子宫肿瘤妇产科课件

1、子宫肿瘤妇产科课件Endometrial carcinoma 子宫内膜癌Cervical tumors 宫颈肿瘤Cervical intraepithelial neoplasia (CIN)宫颈上皮内瘤样变 Cervical cancer 宫颈癌 Carcinoma of the uterus 子宫肿瘤 Cervical intraepithelial neoplasia (CIN)宫颈上皮内瘤样变Definition：Cervical intraepithelial neoplasia (CIN) is a premalignant condition of the cervix. It

2、is usually asymptomatic and is detected by routine cytological screening. The degree of severity is graded CIN、to CIN 定义:宫颈上皮内瘤样变是宫颈组织的癌前病变。一般没有症状,通常在常规的细胞学筛查时发现。根据严重程度分为CIN、CIN、CINTBS typesatypical squamous cells (ASC)不典型鳞状上皮Low-grade squamous intraepithelial lesion (LSIL)轻度鳞状上皮内病变High-grade squamo

3、us intraepithelial lesion (HSIL) 重度鳞状上皮内病变Aetiology The area of previously exposed columnar epithelium that undergoes squamous metaplasia is known as the transformation zone (TZ) 病因学 原始鳞柱交接部和生理鳞柱交接部间的区域称为移行带 It is the predilection site of cervical carcinoma移行带为宫颈癌好发部位 Ectropion and transformation of

4、 the transformation zone 移行带区的外翻和转化transformation mechanism转化机制squamous metaplasia 鳞状上皮化生squamous epithelization鳞状上皮化The risk factors for CIN and cervical carcinomaCIN和宫颈肿瘤的危险因素Young age at first intercourse初次性生活的年龄过小 Number of sexual partners性伙伴的数目 Smoking 吸烟 Poor uptake of screening programme 筛查过少

5、 Long-term use of the contraceptive pill长期服用避孕药 Exposure to tumor promoters has a greater influence on immature cells不成熟的细胞暴露于致癌因素会对其产生很大的影响 Increases the risk of cervical cancer four-fold; the risk remains elevated in ex-smokers 吸烟的妇女患宫颈癌的危险性会提高4倍；曾经吸烟的妇女患宫颈癌的危险性仍然存在 Pill takers do not necessarily

6、use barrier methods - increasing exposure to seminal fluids 服用药物而没有使用屏障的方法，会增加精液的刺激 Male-related risk factors与男性相关的危险因素 The number of the partners previous sexual relationships is relevant 与以前性伙伴的数目有关 Cervical cancer risk increased if partner has penile cancer 性伙伴患阴茎癌会增加患宫颈癌的危险性 Cervical cancer risk

7、 increased if partners previous sexual contact had cervical cancer 性伙伴的前性伴患宫颈癌也会增加患宫颈癌的危险性 Immunosuppressant 免疫抑制 Risk increased with immune suppressed renal transplant patients, and in HIV-positive women 免疫抑制、肾移植、HIV阳性妇女患宫颈癌危险性增加 HPV infection HPV感染 Mainly subtype 16 主要是16型 Screening for CIN is bas

8、ed on a cervical smear - sampling surface cells from the cervix with a spatula筛查CIN可以利用宫颈表皮细胞涂片Screening(筛查) To obtain a complete diagnosis the triage of cytology, colposcopy and histological biopsy are needed, as smears are often under reported 要想达到完整的细胞学分类诊断需要阴道镜和活检，因为细胞涂片常常取决于报告人的经验 Cytology 细胞学

9、dyskaryosis is a cytological termIt describes features of individual cells such as size and staining of nuclei and the amount of cytoplasm 细胞核异常是细胞学特点。表现为各个细胞核的大小、染色和细胞质的数量的改变 Mild dyskaryosis轻度核异常Moderate dyskaryosisSevere dyskaryosis中度核异常重度核异常Normal-sized nucleusMild nuclear abnormalitiesNucleus l

10、arger than normalbut 50% of cellNucleus irregular细胞大小正常轻度核异常细胞核大于细胞的50胞核不规则Cell border rounded细胞边界变圆Angular cell borders细胞边界有角Histology 组织学 Dysplasia is a histological term. It requires a full-thickness biopsy for diagnosis. Carcinoma-in-situ and CINare more or less synonymous. The basement membrane

11、 remains intact 组织学检查发现分化异常。需要取表皮全层活组织检查诊断，原位癌和CIN在某种程度上是相同的，都没有突破基底膜 CIN CIN CIN Upper 2/3 of epithelium exhibitsreasonable differentiation2/3以上的上皮组织分化正常Upper 1/2 of epithelium welldifferentiated1/2以上的上皮组织分化正常Maturation confined tosuperficial 1/3 (or absent)分化成熟的组织局限于表皮1/3或没有Colposcopy（阴道镜检查）In dys

