子宫内膜癌治疗相关问题-妇产科课件

I肿瘤局限于子宫体IA肿瘤局限于子宫内膜IB肿瘤浸润深度<1/2肌层IC肿瘤浸润深度>1/2肌层Ⅰ肿瘤局限于子宫体Ⅰa肿瘤浸润深度<1/2肌层Ⅰb肿瘤浸润深度≥1/2肌层和II期有关的新证据（修订2）II肿瘤侵犯宫颈，但无宫体外蔓延IIA仅宫颈内膜腺体受累IIB宫颈间质浸润II肿瘤侵犯宫颈间质，但无宫体外蔓延和III期有关的新证据腹水或腹腔冲洗液细胞学阳性88分期为ⅢA期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？III局部和(或)区域的扩散IIIA肿瘤侵犯浆膜层和(或)附件(直接蔓延或转移)，和(或)腹水或腹腔洗液有癌细胞IIIB阴道浸润(直接蔓延或转移)Ⅲ局部和(或)区域扩散Ⅲa肿瘤累及浆膜层和(或)附件Ⅲb阴道和(或)宫旁受累09分期删去细胞学检查结果IIIC盆腔和(或)腹主动脉旁淋巴结转移资料表明主动脉旁淋巴结转移预后比盆腔淋巴结转移差。IIIc盆腔和(或)腹主动脉旁淋巴结转移IIIc1盆腔淋巴结阳性IIIc2腹主动脉旁淋巴结阳性(和盆腔淋巴结阳性)CochraneDatabaseSystRev.2010Jan20;(1):CD007585.Lymphadenectomyforthemanagementofendometrialcancer.MayK,BryantA,DickinsonHO,KehoeS,MorrisonJUniversityofOxford,Women'sCentreNoevidencethatlymphadenectomydecreasestheriskofdeathordiseaserecurrencecomparedwithnolymphadenectomyinwomenwithpresumedstageIdisease.Theevidenceonseriousadverseeventssuggeststhatwomenwhoreceivelymphadenectomyaremorelikelytoexperiencesurgicallyrelatedsystemicmorbidityorlymphoedema/lymphocystformation.JNatlCancerInst.2008Dec3;100(23):1707-16.Epub2008Nov25Systematicpelviclymphadenectomyvs.nolymphadenectomyinearly-stageendometrialcarcinoma:randomizedclinicaltrial.Rome,Italy

CONCLUSION:Althoughsystematicpelviclymphadenectomystatisticallysignificantlyimprovedsurgicalstaging,itdidnotimprovedisease-freeoroverallsurvival.Lancet.2009Jan10;373(9658):125-36.Epub2008Dec16.Efficacyofsystematicpelviclymphadenectomyinendometrialcancer(MRCASTECtrial):arandomisedstudy.Collaborators(180)

AmosC,BlakeP,BransonA,BuckleyCH,RedmanCW,ShepherdJ,DunnG,HeintzP,YarnoldJ,JohnsonP,MasonM,RuddR,BadmanP,BegumS,ChadwickN,CollinsS,GoodallK,JenkinsJ,LawK,MookP,SandercockJ,GoldsteinC,UscinskaB,CruickshankM,ParkinDE,CrawfordRA,LatimerJ,MichelM,ClarkeJ,DobbsS,McClellandRJ,PriceJH,ChanKK,MannC,RandR,FishA,LambM,GoodfellowC,TahirS,SmithJR,GornallR,Kerr-WilsonR,SwinglerGR,LaveryBA,ChanKK,KehoeS,FlavinA,EddyJ,Davies-HumphriesJ,HockingM,Sant-CassiaLJ,PearsonS,ChapmanRL,HodgkinsJ,ScottI,GuthrieD,PersicM,DanielFN,YiannakisD,AlloubMI,GilbertL,HeslipMR,NordinA,SmartG,CowieV,KatesmarkM,MurrayP,EddyJ,GornallR,SwinglerGR,FinnCB,MoloneyM,FarthingA,HanochJ,MasonPW,McIndoeA,SoutterWP,TebbuttH,MorganJS,VaseyD,CruickshankDJ,NevinJ,KehoeS,McKenzieIZ,GieC,DaviesQ,IrelandD,KirwanP,DaviesQ,LambM,KingstonR,KirwanJ,HerodJ,FianderA,LimK,HeadAC,LynchCB,BrowningAJ,CoxC,MurphyD,DuncanID,MckenzieC,CrockerS,NietoJ,PatersonME,TidyJ,DuncanA,ChanS,WilliamsonKM,WeekesA,AdeyemiOA,HenryR,LaurenceV,DeanS,PooleD,LindMJ,DealeyR,GodfreyK,HatemMM,LopesA,MonaghanJM,NaikR,EvansJ,GillespieA,PatersonME,TidyJ,IndT,LaneJ,OatesS,RedfordD,FordM,FishA,Larsen-DisneyP,JohnsonN,BolgerA,KeatingP,Martin-HirschP,RichardsonL,MurdochJB,JeyarajahA,LambM,McWhinneyN,FarthingA,MasonPW,KitchenerH,BeynonJL,HogstonP,LowEM,WoolasR,AndersonR,MurdochJB,NivenPA,Kerr-WilsonR,ChinK,FlynnP,FreitesO,NewmanGH,McNallyO,CullimoreJ,OlaitanA,MouldT,MenonV,RedmanCW,GeorgeM,HatemMH,EvansA,FianderA,HowellsR,LimK,CawdellG,WarwickAP,EustaceD,GilesJ,LeesonS,NevinJ,vanWijkAL,KarolewskiK,KlimekM,BlecharzP,McConnellD.

