子宮內(nèi)膜癌診治關(guān)注幾個(gè)問題-婦產(chǎn)科課件

王建六北京大學(xué)人民醫(yī)院婦產(chǎn)科OUTLINE如何判斷侵肌深度？DC或HS宮頸管陰性宮頸上皮浸潤子宮切除術(shù)MRITVS局限于頸管內(nèi)膜侵犯宮頸間質(zhì)廣泛子宮切除術(shù)宮頸間質(zhì)浸潤09分期刪去細(xì)胞學(xué)檢查結(jié)果為什么要?jiǎng)h去細(xì)胞學(xué)檢查？腹水細(xì)胞學(xué)陽性和腹腔或淋巴結(jié)的轉(zhuǎn)移不相關(guān)，不影響預(yù)后沒有足夠的證據(jù)說明腹水細(xì)胞學(xué)陽性與復(fù)發(fā)風(fēng)險(xiǎn)和治療效果有何關(guān)系FIGO仍推薦進(jìn)行細(xì)胞學(xué)檢查，并單獨(dú)報(bào)告結(jié)果主動(dòng)脈旁淋巴結(jié)轉(zhuǎn)移預(yù)后比盆腔淋巴結(jié)轉(zhuǎn)移差163case35(21.5%)nodalmetastasespositivepelvic26(16.0%)aortic24(27.3%)Isolatedaortic17(19.3%)Therecurrenceratewashigher(63.6%)amongpatientswithupperaorticlymphnodemetastasesallthosewhorecurreddiedofdiseasewithinsevento28months.EurJGynaecolOncol.2007;28(2):98-102Isaorticlymphadenectomynecessary?1517KOREA，JAPAN：Choosethesurgicalextentofhysterectomythroughtheirowndispositionanddonotstrictlyadheretheresultsofpreoperativeevaluation.JAPANESEgroup

morethan70%ofinstitutesneverperformRHwithoutregardingthepreoperativestatusofcervicalinvolvement(Watanabe)NORTHAMERICAN：20%-30%centerTHISISANAREAOFCONTINUEDDEBATE??！

21JKoreanMedSci2010;25:552-6原因：Currentpre-operativeevaluationmethodisnotsensitiveenoughtodetectcervicalinvasionMedicalstatuscervicalstromalinvasionshouldbefollowedbyadjuvantradiotherapyandthus,theprognosiswouldnotbechangedbyperforminga‘highmorbidityproducingsurgery’consideringthelowincidenceofPMI原因：4.Metastasischaracteristics:

differentfromcervicalcancerPMI:lowincidence6%PMI(+):LN(+)80%LN(+):PMI(+)<45%Metastasispatterns:

directinvasionofcancercellstotheparametrialconnectivetissues

parametriallymphvascular

spaceinvasionfrequentlyseeninpatientswithdeepmyometrialinvolvementwithoutcervicalinvolvementCochraneDatabaseSystRev.2010Jan20;(1):CD007585.Lymphadenectomyforthemanagementofendometrialcancer.MayK,BryantA,DickinsonHO,KehoeS,MorrisonJUniversityofOxford,Women'sCentreNoevidence

thatlymphadenectomydecreasestheriskofdeathordiseaserecurrencecomparedwithnolymphadenectomyinwomenwithpresumedstageIdisease.

Theevidenceonseriousadverseeventssuggeststhatwomenwhoreceivelymphadenectomyaremorelikelytoexperiencesurgicallyrelatedsystemicmorbidityorlymphoedema/lymphocystformation.國外近2年的文獻(xiàn)報(bào)道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.medianfollow-upof37months(IQR24-58)191womenhaddied:88/704standardsurgerygroup103/704lymphadenectomygroup251Recurrentdisease107/704standardsurgerygroup144/704lymphadenectomygroup)noevidenceofbenefit：ORorDFSforpelviclymphadenectomyinearlyendometrialcancer.Pelviclymphadenectomy

cannotberecommendedasroutineprocedurefortherapeuticpurposesoutsideofclinicaltrials.早期：LND并未降低復(fù)發(fā)改善生存意大利研究生存上沒有差異復(fù)發(fā)時(shí)間和復(fù)發(fā)率相似復(fù)發(fā)部位相似 I期患者真的可以不切除淋巴結(jié)嗎？LesionsitesandregionDepthofmyometrialinvasionCervicalinvasionExtrauterineinvasionornot,singleormultiplePathologicalgradeandclassificationLymphvascularinvasion(LVI)淋巴轉(zhuǎn)移相關(guān)因素TodoYetal.Survivaleffectofpara-aorticlymphadenectomyinendometrialcancer(SEPALstudy):aretrospectivecohortanalysis.Lancet.2010Apr3;375(9721):1165-72Combinedpelvicandpara-aorticlymphadenectomyisrecommended

astreatmentforpatientswithendometrialcarcinoma

ofintermediateorhighriskofrecurrence.

一定要切除腹主動(dòng)脈旁淋巴結(jié)嗎？ESMO2009Intermediate-riskgroup:aged60yrsdeeplyinvasiveG1orG2superficiallyinvasiveG3High-riskgroup:deeplyinvasiveG3StageIILVSI+Rarepathologicaltypes(UPSCCCC)內(nèi)分泌治療必要性？抗雌激素治療-孕激素治療甲羥孕酮（MPA）,250-500mg/d，口服甲地孕酮160mg/日，口服己酸孕酮250-500mg/日，肌注建議應(yīng)用孕激素1年及以上內(nèi)分泌治療對(duì)預(yù)后的影響復(fù)發(fā)/轉(zhuǎn)移內(nèi)分泌治療組11例（13.4%）對(duì)照組21例（23.6%）（X2=2.908，p=0.088）癌死亡內(nèi)分泌治療組10例（12.2%）對(duì)照組18例（20.2%）