子宫内膜癌治疗相关问题妇产科课件.ppt

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 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 p

2、275I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 Database Syst Rev.2019 Jan 20;(1):CD007585.Lymphadenectomy for the management of endometrial cancer.May K,Bryant A,Dickinson HO,Kehoe S,Morrison J University of O

3、xford,Womens Centre No evidence that lymphadenectomy decreases the risk of death or disease recurrence compared with no lymphadenectomy in women with presumed stage I disease.The evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgical

4、ly related systemic morbidity or lymphoedema/lymphocyst formation.J Natl Cancer Inst.2019 Dec 3;100(23):1707-16.Epub 2019 Nov 25Systematic pelvic lymphadenectomy vs.no lymphadenectomy in early-stage endometrial carcinoma:randomized clinical trial.Rome,Italy CONCLUSION:Although systematic pelvic lymp

5、hadenectomy statistically significantly improved surgical staging,it did not improve disease-free or overall survival.Lancet.2009 Jan 10;373(9658):125-36.Epub 2019 Dec 16.Efficacy of systematic pelvic lymphadenectomy in endometrial cancer(MRC ASTEC trial):a randomised study.Collaborators(180)Amos C,

6、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,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

7、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 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 M

8、R,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,Soutter 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,Fiande

9、r 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 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,In

10、d 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 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,New

11、man 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,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 s

12、urgery for stage I endometrial cancer.Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease 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

13、disease 107/704 standard surgery group 144/704 lymphadenectomy group)INTERPRETATIONno evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early endometrial cancer.Pelvic lymphadenectomy cannot be recommended as routine procedure for therapeuti

14、c purposes outside of clinical trials.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？Disease limited to uterusMe

15、dically 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 by cervical biopsy.2009NCCN I 期子宫内膜癌期子宫内膜癌-手术方式手术方式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（累及宫颈粘膜（一期）一期）？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润宫颈间质浸润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