參考09級-婦產科學3

1、New wordscervical intraepithelial neoplasia:宮頸上皮內瘤變Ectocervix子宮頸陰道部,外(子)宮頸部Squamocolumnar junction 磷柱交界部Squamous metaplasia 鱗狀上皮化生squamous epithelization鱗狀上皮化New wordsCervical erosion子宮頸糜爛Colposcopy陰道鏡檢查redundant prepuce包皮過長 circumcision包皮環(huán)切術Israel以色列New wordsSquamous cell cancer鱗癌adenocarcinoma腺癌Ad

2、enosquamous Carcinoma腺鱗癌Mitoses 核分裂 Parametrium子宮旁組織Coital 性交的New wordsfornix穹窿cardinal ligament主韌帶iodine test 碘試驗Colposcopy陰道鏡檢查Cone biopsy 錐形活組織檢查infusorian纖毛蟲Candida 假絲酵母屬New wordsendometriosis子宮內膜異位hysterectomy子宮切除術Conization 錐形切除術radical hysterectomy根治性子宮切除術New wordsParametria子宮旁組織Oophorectomy卵

3、巢切除(術)Lymphocyst/lymphedema淋巴囊腫Urethral strictures尿道狹窄Ureterovaginal fistula輸尿管陰道漏New wordsvaginal stenosis陰道狹窄Haematuria血尿Dysuria排尿困難diarrhoea腹瀉Composited therapy綜合治療uraemia尿毒癥Cervical intraepithelial neoplasiaCervical cancer is usually preceded by a preinvasive stage called cervical intraepithelia

4、l neoplasia (CIN) Risk factorEarly age at first intercourseMultiple sexual partnersSexually transmitted diseaseSmokingLow socioeconomic statusOral pill usersEtiology HPV human papillomavirus high risk type：16,18,31,33,35,39,45,51,52,56,58 low risk type：6,11,42，43，44 CIN:6,11,31,35 CIN、 CIN:16,18,31,

5、33Normal cervix epithelium physiology Ectocervix is lined by squamous epitheliumEndocervix is lined by columnar epitheliumSquamocolumnar junction and transfermation zoneFormation process :Squamous metaplasia & squamous epithelizationCharacters of cervical epithelium Histological genesisNormal cervic

6、al epithelium： Squamo-columnar junction: It includes ectocervical squamous epithelium and cervical canals columnar Epithelium. Transformation zone:In the formation process,there are two modalities：squamous metaplasia and squamous epithelizationSquamous metaplasiaWhen the squamocolumnar junction loca

7、ted at ectocervical ,the columnar epithelium is influenced by vaginal PH, the reserve cell below the transformation zone is hyperplasy and transform to squamous epithelium ,then the columnar epithelum amotic.Squamous epithelizationThe squamous epithelium of ectocervical grow into columnar epithelium

8、 CIN (Cervical Intraepithelial Neoplasia) In the transformation zone, Premature metaplastic squamous cells metabolize actively , and may develop into dysplasia or untypical change under the stimulation of some factors .Then CIN forms. It is precancerous lesion for cervical cancer.Pathologic diagnosi

9、s and gradeCIN: neoplastic changes are confined to the lowest layers of the epitheliumCIN: neoplastic changes extend to middle third of epitheliumCIN: neoplastic changes passes more than two third of epithelium thicknessHPV-related ChangesNormal CervixAtypia, CIN ICIN II, IIIInvasive CancerHPV Infec

10、tionCofactorsHigh-Risk HPV(Types 16, 18, etc.)About 60% regress within 2-3 yrsAbout 15% progress within 3-4 yrs30% progressBlock diagram for the process of cervical cancer Clinical presentationSymptomlessCombined with infectionCervical erosion Special examinationsCervical smear cytologic examination

11、: Bathesda System(TBS)ASC-US,ASC-H,LSIL(HPV infection/CIN I),HSIL(CIN II, III), etcColposcopy examinationCervical biopsyHPV testingtreatmentLaser excision or ablationCryotherapyCone biopsy:three excision procedues: knife conization,laser cone excision and LEEPhysterectomyTreatment CIN: follow up & r

