子宫肌瘤的个性化治疗原则.ppt

Individualizedtreatmentforuterinemyoma 子宫肌瘤的个性化治疗原则 子宫平滑肌瘤是最常见的妇科良性肿瘤 发病率占育龄期妇女20 40 Background Uterinemyomasarethemostcommonbenignuterinetumors presentin20 40 ofwomenatreproductiveage Hysterectomyhasbeenthemostcommontreatmentmodalityforsymptomaticfibroidsinthepast Background 过去 子宫切除的有症状的子宫肌瘤的最主要治疗方式 Basedondatafrom1990to1997 thepresenceofuterinefibroidsformedthemainindicationforhysterectomyintheUnitedStates 资料显示 从1990年至1997年 子宫肌瘤在美国是子宫切除术的主要适应症 Despitethefrequencywithwhichfibroidsarediagnosedandtreated thereremainsconsiderableuncertaintyandcontroversyamongcliniciansandwomenregardingthebestwaytomanagethem Myomectomy theremovaloffibroidssurgicallywithouthysterectomy isthesecondmostcommonsurgicalprocedureforthiscondition 子宫肌瘤剔除术 即只切除肌瘤而保留子宫的手术 是子宫肌瘤第二主要的手术治疗方式 关于子宫肌瘤的最佳治疗方式 临床医生及患者仍存在相当的争议 Background factorsaffectingthechoiceoftherapeuticapproach age 年龄 parity 产次 childbearingaspirations 生育要求 extentandseverityofsymptoms 症状的程度 size numberandlocationofmyomas 大小 数目 位置 associatedmedicalconditions 相关适应症 theriskofmalignancy 恶性的风险 proximitytomenopause 距绝经的时间 thedesireforuterinepreservation 保子宫的愿望 Hence thetreatmentshouldbeindividualized Background 影响治疗方式的因素 因此 应当采取个性化的治疗 Treatment 1 Expectantmanagement 期待治疗 Asymptomaticwomenwithleiomyomaoftheuterusoflessthan12weekssize especiallythoseapproachingmenopause 小于12周大小的无症状子宫肌瘤患者 特别是接近绝经期 follow upevery3 6months Treatment carriyout adetailedhistory clinicalexamination tonote theuterinesize rateofgrowthofthetumor 2 Medicaltherapy 药物治疗 Treatment 2 1Antifibrinolytics 抗纤维蛋白溶解药 Tranexamicacid 氨甲环酸 Fist linenonhormonaltherapyforheavybleedingassociatedwithuterinefibroidsanddysfunctionaluterinebleeding 作为一线非激素药物 用于治疗子宫肌瘤及功能失调性子宫出血所致的大量出血 Prolongedtreatmentmaytheoreticallyincreasetheriskofdeepveinthrombosis Treatment 长期应用可能会增加患深静脉血栓的风险 Treatment 2 2Nonsteroidalanti inflammatorydrugs NSAIDs 非类固醇抗炎药 antagonistsofprostaglandins前列腺素抑制剂 reducedysmenorrheaandheavymenstruallosses Stimulateuterinecontractilityresultinginpain eg Aspirin ibuprofen andnaproxen 如 阿司匹林 布洛芬 萘普生 缓解痛经 减少经量 Treatment long termuse gastriculcers 胃溃疡 gastrointestinalbleeding 胃肠道出血 gastrointestinaladverseeffects 胃肠道副反应 anemia byinhibitingthecyclooxygenase 1enzyme 长期应用 贫血 通过抑制环加氧酶 1 Treatment 2 3Oralcontraceptivepills 口服避孕药 However asmyomasareestrogendependent theymayexhibitanincreaseinsizewithcombinedpills controlmenorrhagiaanddysmenorrhea 控制月经过多及痛经 Forsomewomen thebenefitsofhormonalcontraceptionoutweightheriskofthisadverseaffect 由于肌瘤是雌激素依赖性的 该药可能导致肌瘤增大 对于某些女性来说 激素避孕的益处超过了其副作用 Treatment 2 4Danazol 达那唑 createsahighandrogenandlowestrogenenvironment resultinginthewastingofendometriumandshrinkageoffibroids Hasbeenreportedtobeaneffectivetherapytoshrinkfibroidsandcontroltheirsymptoms 造成高雄激素 低雌激素环境 导致子宫内膜和肌瘤萎缩 已证实是一种缩小肌瘤 控制症状的有效治疗方式 Treatment sideeffects acne 粉刺 hirsutism 多毛症 weightgain 