Hysterectomyandbilateralsalpingo-oophorectomy(BSO)isthestandardsurgeryforstageIendometrialcancer.Systematicpelviclymphadenectomyhasbeenusedtoestablishwhetherthereisextra-uterinediseaseandasatherapeuticproceduremedianfollow-upof37months(IQR24-58)191womenhaddied:88/704standardsurgerygroup103/704lymphadenectomygroup251Recurrentdisease107/704standardsurgerygroup144/704lymphadenectomygroup)INTERPRETATIONnoevidenceofbenefitintermsofoverallorrecurrence-freesurvivalforpelviclymphadenectomyinwomenwithearlyendometrialcancer.Pelviclymphadenectomycannotberecommendedasroutineprocedurefortherapeuticpurposesoutsideofclinicaltrials.早期：淋巴结转移率较低国内中山肿瘤：临床Ⅰ7.9%,Ⅱ8.6%,Ⅲ38.4%浙江肿瘤：临床Ⅰ4.4%,Ⅱ14%，Ⅲ34.8%国外StageⅠb（a）G1-2或IaG3：转移率0-2%StageⅠb（a）G3或Ic（b）G1：转移率16%-20%早期：LND并未降低复发改善生存“冲锋在前”的意大利研究生存上没有差异复发时间和复发率相似复发部位相似改变观念无容置疑淋巴结真的可以不切除吗？LesionsitesandregionDepthofmyometrialinvasionCervicalinvasionExtrauterineinvasionornot,singleormultiplePathologicalgradeandclassificationLymphvascularinvasion(LVI)淋巴转移相关因素病灶大小与淋巴结转移TumorSizeLNmets:

2cm4%>2cm15%entireuterinecavity35%5-ysurvival:

2cm-98%>2cm-84%entireuterinecavity-64%

腹膜后淋巴结切除指征一定要切除腹主动脉旁淋巴结吗？EurJGynaecolOncol.2007;28(2):98-102.

PrinceofWalesHospital,Shatin,HongKongIsaorticlymphadenectomynecessaryinthemanagementofendometrialcarcinoma?75(46.0%)pelviclymphadenectomyalone88(54.0%)hadbothpelvicandaorticlymphadenectomy35(21.5%)nodalmetastasespositivepelvic26(16.0%)positiveaortic24(27.3%)Isolatedaorticmetastases17cases(19.3%)35patientswithnodalmetastasesrecurrencedevelopedin15(42.9%)andallexceptonediedwithinfiveto50monthsTherecurrenceratewashigher(63.6%)amongpatientswithupperaorticlymphnodemetastasesallthosewhorecurreddiedofdiseasewithinsevento28months.CONCLUSIONSaorticlymphadenectomyprovidesbothdiagnosticandtherapeuticvalueinthemanagementofendometrialcarcinomawithhighmetastaticrisk.TodoYetal.Survivaleffectofpara-aorticlymphadenectomyinendometrialcancer(SEPALstudy):aretrospectivecohortanalysis.Lancet.2010Apr3;375(9721):1165-72

671patientswithendometrialcarcinomasystematicpelviclymphadenectomy(n=325)pelvicandpara-aorticlymphadenectomy(n=346)

INTERPRETATION:Combinedpelvicandpara-aorticlymphadenectomyisrecommendedastreatmentforpatientswithendometrialcarcinomaofintermediateorhighriskofrecurrence.33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？DiseaselimitedtouterusMedicallyinoperable

operableTumordirectedRTTotalhysterectomyandbilateralsalpingo-oophorectomyLymphonodesdissectionpelvic+paraaorticThecurrentNCCN

ClinicalPracticeGuidelinerecommendspracticingradicalhysterectomyonlywhencervicalinfiltrationissuspectedonMRIorwhenconfirmedbycervicalbiopsy.2009NCCNGanToKagakuRyoho.1995Aug;22(9):1163-8.

Totalhysterectomyisdoneforcasesofstage0,modifiedradicalhysterectomyforstageI,radicalhysterectomyforstageII,andradicalhysterectomycombinedwithresectionofthemetastaticlesionsforstageIIIandIVZhonghuaFuChanKeZaZhi.2002Feb;37(2):90-3.

SurgicalmethodisnotthemainfactorinfluencedthesurviveofstageIendometrialcarcinoma.

Mauro

Signorelli,etal.GynecologicOncology2009ModifiedRadicalHysterectomyVersusExtrafascialHysterectomyintheTreatmentofStageIEndometrialCancer

Recurrence

ClassIhysterectomy(n=

263)ClassIIhysterectomy(n

=

257)NOrecurrence231(87.8)228(88.7)WIthrecurrence32(12.2)29(11.3)DFSHR(95%CI)87.7%(1.0ref)89.7%(0.91)(0.55–1.51)OSHR(95%CI)88.9%(1.0ref)92.2%(0.77)(0.44–1.33)方法：Thepositiono