Ⅰ期子宫内膜癌子宫切除的范围课件

1、 期子宫内膜癌子宫切除的范围 北京大学第三医院妇产科 郭红燕第1页，共25页。2I期子宫内膜癌子宫切除范围：比较明确，存在混淆 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？FIGO 2009 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第2页，共25页。子宫内膜癌分期改变筋膜外子宫切除术？II 期子宫内膜癌子宫切除范围？ 子宫切除范围探讨OUTLINEI期子宫内膜癌次广泛子宫切除术？第3页，共25页。 内膜癌病变局限于子宫-手术方式Disease limited to uter

2、usMedically 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 infiltrationis suspected on MRI or when confirmed

3、by cervical biopsy.2009NCCN第4页，共25页。FIGO: 筋膜外子宫切除术GOG2019:Women with endometrial cancers should undergo total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO), pelvic/paraaortic dissection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-手术方式第5页，共25页。 I 期子宫内膜癌-手

4、术方式Gan To Kagaku Ryoho. 2019 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 III and IV Zhonghua Fu Chan Ke Za Zhi. 20

5、19 Feb;37(2):90-3. Surgical method is not the main factor influenced the survive of stage I endometrial carcinoma. Zhonghua Fu Chan Ke Za Zhi. 2019 Mar;39(3):156-8. The patients with stage I endometrial carcinoma who were treated with simple hysterectomy and salpingo-oophorectomy did almost as well

6、as those who underwent radical hysterectomy.第6页，共25页。为什么不行广泛或次广泛子宫切除术 MauroSignorelli, et al. Gynecologic Oncology 2009Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer 第7页，共25页。宫颈癌宫旁切除范围分类 子宫切除范围类型Piver-Rutledge: 5类LANCET 2019 ：Denis Querl

7、eu, et al: Classification of radical hysterectomyExtrafacial hysterectomyModified hysterectomyRadical hysterectomyLaterally extended resectionExtenteration第8页，共25页。 筋膜外子宫切除术目的 to ensure that the cervix is entirely removed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？第9页，共25页。 筋膜外子宫切除术方法： The position of the u

8、reters is determined by palpation without freeing the ureters from their beds. The parametrium is transected medial to the ureter, but lateral to the cervix, keeping the paracervical ring intact. The uterosacral and vesicouterine ligaments are transected close to the uterus. There is no removal of p

9、aracolpos and a minimal part of vagina is resected at fornix level. 10第10页，共25页。 筋膜外子宫切除术 仁者见仁，智者见智 我们： 膀胱抚摸返折： 下推膀胱至宫颈外口水平下较低水平 子宫动脉：峡部水平以下 主韧带：贴而略离开 宫骶韧带：单独处理11第11页，共25页。宫颈癌子宫肉瘤子宫内膜癌FIGO 2009外阴癌FIGO 2009 年肿瘤分期改变第12页，共25页。FIGO 子宫内膜癌分期 （1988年） 期 a （G1,2,3） 癌瘤局限于子宫内膜 b （G1,2,3） 癌瘤浸润深度 1/2 肌层 期 a （G1,

10、2,3） 宫颈内膜腺体受累 b （G1,2,3） 宫颈间质受累 期 a （G1,2,3） 病变累及子宫浆膜和(或)附件和(或)腹腔细胞学阳性 b （G1,2,3） 阴道转移 c （G1,2,3） 盆腔淋巴结和(或)腹主动脉淋巴结 期 a （G1,2,3） 癌瘤侵及膀胱或直肠粘膜 b （G1,2,3） 远处转移，包括腹腔内和(或)腹股沟淋巴结转移 OLD第13页，共25页。FIGO 子宫内膜癌分期 （2009年）*累及宫颈腺体为期，不再定为期*腹水细胞学结果单独报告，但是不改变分期NEW第14页，共25页。子宫内膜癌分期修订的原因和主要修订内容1988分期中Ia及Ib期患者预后差异不大，将原Ia

11、和Ib期合并。Ia期/G1、 Ib期/G1、 Ia期/G2、 Ib期/G2的5年生存率分别为93.4%、91.2%、91.3%、93.4%，无显著差异宫颈粘膜受累作为上皮内癌，归为I期。腹膜后淋巴结转移是预后不良的独立因素，伴有腹主动脉旁淋巴结转移者预后更差。因此将原IIIc期分为IIIC1和IIIC2。腹腔冲洗液细胞学阳性是其它危险因素的潜在结果，而不是独立的危险因素。因而不改变分期。第15页，共25页。 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术（IIIII型子宫根治术）累及宫颈粘膜，现在归为I期，子宫切除范围？累及粘膜和间质如果应该选择不同的手术范围，如何

12、术前鉴别诊断之？宫颈是否累及？是否间质浸润？术前诊断困难16分期改变带来的新问题第16页，共25页。累及宫颈粘膜（I期）？OLD：IC差于IIANEW：II差于所有I期IIA期宫旁累及？ 宫颈癌早期手术范围如何识别粘膜累及还是间质浸润累及宫颈粘膜（ 一期）？第17页，共25页。诊断和鉴别宫颈粘膜累及还是间质浸润分段诊刮或宫腔镜检查宫颈管阴性宫颈上皮浸润I 型子宫切除术MR局限于颈管内膜侵犯宫颈间质II或III型子宫切除术宫颈间质浸润第18页，共25页。 宫颈累及一定要行广泛子宫切除术吗？广泛子宫切除术目的：切除宫旁可能的转移 文献：样本例数较多的回顾性研究Sartori E, et al. I

13、nt J Gynecol Cancer 2019;11(6):430437 203 cases：10-Y OS 74% (TAH) vs 94%(RH)Boente MP,et al. Gynecol Oncol 1993;51(3):316322. 202 cases：5-Y OS 77% (TAH) vs 86%(RH)Cornelison TL, Gynecol Oncol 2019;74(3):350355. 932 cases：5-Y OS 84% (TAH) vs 93%(RH) OP alone 5-Y OS 83% (TAH) vs 88%(RH) OP+RT 第19页，共25

14、页。 宫颈累及时子宫切除范围选择指 南：广泛子宫切除术 局限于子宫归为一类II期子宫内膜癌: 筋膜外或广泛子宫切除术现 状KOREA， JAPAN： Choose the surgical extent of hysterectomy through their own disposition and do not strictly adhere the results of pre operative evaluation.JAPANESE group more than 70% of institutes never perform RH without regarding the pre

15、operative status of cervical involvement (Watanabe)NORTH AMERICAN：20-30% center 第20页，共25页。II期子宫内膜癌RH 手术的必要性II期子宫内膜癌手术方式的选择第21页，共25页。II期子宫内膜癌RH 手术的必要性Depth of myometrial invasion and pelvic or paraaortic lymph node positivity were significantly correlated with paramatrial involvement. Of the 19 patie

16、nts with pelvic lymph node metastasis, 8 patients (42.1%) had concomitant PMI. Conversely, of the 10 patients with PMI, 8(80.0%) had lymph node metastasis.第22页，共25页。THIS IS AN AREA OF CONTINUED DEBATE 23J Korean Med Sci 2019; 25: 552-6原因：Current pre-operative evaluation method is not sensitive enoug

17、h to detect cervical invasionMedical statuscervical stromal invasion should be followed by adjuvant radiotherapy and thus, the prognosis would not be changed by performing a high morbidity producing surgery considering the low incidence of PMI原因：4.Metastasis characteristics: different from cervical cancerPMI: low incidence 6%PMI(+): LN(+) 80%LN(+): PMI(+)45%Metastasis patterns: direct invasion of cancer cells to the parame