体重增加 irritability 易激惹 musculoskeletalpain 肌肉骨骼痛 hotflushes 热潮红 breastatrophy 乳房萎缩 However thereisnoreliableevidencefromrandomizedcontrolledtrials RCTs regardingthebenefitsand orharmsofuseofthisdrugfortreatinguterinemyomas 副作用 然而 并无来自随机对照实验的可靠证据表明该药治疗子宫肌瘤的益处或危害 Treatment 2 5Gonadotropin releasinghormoneanalogs GnRHa 促性腺激素释放激素类似物 achievehypoestrogenism conservativetherapyformyomas anadjuncttomyomectomy hysterectomybecometechnicallyeasierandquickerafter eliminatetheneedforsurgeryforperimenopausalwomen 造成低雌激素环境 保守治疗 子宫肌瘤切除术辅助治疗 围绝经期妇女避免手术 子宫切除变得容易 迅速 Treatment adverseeffects menopausalsymptoms 更年期症状 osteoporosis 骨质疏松症 pelvicpain 盆腔痛 ahormonaladd back prolongthetherapeuticeffectsofGnRHa improvethereducetionofbonemineralcontent 副作用 激素反向添加 延长GnRHa的治疗效果 改善骨密度的减少 Treatment tibolone 替勃龙 raloxifene 雷诺昔芬 progestogensalone 单纯孕激素 estrogensalone acombinationofestrogensandprogestogens Someadd backregimes 单纯雌激素 雌孕激素联合 Treatment 3 Uterinearteryembolization UAE 子宫动脉栓塞 Thisprocedure firstdescribedformanagementofmyomasin1995 attemptstolimitgrowthbylimitingthebloodsupply 该方法于1995年首次被用于子宫肌瘤的治疗 通过抑制肌瘤血供来抑制其生长 Berecommendedforlargesymptomaticmyomasinwomenwhodonotwishorarepoorcandidatesformajorsurgery 对于肌瘤较大 有症状 又不愿或不适合进行手术的妇女 推荐采用该方法 Treatment Comparedwithhysterectomy merits 优点 demerits 缺点 ashorthospitalstay 住院时间短 improvementinqualityoflife 改善生活质量 muchfewerseriousadverseeffects 副作用少 moreminorcomplications 小并发症多 unscheduledhospitalvisits 不定期随访 higherreadmissionrates 再入院率高 Treatment maybeconsidered abnormaluterinebleedingthatisunresponsivetoconservativemanagement ahighdegreeofsuspicionofpelvicmalignancy growthofmyomaaftermenopause distortionofendometrialcavityortubalobstructionininfertilewomen thosewithrecurrentpregnancylosses pain orpressuresymptomsinterferingwithqualityoflife anemiasecondarytochronicuterinebloodloss 4 Surgicalmanagement 手术治疗 maybeconsideredinpatients 可适用于以下患者 largemyomas 大肌瘤 adistortedendometrialcavity 子宫腔扭曲 unexplainedinvitrofertilizationfailures 不明原因的体外受精失败 mayinterferewithoocyteretrieval 可能影响卵的拾取 beforegonadotrophin 促性激素应用之前 Treatment 4 1Abdominalmyomectomy 经腹子宫肌瘤切除术 Treatment withmenstrualirregularities 月经失调 withriskofendometrialpatholog 子宫内膜病变高危因素 particularlyifagedmorethan35years 特别是超过35岁 requireendometrialhistologicevaluationbeforemyomectomy 子宫肌瘤切除前应行内膜组织学检查 Athoroughpreoperativeevaluationisadvisablepriortomyomectomy 全面的术前评估是必要的 Treatment Theprocedurecanbecarriedoutbylaparoscopy 腹腔镜 orlaparotomy 剖腹手术 laparoscopicmyomectomy lesshemoglobindrop reducedoperativebloodloss morepatientsfullyrecuperatedatday15 diminishedoperativepain diminishedoperativepain Superficialsubserousorpedunculatedmyomasarebestsuitedforlaparoscopicremoval 表浅的浆膜下肌瘤或带蒂的肌瘤非常适合腹腔镜切除 Treatment Thepatientwasa21 year oldnulliparouswomanpresentingwithalumpintheabdomenandinfertility Aclinicalintraoperativephotographtakenduringmyomectomyofananterioristhmicfibroidandanormal