12、plastic tissue the normal pattern of blood vessels becomes distorted and punctation and mosaicism are seen 在异常的组织中可以看到正常结构的血管变得弯曲、极细的点、血管网围绕的镶嵌现象（镶嵌的白色或黄色的上皮块） Colposcope 阴道镜Abnormal tissue stains white with acetic acid but will not take up the brown iodine stain. Studying the vessel patterns and st

13、aining reactions, a colposcopist gauges the degree of CIN present 异常的组织（醋酸染色白色）不会被碘溶液染成棕色，根据血管的模式和染色反应，用阴道镜可以较精确地估计CIN的程度 CINCIN CIN Local treatment 局部治疗 loop diathermy环形电热疗法 running an electric current through a thin loop of varying size and shape 电流可以通过不同大小和形状的细环cold coagulation 冷凝法carbon dioxide

14、laser 二氧化碳激光器cone biopsy锥切Loop diathermy apparatus 环形透热电疗仪The process of cone biopsy 锥切的过程Loop Electrosurgical Excision Procedure (LEEP)Cervical carcinoma 宫颈肿瘤normal cervix Cervical carcinoma rough and uneven in surface smooth 凸凹不平宫颈癌正常宫颈光滑Epidemiology 流行病学cancer of the cervix is the second most com

15、mon malignancy in women after breast cancer - 77% of cases occur in developing countries在发展中国家，宫颈癌的发病率位于妇女恶性肿瘤的第二位，仅次于乳腺癌（77）Risk factors危险因素The main aetiological agent is infection with certain subtypes of human papilloma virus (HPV) 主要的病原学因素是感染了人乳头瘤病毒的某一亚型HPV subtype 16 appears to be the main onco

16、logical agent HPV16是肿瘤学的主要原因 Only 5% of cytologically normal women细胞学正常的妇女中HPV16阳性占5 Up to 50% of smears containing CIN在涂片异常含CIN 中HPV16阳性占50 Over 90% of invasive cervical cancer浸润性宫颈癌中90以上患者HPV16阳性Possible aetiological pathway for CIN and carcinoma CIN和宫颈癌可能的病原学途径Pathology 病理学Malignant tumors of the

17、 cervix maybe squamous (8590%) or glandular (10%) in type 宫颈癌中约8590为鳞癌，10为腺癌 exophytic外生型growing outwards in a papillary or polypoidal excrescence endophytic 内生型Ulceration 溃疡型infiltrating the surrounding structures excavation frequently occur 向外呈乳头状生长或菜花状 向深部浸润周围的组织 常常形成凹陷 ulceration颈管型endocervical常

18、侵入宫颈及子宫狭部infiltrating cervix and isthmus uteriRoute of metastasis转移途径Direct metastasis 直接蔓延Lymphatic metastasis 淋巴转移 Hematogenous metastasis 血行转移Presentation 临床表现Symptoms 症状Signs 体征Confined to cervix 局限于宫颈At routine examinationPostcoital bleeding 性交后出血Cervix looks suspicious at time of smear 宫颈刮片时可疑

19、Postmenopausal bleedingAbnormal cells, indicative of invasive carcinoma on cytology 异常细胞，细胞学提示浸润癌Intermenstrual bleeding 月经间期出血绝经后出血常规检查Offensive, blood-stained vaginal discharge血性白带At colposcopy 阴道镜检查Spread to adjacent structures 侵犯临近组织Heavy, contact bleeding 接触性出血Fistulae - passage of urine, faece

20、s or flatus vaginally (if bowel/ bladder involved) （尿瘘、粪瘘形成）如果直肠膀胱受累irregular surface contour表面轮廓不规则Renal failure - bilateral ureteric obstruction 肾衰竭双侧输尿管梗阻Atypical vessels - capillaries of irregular calibre and branching pattern 不典型血管毛细血管口径、分支不规则Deep visceral or nerve root pain (if sacral nerve ro

21、ot involved) 内脏或神经根疼痛（如果骶神经根受累）Lower limb oedema - extensive pelvic side wall infiltration 骨盆侧壁广泛浸润下肢水肿Staging 分期Staging 分期Stage 1: Tumor confined to the cervix期 肿瘤局限于宫颈 a Microinvasive carcinoma a 微浸润肿瘤 a1 stromal invasion 3 mm depth and 7 mm horizontal spread a1 间质浸润深度3 mm 宽度7 mm a2 Lesions with a

22、 depth 3 mm, but 5 mm, and a horizontal spread 7 mm a2 浸润深度3 mm 5 mm，宽度7 mm b Clinical lesions confined to the cervix b 肿瘤损害局限于宫颈b l Tumor diameter 4 cm b1 肿瘤直径4 cmb2 Tumor diameter 4 cm b2 肿瘤直径4 cmStage 2: Spread beyond the cervix, but not to the pelvic side wall, with involvement of upper two-thir

