宫颈癌的诊断和治疗课件

CERVICALCANCER...Diagnosis

＆TreatmentCERVICALCANCER...Diagnosis1宫颈癌的诊断和治疗ppt课件2CERVICALCANCER...ThemostcommonmalignancyingynecologicaloncologyIncidence:7.8/100,000Mortality:2.7/100,000Diagnosis:biopsyMainmodalityoftreatment:surgeryandradiationGoaloftreatment:cure,exceptstage4bCERVICALCANCER...Themostcom3SpecialCase38yrs,G3/P1,nurseC/O:postcoitalbleedingfor2monthsMenstruationregularwith30dayscycleand5daysduration.Abnormaldischargewithbadsmell.LMP:12daysagoPapsmear:squamouscellcancerPV:Vulva:Normal,Vaginal:yellowishdischargewithbloodystained,Cervix:growthwithulcerationandcontactbleeding.Uterus:N/S,mobile.Parametrium:thickeningnottopelvicsidewallonbothsideSpecialCase38yrs,G3/P1,nur4

CERVICALCANCER…..Howcanwemakeadiagnosis?Howcanweevaluatethepatient?Howcanwemanagethepatient?Howshouldweexplaintothepatient?Canwepreventcervicalcancer?

CERVICALCANCER…..Howcanwe5Howcanwemakeadiagnosis?SYMPTOMSAbnormalvaginalbleedingpostcoitalbleeding*contactbleedingAbnormalvaginaldischargeAsymptomatic,justabnormalpapsmearHowcanwemakeadiagnosis?SY6SYMPTOMSTheclassicsymptomisintermittent,painlessmetrorragiaorspottingonlypostcoitallyorafterdouching.Probablythefirstsymptomofearlycancerofthecervixisathin,watery,blood-tingedvaginaldischargethatfrequentlygoesunrecognizedbythepatients.Asthemaligancyenlarges,thebleedingepisodesbecomeheavierandmorefrequent,andtheylastlonger.SYMPTOMSTheclassicsymptomis7SYMPTOMSLatesymptomorindicatorsofmoreadvanceddiseaseincludethedevelopmentofpainreferredtotheflankorleg.Manypatientsc/odysuria,hematuriaorrectalbleedingorobstipationresultingfrombladderorrectalinvasion.Distantmetastasisandpersistentedemaofoneorbothlowerextremitiesasaresultoflymphaticandvenousblockagebyextensivepelvicwalldiseasearelatemanifestationofprimarydiseaseandfrequentmanifestationsofrecurrentdisease.SYMPTOMSLatesymptomorindic8Howcanwemakeadiagnosis?SIGNSVagina:mucous,fornixCervix:erosiongrowthulcerationbarrel-shapedUterus:size,mobilityParamet:thickening