12、emove or destroy the focusCIN: physical therapy or cone biopsyCIN: cone biopsy or hysterectomyFollow up after treatment Colposcopy and smear 4-6 months after treatmentAnnual smear for 5 yearsScreening program per 2 yearsfocal point reviewSquamo-columnar junctiontransformation zoneSquamous metaplasia

13、Squamous epithelizationCIN: cervix epithelium with canceration vergens abnormal hyperplasia ， It is precancerous lesion for cervical cancer.Treatment for CINCervical cancerintroduction The most common gynecologic cancer 500,000 new cases identified each year, 80% of the new cases occur in developing

14、 countries It causes 300,000 women to death every yearThe patient group trends younger Carcinoma in situ usually occurs between 30-35 and invasive carcinoma occurs between 50-66 the group blow 30 increases to 15%-20% 。 Magnitude of the problemincidence of cervical cancer is steadely declining in the

15、 developed world mainly due to Pap smear screening program.Cervical cancer is a preventable disease as the different screening ,diagnostic and therapeutic procedures are effective. 宮頸癌是感染性疾病，是可以預防，可以治愈的疾病。 -郎景和“No women should died of this preventable disease”. -Lenhart S,1999etiologyThe same as CIN

16、 low beta-carotene intake Imbalance of Free radicals Infectious Diseases HPV (human papillomavirus): can be found nearly in all examples Harald zur Haus (哈拉爾德楚爾豪森) , German, was praised with Nobel Prise in 2008 for His founding that HPV causes cervical cancer. HPV type 16,18,31EtiologyetiologyCervic

17、al tumorSex and deliveryothersvirus infection Pathology 80% 85% 15% 20% Squamous cell cancerAdenocarcinomamucinous adenocarcinomamalignant adenoma Adenosquamous carcinoma 3%-5% pathologyThere is no obvious difference among CIN、 Microinvasive Carcinoma and early stage of invasive cancer.Classificatio

18、n from grossExtra typeInner typeUlcer typeCervical canal typeArise from ectocervix form friable massendocervical growth,expension the cervix ,barrel shaped fornices. Excavates the cervix and often involve the vaginal Extra typeInner typeUlcer typeCervical canal typePathology Classification from micr

19、oscopyWell differentiated grade 2 mitoses per high-power fieldModerately differentiated grade 2-4 mitoses per high-power fieldPoor differentiated grade 4 mitoses per high-power fieldDirect extensionLymphatic metastasisBlood vessel transport Metastatic path Para-uterus and pelvic wall Uterus body Vag

20、ina Bladder RectumDirect extensionLymphatic mon iliac lymph nodessacral lymph nodes obturator lymph nodes vaginae fornix Internal and external iliac nodes.parametrium urethra nodesBlood vessel transportIt usually occurs on late cancer , and may transfer to lung ,liver, bone, bowl.focal point reviewP

21、athology of cervical cancer Metastatic path of cervical cancer Clinical stagingThe purpose of staging: -to determine the prognosis -to formulate the line of treatment and to compare the results of one to the other.Clinical stagingThe fallacies are: difficult to assess the lymph node involvement on c

22、linical examination which adversely affects the prognosis.Difficulty in differentiation of inflammatory and malignant induration of the parametrium.Clinical stagingstagefeature0a babPre-invasive disease (carcinoma-in situ or intra-epithelial carcinoma)Carcinoma strictly confined to the cervixSuperfi

23、cial invasive cervical carcinoma (microinvasion)Lesions of greater dimensions than stage a2 whether seen clinically or not.The carcinoma extends beyond the cervix but has not extended to pelvic wall .the carcinoma involves the vagina ,but not the lower-third.Carcinoma extends onto upper vaginaCarcin

24、oma extends into parametrium, but does not reach pelvic side wallClinical stagingstagefeatureababThe carcinoma has extended to the pelvic wall ,the tumor involved the lower-third of the vagina.Carcinoma extends onto lower-third of the vaginaCarcinoma extension onto the pelvic side wall or causes ure

25、teric obstructionThe carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of bladder or rectum.Carcinoma involves bladder or rectumDistant spreadClinical staging stagefeaturea1Up to 3mm depth, 7mm widea2Depth 3-5mm, 7mm wideb14cm in sizeb24cm in sizeStaging of cervical

