子宫内膜癌治疗相问题-妇产科课件

1、子宫内膜癌治疗相关问题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 IA肿瘤局限于子宫内膜 IB肿瘤浸润深度1/2肌层0909分期把累及宫颈内膜腺体归入分期把累及宫颈内膜腺体归入期期 n腹水或腹腔冲洗液细胞学阳性88分期为A期n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n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n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？0909分期删去细胞学检查结果分期删去细胞学检查结果 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

2、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

3、层受累 Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007585.Lymphadenectomy for the management of endometrial cancer.May K, Bryant A, Dickinson HO, Kehoe S, Morrison J University of Oxford, Womens Centre No evidence that lymphadenectomy decreases the risk of death or disease recurrence compared with no

4、 lymphadenectomy in women with presumed stage I disease. The evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgically related systemic morbidity or lymphoedema/lymphocyst formation.J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16. Epub

5、 2008 Nov 25Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.Rome, Italy CONCLUSION: Although systematic pelvic lymphadenectomy statistically significantly improved surgical staging, it did not improve disease-free or overall su

6、rvival.Lancet. 2009 Jan 10;373(9658):125-36. Epub 2008 Dec 16.Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.Collaborators (180) Amos C, Blake P, Branson A, Buckley CH, Redman CW, Shepherd J, Dunn G, Heintz P, Yarnold J, Johnson P, Mason M,

7、Rudd R, Badman P, Begum S, Chadwick N, Collins S, Goodall K, Jenkins J, Law K, Mook P, Sandercock J, Goldstein C, Uscinska B, Cruickshank M, Parkin DE, Crawford RA, Latimer J, Michel M, Clarke J, Dobbs S, McClelland RJ, Price JH, Chan KK, Mann C, Rand R, Fish A, Lamb M, Goodfellow C, Tahir S, Smith

8、JR, Gornall R, Kerr-Wilson R, Swingler GR, Lavery BA, Chan KK, Kehoe S, Flavin A, Eddy J, Davies-Humphries J, Hocking M, Sant-Cassia LJ, Pearson S, Chapman RL, Hodgkins J, Scott I, Guthrie D, Persic M, Daniel FN, Yiannakis D, Alloub MI, Gilbert L, Heslip MR, Nordin A, Smart G, Cowie V, Katesmark M,

9、Murray P, Eddy J, Gornall R, Swingler GR, Finn CB, Moloney M, Farthing A, Hanoch J, Mason PW, McIndoe A, Soutter WP, Tebbutt H, Morgan JS, Vasey D, Cruickshank DJ, Nevin J, Kehoe S, McKenzie IZ, Gie C, Davies Q, Ireland D, Kirwan P, Davies Q, Lamb M, Kingston R, Kirwan J, Herod J, Fiander A, Lim K,

10、Head AC, Lynch CB, Browning AJ, Cox C, Murphy D, Duncan ID, Mckenzie C, Crocker S, Nieto J, Paterson ME, Tidy J, Duncan A, Chan S, Williamson KM, Weekes A, Adeyemi OA, Henry R, Laurence V, Dean S, Poole D, Lind MJ, Dealey R, Godfrey K, Hatem MM, Lopes A, Monaghan JM, Naik R, Evans J, Gillespie A, Pa

11、terson ME, Tidy J, Ind T, Lane J, Oates S, Redford D, Ford M, Fish A, Larsen-Disney P, Johnson N, Bolger A, Keating P, Martin-Hirsch P, Richardson L, Murdoch JB, Jeyarajah A, Lamb M, McWhinney N, Farthing A, Mason PW, Kitchener H, Beynon JL, Hogston P, Low EM, Woolas R, Anderson R, Murdoch JB, Niven

12、 PA, Kerr-Wilson R, Chin K, Flynn P, Freites O, Newman GH, McNally O, Cullimore J, Olaitan A, Mould T, Menon V, Redman CW, George M, Hatem MH, Evans A, Fiander A, Howells R, Lim K, Cawdell G, Warwick AP, Eustace D, Giles J, Leeson S, Nevin J, van Wijk AL, Karolewski K, Klimek M, Blecharz P, McConnel

13、l D. Hysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease and as a therapeutic procedure median follow-up of 37 months (IQR 24-58) 191 women h

14、ad died: 88/704 standard surgery group 103/704 lymphadenectomy group251Recurrent disease 107/704 standard surgery group 144/704 lymphadenectomy group) INTERPRETATIONno evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early endometrial cance

15、r.Pelvic lymphadenectomy cannot be recommended as routine procedure for therapeutic purposes outside of clinical trials.1.术前B超、MRI等估计深肌层受侵2.术前病理分级为G33.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1/26.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？一定要切除腹主动脉旁淋巴结吗？nEur J Gynaecol Oncol. 2007;28(2):98-102.n Prin

16、ce 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 lymphadenectomyn35 (21.5%) nodal metastases npositive pelvic 26 (16.0%)npositive aortic 24 (27.3%) n

17、Isolated aortic metastases 17 cases (19.3%) n35 patients with nodal metastasesn recurrence developed in 15 (42.9%) nand all except one died within five to 50 monthsnThe recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastasesnall those who recurred died of disease wi

18、thin seven to 28 months. CONCLUSIONSnaortic 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 ana

19、lysis. Lancet. 2010 Apr 3;375(9721):1165-72 n 671 patients with endometrial carcinomansystematic 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 c

20、arcinoma of intermediate or high risk of recurrence. 33I I期子宫内膜癌期子宫内膜癌子宫切除范围：子宫切除范围： 全子宫切除术？筋膜外子宫切除术？二者异同？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？次广泛子宫切除术？FIGO 2009 FIGO 2009 子宫内膜癌分期改变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？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？争议：局限于子宫，宫颈累及？广泛子宫切除术？ 内膜癌病变局限于子

21、宫内膜癌病变局限于子宫-手术方式手术方式Disease limited to uterusMedically inoperable operableTumor directed RTTotal hysterectomy and bilateral salpingo-oophorectomyLympho nodes dissection pelvic+para aorticThe current NCCN Clinical Practice Guideline recommendspracticing radical hysterectomy only when cervical infiltr

22、ationis suspected on MRI or when confirmed by cervical biopsy.2009NCCNnFIGO: 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 dissectionn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

23、子宫切除术 I 期子宫内膜癌期子宫内膜癌-手术方式手术方式 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

24、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为什么不行广泛或次广泛子宫切除术 Mauro Signorelli, et al. Gynecologic Oncology 2009Modified Radical Hysterectomy Versus Extrafascial Hysterecto

25、my 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) (0.551.51) OS HR (95% CI)88.9% (1.0 ref) 92.2%(0.77) (0.441.33) 筋膜外子宫切除术筋膜外

26、子宫切除术n目的 to ensure that the cervix is entirely removedn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, keepin

27、g 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分期分期改变改变带来带来的新的新问题问题累及宫颈粘膜（I期）？nOLD：IC差于IIAnNEW：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 2009I期IAIBIC(56757)91%89%77% 90%78%IIIAIIIBIIICIIIC1IIIC259