Howcanwemakeadiagnosis?SI9GrossappearenceThreecategoriesofgrosslesionshavetraditionallybeendescribed.Themostcommonistheexophyticlesion,whichusuallyarisesontheectocervixandoftergrowstoformalarge,friable,polypoidmass,arisesontheendocervicalcanal,creatingbarrel-shapedlesion.Littlevisibleulcerationorexophyticmasslikeastone-hardcervixthatregressesslowlywithradiationtherapy.Ulcerativetumor,usuallyerodesaportionofthecervixorreplacingthecervix,erodesaportionoftheuppervaginalvaultwithalargecrate.GrossappearenceThreecategori10宫颈癌的诊断和治疗ppt课件11宫颈癌的诊断和治疗ppt课件12宫颈癌的诊断和治疗ppt课件13宫颈癌的诊断和治疗ppt课件14Howcanwemakeadiagnosis?CLINICALTESTS:PapsmearColposcopyandtargetbiopsyEndocervicalcurettage(ECC)ConebiopsyBiopsyHowcanwemakeadiagnosis?CL15PapsmearPapsmearisthemostcommonandeffectivescreeningmethod.Exfoliatedcervicalcellsarescrapedfromthecervixbyspatula.TheentireTzonemustbesampled.Incompletesamplingcouldproduceafalse-negativesmear.Theendocervicalcanalisalsosampledwithaswaborcytobrush.Cellsarefixedimmediatelytoavoidair-dryingcytologicartifactsPapsmearPapsmearisthemost16PapSmearShowSquamousCellCarcinomaPapSmearShowSquamousCell17ColposcopyanddirectedbiopsyApapsmearisonlyascreeningtest.Adefinitivediagnosisrequiresinspectionofawell-visualizedcervixwithacolposcope.Thecervixispaintedwith3%aceticacidsolutiontoenhancesurfacealterationsandvascularchanges.ThecolposcopeevaluationisconsideredadequateorsatisfactoryifthecompleteTzoneandfullextentofthelesionsisvisualized.Areasofabnormality(e.g.,Whiteepithelium,mosaicism,andpunctation)areselectivelypunchbiopsied.Colposcopyanddirectedbiopsy18ColposcopyExaminationColposcopyExamination19ConebiopsyIndicationsforconebiopsy1.Thelesioncannotbefullyvisualized.2.TheECCisposituve3.ThereissignificantdiscrepancybetweenthePapsmearandbiopsy.4.Abiopsyrevealsmicroinvasivesquamouscellcarcinoma5.AbiopsyrevealsadenocarcinomainsituConebiopsyIndicationsforcon20宫颈癌的诊断和治疗ppt课件21宫颈癌的诊断和治疗ppt课件22Howcanwemakeadiagnosis?Apapsmearisonlyascreeningtest!DefinitivediagnosisofcervicalcancerrequiresaBIOPSY!Howcanwemakeadiagnosis?A23Howcanweevaluatethepatient?Histologictype:Squmouscellcarcinoma(SCC)80%Adenocacinoma10%-15%Others5%-10%Howcanweevaluatethepatien24RoutesofspreadIntothevaginalmucosa,extendingmicroscopicallydownbeyondvisibleorpalpabledisease;Intothemyometriumofthelowuterinesegmentandcorpus,particularllywithlesionsarisingfromtheendocervix.Intotheparacervicallymphaticsandfromtheretothemostcommoninvolvedlymphnbodes(theobturator;hypogastric,andexternaliliacnodes).Directextesionintoadjacentstructuresorparametria,reachingtotheobturatorfasciaandthewallofthetruepelvisRoutesofspreadIntothevagin25Howcanweevaluatethepatient?Stage:Pelvicexamination,Rectovaginalexamination,Intravenouspyelography(IVP)UltrasonographyorCTStagingisclinical,butcanuseIVPandCTCervicalcanceristheonlygynecologicmalignancythatisnotsurgicallystagedHowcanweevaluatethepatien26ClinicalStagingforCervicalCarcinomaStage0 Carcinoma-insitu; ConfinedtotheepitheliumonlyClinicalStagingforCervical27ClinicalStagingforCervicalCarcinomaStageI

InvasionisstrictlyconfinedtothecervixIa:Invasivecanceridentifiedonlymicroscopically.Ia1:Minimalmicroscopicallyevidentstromalinvasion<=3mmindepthandnowiderthan7mm.Ia2:Microscopicinvasion<=5mmindepthandnowiderthan7mmClinicalStagingforCervical28ClinicalStagingforCervicalCarcinomaStageI

InvasionisstrictlyconfinedtothecervixIB:Allotherspreclinicallesionsandclinicallesionsconfinedtothecervix.Ib1:Clinicallisionsnogreaterthan4cm.Ib2:Clinicallisionsgreaterthan4cm.ClinicalStagingforCervical29ClinicalStagingforCervicalCarcinomaStageII

InvasionisbeyondthecervixbutnottothepelvicwallorlowerthirdofthevaginaIIA ParametriaisnotinvolvedIIB ParametriaisinvolvedClinicalStagingforCervical30ClinicalStagingforCervicalCarcinomaStageIII

