宮頸癌標準治療選擇課件

2/6/2023Dr.XiaohuaWu1StandardTreatmentOptions

forCervicalCancer

FIGO:StagingclassificationsandclinicalpracticeguidelinesofCervicalcancerNationalCancerInstituteM.D.AndersonCancerCenterPracticalGynecologicOncology4thEdition2/6/2023Dr.XiaohuaWu2CancersoftheFemaleReproductiveTract:

WorldwideStatistics1

Ferlayetal.GLOBOCAN2000IARC,WHO2001()

CancerNewCasesDeathsCervical470,000230,000Endometrial189,00045,000Ovarian192,000114,000USANorthernEuropeSouthernEurope23,80010,00010,20015,6007,2006,2002/6/2023Dr.XiaohuaWu31974-2000上海市居民婦科腫瘤發(fā)病率

上海市腫瘤研究流行病研究室年報告2/6/2023Dr.XiaohuaWu52/6/2023Dr.XiaohuaWu6TreatmentOptionOverview

FiverandomizedphaseIIItrialshaveshownanoverallsurvivaladvantageforcisplatin-basedtherapygivenconcurrentlywithradiationtherapy,[1-6]while1trialexaminingthisregimendemonstratednobenefit.[7]Theriskofdeathfromcervicalcancerwasdecreasedby30%to50%byconcurrentchemoradiation.Basedontheseresults,strongconsiderationshouldbegiventotheincorporationofconcurrentcisplatin-basedchemotherapywithradiationtherapyinwomenwhorequireradiationtherapyfortreatmentofcervicalcancer.[1-8]2/6/2023Dr.XiaohuaWu7TreatmentOptionOverviewSurgeryandradiationtherapyareequallyeffectiveforearly-stagesmall-volumedisease.[9]Youngerpatientsmaybenefitfromsurgeryinregardtoovarianpreservationandavoidanceofvaginalatrophyandstenosis.Patternsofcarestudiesclearlydemonstratethenegativeprognosticeffectofincreasingtumorvolume.Therefore,treatmentmayvarywithineachstageascurrentlydefinedbyFIGO,andwilldependontumorbulkandspreadpattern.[10]2/6/2023Dr.XiaohuaWu9宮頸癌分期:臨床診斷分期

有經(jīng)驗的醫(yī)師、在麻醉下進行檢查后來的發(fā)現(xiàn)不能改變已經(jīng)確定的期別觸診、視診、陰道鏡、宮頸管診刮術(shù)(ECC)、宮腔鏡、膀胱鏡、直腸鏡、靜脈尿路造影、以及骨骼和肺部x線檢查膀胱和直腸懷疑病灶須經(jīng)活檢并有組織學證實淋巴管造影、動脈造影、靜脈造影、剖腹探查術(shù)、超聲探查、CT掃描和磁共振（MRI）等，故不能作為改變期別的根據(jù)對掃描檢查懷疑的淋巴結(jié)行細針穿刺，能幫助制定治療計劃2/6/2023Dr.XiaohuaWu10宮頸癌分期:手術(shù)治療后病理分期

手術(shù)--病理檢查切除的標本結(jié)果，是最確切診斷腫瘤侵犯范圍這些結(jié)果不能改變臨床分期，但可將這些結(jié)果記錄在疾病的病理分期法則中，TNM分期正是符合情況首次診斷時確定分期，而且不能更改，即使在復發(fā)時也是如此只有在臨床分期的準則嚴格執(zhí)行時，才有可能比較各個臨床單位和不同治療方式的結(jié)果2/6/2023Dr.XiaohuaWu112/6/2023Dr.XiaohuaWu13SurgicalStagingPretreatmentsurgicalstagingisthemostaccuratemethodtodetermineextentofdisease.Becausethereislittleevidencetodemonstrateoverallimprovedsurvivalwithroutinesurgicalstaging,itusuallyshouldbeperformedonlyaspartofaclinicaltrial.Pretreatmentsurgicalstaginginbulky,butlocallycurable,diseasemaybeindicatedinselectcaseswhenanonsurgicalsearchformetastaticdiseaseisnegative.IfabnormalnodesaredetectedbyCTscanorlymphangiography,fineneedleaspirationshouldbenegativebeforeasurgicalstagingprocedureisperformed.2/6/2023Dr.XiaohuaWu14腹主動脈旁淋巴結(jié)CT陰性患者中生存率曲線與PET掃描結(jié)果的關(guān)系