23、ds of the vagina 期 超越宫颈但未达盆壁，侵犯阴道，但未及下1/3a Vaginal spread, but no obvious parametrial spreada 侵犯阴道，无明显盆壁浸润b Parametrial spread, but not as far as pelvic side wallb 宫旁浸润，但未达盆壁Stage 3: Spread in the pelvis期 侵犯骨盆a Involvement of lower one-third of the vagina a 侵犯阴道的下1/3b Extension to the pelvic side wa

24、ll or hydronephrosis b 扩散至骨盆壁或肾盂积水Stage 4: Distant spread期 远处转移a Spread to involve adjacent organs bladder, rectum a 侵犯临近组织（膀胱、直肠）b Distant spread b 远处转移Clinic stage block diagram of cervical cancer宫颈癌临床分期示意图Clinic stage block diagram of cervical cancer宫颈癌临床分期示意图Treatment options 治疗方法选择Microinvasive

25、 disease 微观浸润性病变not yet completed her family conservative approach cone biopsy锥切 completed her family Hysterectomy子宫全切 Invasive disease 浸润癌stages I b, a and some cases of 2b Radical treatment 根治术when surgical expertise is not available in women with a tumor greater than 4 cm in diameter in women who

26、 are not medically fit for surgery Radiotherapy放疗 Advanced disease (stage 4) Combinations of chemo- and radiotherapy 联合放化疗保守治疗Radical treatment is indicated for stages I b, a and some cases of b 子宫根治术适合于Ib, a 和某些b患者 Wertheims radical hysterectomy Wertheim子宫根治术 pelvic lymphadenectomy 盆腔淋巴结清扫术 3 cm va

27、ginal cuff 切除阴道上端3厘米 Squamous carcinoma conserved the ovaries 鳞状细胞癌保留卵巢Adenocarcinoma 腺癌Oophorectomy卵巢切除术Squamous carcinoma does not spread directly to the ovaries 宫颈鳞癌不会直接蔓延至卵巢 腺癌卵巢转移发生率约510 there is a 5-10% incidence of ovarian metastases Advanced disease (stage 4) 晚期患者期 Combinations of chemo- and

28、 radiotherapy 联合放化疗 survival rate is very poor 存活率很低 Endometrial carcinoma子宫内膜癌Carcinoma of the endometrium forms the most common type of uterine cancer. These are mainly adenocarcinomas derived from endometrial glandular cells 子宫内膜癌是子宫恶性肿瘤中最常见的一种类型，主要是来源于子宫内膜腺体的腺癌 Risk factors 危险因素Obesity 肥胖 Impair

29、ed glucose tolerance 糖耐量下降Nulliparity 从未生育的妇女Late menopause 绝经迟Unopposed oestrogen therapy 无对抗的雌激素治疗Functioning ovarian tumors granulosa-theca cell tumor 功能性卵巢肿瘤颗粒卵泡膜细胞瘤Family history of carcinoma of breast、ovary or colon 家族性乳腺癌、卵巢癌、结肠癌 Pathology 病理学the commonest is the endometrioid adenocarcinoma最常

30、见的为子宫内膜样腺癌 (a) View of cut surface of the uterus (b) High-power view of Grade 1 cancer大体观子宫切面 高倍镜下看期子宫内膜癌 Route of metastasis转移途径Direct metastasis 直接蔓延Lymphatic metastasis 淋巴转移Hematogenous metastasis 血行转移Symptoms and Signs 症状和体征postmenopausal bleeding 绝经后出血 Discharge 阴道排液 pyometra 子宫积脓 Metastatic di

31、sease 转移Pain 疼痛Ultrasonography and color Doppler blood-flow imaging provide useful screening tools 超声和彩色多普勒血流显像图是有效的检查工具irregular and/or heavy regular bleeding in the premenopausal group 绝经前患者中不规则的和/或量较多的规则的出血 Renal and hepatic function tests, tumor markers, chest X-ray and possibly an intravenous u

32、rogram will need to be undertaken Before the operation手术前检查肝肾功能，肿瘤标记物，胸部X线检查，必要时进行静脉尿路造影 Treatment 治疗Operation 手术The operation of choice is a total abdominal hysterectomy and bilateral salpingo-oophorectomy手术选择腹式子宫全切加双侧输卵管卵巢切除The pelvic and the para-aortic nodes should be removed if the cervix or adnexa are involved, or if the myometrium is obviously deeply infiltrated 如果侵犯宫颈、附件或明显的浸润子宫深肌层需要行盆腔和主动脉旁淋巴结清扫histology shows a poorly differenti