnsonN,BolgerA,KeatingP,Martin-HirschP,RichardsonL,MurdochJB,JeyarajahA,LambM,McWhinneyN,FarthingA,MasonPW,KitchenerH,BeynonJL,HogstonP,LowEM,WoolasR,AndersonR,MurdochJB,NivenPA,Kerr-WilsonR,ChinK,FlynnP,FreitesO,NewmanGH,McNallyO,CullimoreJ,OlaitanA,MouldT,MenonV,RedmanCW,GeorgeM,HatemMH,EvansA,FianderA,HowellsR,LimK,CawdellG,WarwickAP,EustaceD,GilesJ,LeesonS,NevinJ,vanWijkAL,KarolewskiK,KlimekM,BlecharzP,McConnellD.,Hysterectomyandbilateralsalpingo-oophorectomy(BSO)isthestandardsurgeryforstageIendometrialcancer.Systematicpelviclymphadenectomyhasbeenusedtoestablishwhetherthereisextra-uterinediseaseandasatherapeuticprocedure,medianfollow-upof37months(IQR24-58)191womenhaddied:88/704standardsurgerygroup103/704lymphadenectomygroup251Recurrentdisease107/704standardsurgerygroup144/704lymphadenectomygroup),INTERPRETATIONnoevidenceofbenefitintermsofoverallorrecurrence-freesurvivalforpelviclymphadenectomyinwomenwithearlyendometrialcancer.Pelviclymphadenectomycannotberecommendedasroutineprocedurefortherapeuticpurposesoutsideofclinicaltrials.,子宫内膜癌淋巴结切除利与弊争论“由来已久”！,早期：淋巴结转移率较低,国内中山肿瘤：临床7.9%,8.6%,38.4%浙江肿瘤：临床4.4%,14%，34.8%国外Stageb（a）G1-2或IaG3：转移率0-2%Stageb（a）G3或Ic（b）G1：转移率16%-20%,早期：LND并未降低复发改善生存,2019年10月到2019年3月意大利多个中心的514例术前FIGO分期为期子宫内膜癌患者随机分配接受盆腔淋巴结切除术（n=264）或者不进行此手术（n=250）,“冲锋在前”的意大利研究,生存上没有差异,5年DFS5年OS未接受淋巴结切除术81.7%90.0%接受淋巴结切除术81%85.9%,复发时间和复发率相似,复发时间复发率（mth）（49mth）未进行淋巴结切除13mth33例（13.2%）淋巴结切除术者为14mth34例（12.9%）,复发部位相似,LND手术并发症明显增加,在手术时间和住院时间上，两组有显著的统计学差异接受盆腔淋巴结切除术的患者有较高的早期和晚期术后并发症率，两组出现并发症的患者分别为81例和34例。,改变观念无容置疑,子宫内膜癌治疗正朝个性化治疗发展已有充足证据证明期子宫内膜癌患者，淋巴结切除术不能带来任何生存获益。,特殊患者手术难度增加，风险增加肥胖高龄心血管疾病糖尿病,淋巴结真的可以不切除吗？,LesionsitesandregionDepthofmyometrialinvasionCervicalinvasionExtrauterineinvasionornot,singleormultiplePathologicalgradeandclassificationLymphvascularinvasion(LVI),淋巴转移相关因素,病灶大小与淋巴结转移,TumorSizeLNmets:2cm4%2cm15%entireuterinecavity35%5-ysurvival:2cm-98%2cm-84%entireuterinecavity-64%,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,术前B超、MRI等估计深肌层受侵术前病理分级为G3术前临床分期II期以上术中探查腹膜后淋巴结可疑转移术中发现侵肌1/2术中发现宫腔50%以上有病灶累及子宫内膜浆乳癌、透明细胞癌等,一定要切除腹主动脉旁淋巴结吗？,EurJGynaecolOncol.2019;28(2):98-102.PrinceofWalesHospital,Shatin,HongKongIsaorticlymphadenectomynecessaryinthemanagementofendometrialcarcinoma?75(46.0%)pelviclymphadenectomyalone88(54.0%)hadbothpelvicandaorticlymphadenectomy35(21.5%)nodalmetastasespositivepelvic26(16.0%)positiveaortic24(27.3%)Isolatedaorticmetastases17cases(19.3%),35patientswithnodalmetastasesrecurrencedevelopedin15(42.9%)andallexceptonediedwithinfiveto50monthsTherecurrenceratewashigher(63.6%)amongpatientswithupperaorticlymphnodemetastasesallthosewhorecurreddiedofdiseasewithinsevento28months.,CONCLUSIONS,aorticlymphadenectomyprovidesbothdiagnosticandtherapeuticvalueinthemanagementofendometrialcarcinomawithhighmetastaticrisk.,TodoYetal.Survivaleffectofpara-aorticlymphadenectomyinendometrialcancer(SEPALstudy):aretrospectivecohortanalysis.Lancet.2019Apr3;375(9721):1165-72,671patientswithendometrialcarcinomasystematicpelviclymphadenectomy(n=325)pelvicandpara-aorticlymphadenectomy(n=346)INTERPRETATION:Combinedpelvicandpara-aorticlymphadenectomyisrecommendedastreatmentforpatientswithendometrialcarcinomaofintermediateorhighriskofrecurrence.,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？,FIGO2009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,内膜癌病变局限于子宫-手术方式,Diseaselimitedtouterus,Medicallyinoperable,operable,TumordirectedRT,Totalhysterectomyandbilateralsalpingo-oophorectomyLymphonodesdissectionpelvic+paraaortic,ThecurrentNCCNClinicalPracticeGuidelinerecommendspracticingradicalhysterectomyonlywhencervicalinfiltrationissuspectedonMRIorwhenconfirmedbycervicalbiopsy.,2009NCCN,FIGO:筋膜外子宫切除术GOG2019:Womenwithendometrialcancersshouldundergototalabdominalhysterectomyandbilateralsalpingo-oophorectomy(TAH-BSO),pelvic/paraaorticdissection妇科常见恶性肿瘤治疗指南：筋膜外子宫切除术林巧稚妇科肿瘤学：全子宫切除术中国妇产科学（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,GanToKagakuRyoho.2019Aug;22(9):1163-8.Totalhysterectomyisdoneforcasesofstage0,modifiedradicalhysterectomyforstageI,radicalhysterectomyforstageII,andradicalhysterectomycombinedwithresectionofthemetastaticlesionsforstageIIIandIVZhonghuaFuChanKeZaZhi.2019Feb;37(2):90-3.SurgicalmethodisnotthemainfactorinfluencedthesurviveofstageIendometrialcarcinoma.,为什么不行广泛或次广泛子宫切除术,MauroSignorelli,etal.GynecologicOncology2009ModifiedRadicalHysterectomyVersusExtrafascialHysterectomyintheTreatmentofStageIEndometrialCancer,筋膜外子宫切除术,目的toensurethatthecervixisentirelyremoved适应症：子宫内膜癌，早期宫颈癌与全子宫切除术异同？定义？手术中要点？,筋膜外子宫切除术,方法：Thepositionoftheuretersisdeterminedbypalpationwithoutfreeingtheuretersfromtheirbeds.Theparametriumistransectedmedialtotheureter,butlateraltothecervix,keepingtheparacervicalringintact.Theuterosacralandvesicouterineligamentsaretransectedclosetotheuterus.Thereisnoremovalofparacolposandaminimalpartofvaginaisresectedatfornixlevel.,病变累及宫颈手术范围的选择,II期子宫内膜癌子宫切除范围首选广泛子宫切除