JClinOncol2001;19:3745–3749.)2/6/2023Dr.XiaohuaWu15IB期宮頸癌盆腔淋巴結(jié)轉(zhuǎn)移率

2/6/2023Dr.XiaohuaWu17宮頸癌治療：根據(jù)期別選擇0期微小浸潤癌ⅠB1期和早ⅡA癌ⅡB至ⅣA期宮頸癌2/6/2023Dr.XiaohuaWu18Stage0CervicalCancer

Standardtreatmentoptions:

Methodstotreatectocervicallesionsinclude:Loopelectrosurgicalexcisionprocedure(LEEP).[7,8]Lasertherapy.[9]Conization.Cryotherapy.[10]Whentheendocervicalcanalisinvolved,laserorcold-knifeconizationmaybeusedforselectedpatientstopreservetheuterusandavoidradiationtherapyand/ormoreextensivesurgery.Totalabdominalorvaginalhysterectomyisanacceptedtherapyforthepostreproductiveagegroupandisparticularlyindicatedwhentheneoplasticprocessextendstotheinnerconemargin.Formedicallyinoperablepatients,asingleintracavitaryinsertionwithtandemandovoidsfor5,000milligramhours(8,000cGyvaginalsurfacedose)maybeused.[11]2/6/2023Dr.XiaohuaWu19對異常Pap

涂片或活檢示微小浸潤癌處理步驟

Pap涂片異?；蜚Q取活檢“微小浸潤癌”錐切活檢微小浸潤≤5mm切緣陰性ECC陰性ECC陰性切緣和/或ECC示非典型增生ⅠA1期無廣泛LVSI如有生育愿望者錐切筋膜外子宮切除再次錐切活檢如錐切不便行改良RH±盆腔淋巴結(jié)切除術(shù)廣泛LVSI的ⅠA1期ⅠA2期如有生育愿望者盆腔淋巴結(jié)切除加錐切，或廣泛宮頸切除改良RH和盆腔淋巴結(jié)切除2/6/2023Dr.XiaohuaWu21IB

和早

IIA期宮頸癌的治療步驟Ⅰ期早Ⅱ期（陰道前壁侵犯）除外根治性子宮切除盆腔淋巴結(jié)切除切除任何增大腹主動脈旁淋巴結(jié)淋巴結(jié)陰性高危險（GOG分數(shù)>120）多個陽性淋巴結(jié)或增大陽性淋巴結(jié)淋巴結(jié)陰性低危險觀察小野盆腔放療延伸野放療順鉑周療2/6/2023Dr.XiaohuaWu22StageIIBCervicalCancer

StageIIICervicalCancer

StageIVACervicalCancer

Radiationtherapypluschemotherapy:Intracavitaryradiationandexternal-beampelvicirradiationcombinedwithcisplatinorcisplatin/fluorouracil.[7-12]2/6/2023Dr.XiaohuaWu23晚期宮頸癌的診治步驟ⅡB-ⅣA宮頸癌腹、盆腔CT盆、腹腔陰性盆腔或腹腔淋巴結(jié)≥1.5cm附件包塊胸部CT胸部CT陰性胸部CT陽性切除附件包塊腫大淋巴結(jié)腹膜外切除延伸野放療和DDP周療姑息性盆腔放療預防性延伸野放療和DDP周療2/6/2023Dr.XiaohuaWu25術(shù)后放射治療：范圍及適應癥

標準野：陽性盆腔淋巴結(jié)陽性宮旁組織陽性手術(shù)切緣陽性患者