子宫内膜癌治疗相关问题妇产科课件

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1、子宫内膜癌治疗相关问题北京大学人民医院妇产科 王建六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为筋膜外子宫切除术及双

2、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 深肌层受累 Cochrane

3、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 lymphadenectomy in

4、 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 2008 Nov 25Systematic

5、 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 survival.Lancet.2009 Jan 10;3

6、73(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,Rudd R,Badman P,Begum S,Chadwick N,Collins S

7、,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 JR,Gornall R,Kerr-Wilson R,Swingler GR,Lavery BA,Chan KK,Kehoe S,Flavin

8、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,Murray P,Eddy J,Gornall R,Swingler GR,Finn CB,Moloney M,Farthing A,Hanoch J,Mason PW,McIndoe A,Sout

9、ter 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,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

10、 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,Paterson 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

11、A,Lamb M,McWhinney N,Farthing A,Mason PW,Kitchener H,Beynon JL,Hogston P,Low EM,Woolas R,Anderson R,Murdoch JB,Niven 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,

12、Eustace D,Giles J,Leeson S,Nevin J,van Wijk AL,Karolewski K,Klimek M,Blecharz P,McConnell 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

13、and as a therapeutic procedure median follow-up of 37 months(IQR 24-58)191 women had 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 recurrenc

14、e-free survival for pelvic lymphadenectomy in women with early endometrial cancer.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

15、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 Prince 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%)no

16、dal metastases npositive pelvic 26(16.0%)npositive aortic 24(27.3%)nIsolated 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 l

17、ymph node metastasesnall those who recurred died of disease within 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

18、endometrial cancer(SEPAL study):a retrospective cohort analysis.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 reco

19、mmended as treatment for patients with endometrial carcinoma 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

20、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

21、 radical hysterectomy only when cervical infiltrationis 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

22、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 resect

23、ion of the metastatic lesions for stage 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 Hysterec

24、tomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer 筋膜外子宫切除术筋膜外子宫切除术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 the

25、ir beds.nThe parametrium is transected medial to the ureter,but lateral to the cervix,keeping 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

26、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）？累及宫颈粘膜（累及宫颈粘膜（一期）一期）？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分段诊刮或宫腔镜检查宫颈管阴性宫颈管阴性宫颈上皮浸润宫颈上皮浸润I 型子宫切除术型子宫切除术MR局限于颈管内膜局限于颈管内膜侵犯宫颈间质侵犯宫颈间质II或或III型子宫切除术型子宫切除术宫颈间质浸

27、润宫颈间质浸润 宫颈累及时子宫切除范围选择 n局限于子宫归为一类nII期子宫内膜癌:筋膜外或广泛子宫切除术nKOREA，JAPAN：Choose the surgical extent of hysterectomy through their own disposition and do not strictly adhere the results of pre operative evaluation.nJAPANESE group more than 70%of institutes never perform RH without regarding the preoperative

28、 status of cervical involvement(Watanabe)nNORTH AMERICAN：20-30%center II期子宫内膜癌RH 手术的必要性II期子宫内期子宫内膜癌手术方膜癌手术方式的选择式的选择II期子宫内膜癌RH 手术的必要性nDepth of myometrial invasion and pelvic or paraaortic lymph node positivity were significantly correlated with paramatrial involvement.nOf the 19 patients with pelvic lymph node metastasis,8 patients(42.1%)had concomitant PMI.nConversely,of the 10 patients with PMI,8(80.0%)had lymph node metastasis.