InvasionistothepelvicwallorlowerthirdofvaginaIIIA PelvicwallisnotinvolvedIIIB Pelvicwallisinvolved;hydronephrosisornonfunctioningofthekidneymayoccurbecauseoftumorClinicalStagingforCervical31ClinicalStagingforCervicalCarcinomaStageIV

Invasionisbeyondtothetruepelvisortothemucosaofthebladderorrectum.IVA Spreadistoadjacentorgans IVB SpreadistodistantorgansClinicalStagingforCervical32Howcanweevaluatethepatient?Age:treatmentvarywiththepatient’sageMarriagestatue

Reproductivehistory：menstrual,contraceptive,Gynecologic,ObstetricSocialhistory:sexuallyactivity,socialstatueFamilyhistory:children,partner,parentsPastmedicalhistoryHowcanweevaluatethepatien33Howcanweevaluatethepatient?Generalcondition:pulmonary(Chest-x-ray)cardiacfunction(ECG)liverfunctionrenalfunctionSpecialdisorders:bleedingdiseases,diabetesmellitus,andinfectionHowcanweevaluatethepatien34Howcanwemanagethepatient?Managementofpremalignantlesions:makedefinitivediagnosisselectionofanappropriatemodeoftherapy1.carbondioxidelaser2.cryotherapy3.electrocautery4.loopelectrodiathermyexcisionprocedure(LEEP）5.Conization6.hysterectomyHowcanwemanagethepatient?35Howcanwemanagethepatient?CervicalIntraepithelialNeoplasia(CIN)ForCINI-II:observation(onlyforCINI),carbondioxidelasercryotherapyelectrocauteryloopelectrdiathermyexcisionprocedure(LEEP)

Howcanwemanagethepatient?36Howcanwemanagethepatient?CervicalIntraepithelialNeoplasia(CIN)ForCINIIIorCIS:conization:coldknifecarbondioxidelaserdiathermyandLEEPsimplehysterectomyHowcanwemanagethepatient?37Howcanwemanagethepatient?Forinvasivecancer:

1Simplehysterectomy(Ia1)2Modifiedradicalhysterectomy(Ia2)3RadicalhysterectomyandRPND(Ib-IIa)4Radiotherapy(anystage,IIbIIIIV)5ChemotherapyHowcanwemanagethepatient?38CERVICALCANCER...Prognosis:55%five-yearsurvival(allstagecombined)stageI85%stageII60%stageIII30%stageIV10%CERVICALCANCER...Prognosis:39Howcanwepreventcervicalcancer?RiskfactorsEducationScreeningprogramTreatmentofpremalignantlesionsHowcanwepreventcervicalca40Howcanwepreventcervicalcancer?RISKFACTORS:

earlyageofsexualintercoursemultiplesexualpartnerslowsocioeconomicclassesearlyageofpregnancyhighparitycigarettesmokingHPV(16,18）immunocompromisedhostHowcanwepreventcervicalca41Howcanwepreventcervicalcancer?EDUCATION:PopulationeducationMedicalstaffeducationHowcanwepreventcervicalca42Howcanwepreventcervicalcancer?SCREENING:committeeprogram:onsetofscreening,duration,endofscreeningmethodsforscreeningpapsmear,CCT,thin-rep,HPVtyping

Howcanwepreventcervicalca43Casediscussion27yrs,G0/P0,marriedfor2yrsC/O:oneepisodeofpostcoitalbleedingfor2weeksMenstruationregularwith30dayscycleand5daysduration.Noabnormaldischarge.LMP:2weeksagoPapsmear:LSILwithHPVinfection,cluecell>50%PV:Vulvaandvaginal:normalCervix:erosionwithcontactbleeding,Uterus:N/S,mobile.Parametrium:clearWantstopreserveherreproductivefunctionCasediscussion27yrs,G0/P0,44TreatmentstrategyforCINTreatmentstrategyforCI