sizedbodyoftheuterus Treatment Thequalityofuterinerepairwouldinfluencetheriskofuterineruptureduringasubsequentpregnancyevent 子宫的恢复情况将影响以后妊娠时子宫破裂的风险 Hemorrhageandadhesionformationcontinuetobeotherareasofconcernaftermyomectomy 出血和粘连形成也是肌瘤切除术后值得关注的问题 Forthosewhodesireconception adelayof4 6monthsbeforeattemptingpregnancyisrecommendedaftermyomectomytoallowformyometrialhealing 对希望妊娠的患者 建议子宫肌瘤切除术后休息4 6个月再妊娠 以利于子宫肌层的恢复 Treatment 4 2Hysteroscopicmyomectomy 宫腔镜子宫肌瘤切除术 Indication 适应症 abnormalbleeding 异常出血 historyofpregnancyloss 流产史 Infertility 不孕 pain 疼痛 suspicionofendometrialmalignancy 怀疑内膜恶变 inabilitytodistendthecavity 无法膨胀宫腔 tumorextensiondeepintothemyometrium 肌瘤深入子宫肌层 Contraindications 禁忌症 Treatment Classificationofsubmucousmyomas CategoryT OandT Icanberemovedhysteroscopicallybyasurgeonwithmodestpreviousexperience reservedforhighlyskilledhysteroscopicsurgeons Treatment ahysteroscopicviewofasubmucusmyomaarisingfromtheuterinefundus 4 3Vaginalmyomectomy 经阴道子宫肌瘤切除术 Treatment Largemyomasarisingfromtheuterinebodymayfillthevaginaandresultinintermenstrualbleeding unhealthydischarge orurinaryretention 来源于宫体的大肌瘤可能填满阴道 导致月经间期出血 不洁分泌物或尿潴留 Mostofthesecanbeenucleatedpervaginumandthestalkligated 大部分这类肌瘤可经阴道剜出 并将瘤蒂结扎 Treatment anintraoperativeclinicalphotographofpartial right sided inversionofuterinefunduscausedbyalargestalkedmyomaarisingfromthefundus 来源于宫底的带蒂大肌瘤导致部分 右侧 子宫底的内翻 Treatment Hysterectomy Whenchildbearingconsiderationshavebeenfulfilled thereisreasonablelikelihoodofmalignancy themostcommonmajorgynecologicalsurgicalprocedure 33 5 aredoneformyomas 4 4Hysterectomy 子宫切除 Treatment Hysterectomy eliminatestheneedforprogestationalagents ahighdegreeofpatientsatisfaction enablesthewomantotakeunopposedestrogentherapy Treatment Aclinicalphotographofleiomyosarcomaarisinginaleiomyomatousuterusasseenathysterectomy 子宫切除术中所见子宫平滑肌肉瘤 Treatment anondescentvaginalhysterectomyofamyomatousuterusinprogress 正在进行的阴式子宫切除术 Treatment Anintraoperativephotographofafalsebroadligamentmyomatakenathysterectomy 子宫切除术时见一假性阔韧带肌瘤 Treatment Anintraoperativeclinicalphotographofenucleationofatruebroadligamentmyoma 子宫切除术中见一真性阔韧带肌瘤 Treatment Anormalsizeduterinebodysittingatopalargeposteriorcervicalmyomaafterhysterectomy 一正常大小子宫位于一个大的宫颈后肌瘤的上方 Treatment 5 HighIntensityFocusedUltrasound HIFU HighIntensityFocusedUltrasound HIFU isahighlyprecisemedicalprocedurethatapplieshigh intensityfocusedsonicenergytolocallyheatanddestroydiseasedordamagedtissuethroughablation Treatment thebasisofthistreatmentmodality Theriseintemperatureofthetissue theresultantproteindenaturation irreversiblecelldamage Treatment Themethodusesmultipleexposuresofhighintensityfocusedultrasoundenergyonthetargetfibroidtoraisethetissuetemperaturetolevelshighenoughtodestroyit Symptomaticwomenwhoaredesiringanoninvasivetherapeuticoutpatientop