26、 cancer is based principally on clinical examination.Final staging cannot changed once therapy has begun .Clinical staging review Clinical presentationVaginal bleedingVaginal discharge: white or bloody discharge , purulent or rice water-like dischargePost-coital bleedingIntermenstrual bleedingPost-m

27、enopause bleeding symptoms of late stage cancer: Pelvic pain and symptoms of malignant disease leg pain, urinary leakage, uraemiaDifferent complicationscome out depending on the organs infiltrated. rectumClinical presentationPelvic examination vaginal fornix deformed nodular thicken of uterosacral a

28、nd cardinal ligamentDiagnosis Cervical Pap smear & cytologic examination: Pap system and TBS systermDegree I : normal Degree II : InflammationDegree III: doubtful cancer IV: high risk cancerDegree V : Typical cancer cells.TCT (Thinprep liquid based Cytology Test) Result: Viruses (HPV, HSV) Squamous

29、epithelial cell lesions (CIN, cancer) Microorganism (infusorian , candida , bacterial vaginosis) Diagnosis Pap system III or abnormal cells were found by TBS , Colposcopy and biopsy should be taken.DiagnosisSchiller test: Normal mature squamous epithelium of cervix contains glycogen,which combines w

30、ith iodine to produce a deep mahogany-brown color , while the lesion area cannot.Colposcopy It is direct, and can get biopsy. Biopsy of cervix and cervical canal: The most reliable method to make diagnosis Conization of the Cervix Three steps for diagnosis: Cytology Colposcope Biopsy Differential di

31、agnosisCervical erosionCervical polypCervical tuberculosisCervical endometriosisDifferential Diagnosis.cervical polypcondylomatacervicitisTreatment Prevention: primary and secondary prevention ,done staging screeningCurative :pretreatment evaluation and preparations , treatment modalities (primary s

32、urgery ,primary radiotherapy bination therapy ,chemotherapy)Preventionprimary prevention: identifying “high risk” women :early sexual intercourse, early age of first pregnancy ,too many births/too frequent birth ,low socio-econonic status and sexually transmitted oncogens (HPV and HSV type )identify

33、ing “high risk” man :multiple sexual partners and previous wife died of cervical carcinoma. Use of condom during early intercourse ,raising age of marriage and of first birth, limitation of family ,effective therapy of STDRemoval of cervix during hysterectomy.primary preventionsecondary preventionIt

34、 involve identifying and treating the disease earlier in the more treatable stage.This is done by screening procedures done staging screeningIs an experimental approach suggested by WHO as an alternative to regular cytologic screening.The detection of the disease in the early stage when still curabl

35、e ,by nurse and other nonmedical health workers using a simple speculm for visual inspection of the cervix.In the place where prevalence of cancer is high and cytological screening is not available it is usefullCurativethe management of the patient with cervical cancer is a team approach .both the g

36、ynaecologist and radiooncologist should review the patient along with the biopsy report and the plan outlay be individualised.CurativeDue consideration should given to:-general condition of the patient-stage of the disease-facilities available-surgical and radiotherapy-wish of the patient to be judi

37、ciously complied with.Pretreatment evaluationHistoryPhysical examination: general condition and tumor stagingBlood values: complete haemogram , biochemical studies, electrolytesLiver function testsRadiologic studies :x-ray chest , intravenous phelography (IVP), Barium enema(in advanced stage) Cystos

38、copy (as indicated)Treatment modalitiesPrimary surgeryPrimary radiotherapy combination therapy Chemotherapy treatmentPrimary surgery :AA A1: hysterectomy or conization(preservation operation of fertility) A2 A: radical hysterectomy and lymphadenectomy, ovary should be preserved for young women.Radic

39、al Hysterectomy:Removes corpus, cervix, parametria, upper third of vaginaUterine arteries divided at originUreters dissected through tunnel Uterosacral ligaments divided near rectumOophorectomy not mandatedComplications of Radical HysterectomyBladder/rectal dysfunctionLymphocyst/lymphedemaUrethral stricturesUreterovaginal fistulatreatmentPrimary Radiotherapy Later B, advant