輸卵管切除用于預(yù)防卵巢癌課件

Contents1Introduction2Strategy3ChallengesForward4Conclusion1輸卵管切除用于預(yù)防卵巢癌美國婦產(chǎn)科醫(yī)師協(xié)會(huì)委員會(huì)在提出“切除輸卵管可能預(yù)防卵巢癌”這一觀點(diǎn)。ObstetGynecol.2015;125:279-281.FulltextCommitteeonGynecologicPractice

Thisdocumentreflectsemergingclinicalandscientificadvancesasofthedateissuedandissubjecttochange.Theinformationshouldnotbeconstruedasdictatinganexclusivecourseoftreatmentorproceduretobefollowed.2Counselingwomenwhoareundergoingroutinepelvicsurgeryabouttherisksandbenefitsofsalpingectomyshouldincludeaninformedconsentdiscussionabouttheroleofoophorectomyandbilateralsalpingo-oophorectomy.“

Theopinionspecificallyaddresseswomenat"populationrisk"forovariancancer,meaningwomenwhodonothaveanelevatedgeneticriskforovariancancerbutwhoarehavingroutinepelvicsurgeryforbenigndisease.3對(duì)于卵巢癌“大”進(jìn)行常規(guī)盆腔手術(shù)的女性，對(duì)于輸卵管切除風(fēng)險(xiǎn)和好處的咨詢應(yīng)該包括卵巢切除術(shù)和雙側(cè)輸卵管切除術(shù)的一個(gè)知情同意書。4Salpingectomyatthetimeofhysterectomyorasameansoftubalsterilizationappearstobesafe,withoutanincreaseinparedwithhysterectomyaloneortuballigation,"thecommitteewrites.婦產(chǎn)科醫(yī)師協(xié)會(huì)認(rèn)為，與單純子宮切除術(shù)或輸卵管結(jié)扎術(shù)相比，在子宮切除時(shí)行輸卵管切除術(shù)或者輸卵管絕育術(shù)似乎是安全的，不會(huì)增加并發(fā)癥。5nwomenconsideringlaparoscopicsterilization,physicianscandiscussthefactthatbilateralsalpingectomyprovideseffectivecontraception,whilepointingoutthatthisprocedureeliminatestheoptionoftubalreversal.對(duì)于考慮腹腔鏡絕育手術(shù)的婦女，醫(yī)生應(yīng)知會(huì)患者雙側(cè)輸卵管切除術(shù)可提供有效的避孕方法，同時(shí)指出這一手術(shù)后不可再行輸卵管復(fù)通術(shù)。6

婦科癌癥中，卵巢癌死亡率最高；在現(xiàn)在女性癌癥死亡率排名中已上升到第五名。卵巢癌存活率在最近50年中并沒有明顯改善7Morerandomizedcontrolledtrialsareneededtosupporttheuseofsalpingectomyinreducingovariancancer有關(guān)使用輸卵管切除術(shù)預(yù)防卵巢癌的做法，還需要更多的隨機(jī)對(duì)照試驗(yàn)進(jìn)行驗(yàn)證。8Thecommitteeurgessurgeonstocontinuetouseminimallyinvasivetechniques.Fornow,thepossiblebenefitofsalpingectomyshouldnotswaydecisionsaboutwhichtechniquetouseforhysterectomyandsterilization.Forexample,thecommitteeadvisessurgeonsnottoswitchfromvaginaltolaparoscopichysterectomysimplytodoasalpingectomy.委員會(huì)敦促醫(yī)生繼續(xù)使用微創(chuàng)手術(shù)。目前，輸卵管切除術(shù)可能的獲益還不能影響子宮切除術(shù)和結(jié)扎手術(shù)的技術(shù)決策。例如，例如委員會(huì)建議外科醫(yī)生不要僅僅為了做一個(gè)輸卵管切除術(shù)，而從陰道子宮切除術(shù)轉(zhuǎn)變?yōu)楦骨荤R子宮切除術(shù)。9Thelattertechniquescancauseearlymenopauseandincreasedriskforcardiovasculardisease,osteoporosis,andcognitiveimpairmentandwerealsolinkedtoincreasedriskforall-causeandcancerspecificmortalityintheNurses'HealthStudy.后者會(huì)導(dǎo)致更年期提前，心血管疾病風(fēng)險(xiǎn)增加，骨質(zhì)疏松和認(rèn)知障礙，并且在護(hù)士健康研究中發(fā)現(xiàn)，并與所有原因和癌癥死亡專率風(fēng)險(xiǎn)增加有關(guān)。10Onthebasisofcurrentviewsaboutovariancarcinogenesis,thecommitteecontinues,salpingectomywhileleavingtheovariesintactmaybebetterforcancerpreventionthanoophorectomyandbilateralsalpingo-oophorectomy.基于目前有關(guān)卵巢癌變的觀點(diǎn)，委員會(huì)認(rèn)為單純切除輸卵管，保留完整卵巢可能比卵巢切除術(shù)和雙側(cè)輸卵管、卵巢切除術(shù)預(yù)防癌癥的效果更好。11hemostcompellingtheoryofepithelialovariancarcinogenesissuggeststhatserous,endometrioid,andclearcellcarcinomasarederivedfromthefallopiantubeandtheendometriumandnotdirectlyfromtheovary(5–9).Thisisincontrasttothetraditionalviewofovariancarcinogenesisinwhichovariansurfaceepithelium(mesothelium)undergoesmetaplasticchangesleadingtothedifferenthistologictypesofepithelialovariancancer.Inwomenwithageneticpredispositionforovariancancer,lesionshavebeenfoundinthefallopiantubesthatcloselyresembleovarianhigh-gradeserouscarcinomasorseroustubalintraepithelialcarcinomas.Theselesionsarethoughttobetheprimarysourceofovariancarcinomathatsecondarilyinvolvestheovary.Geneticsstudiesshowthatthesetuballesionsexpressacommon

TP53

mutation,asdohigh-gradeserous,high-gradeendometrioid,andundifferentiatedcarcinomas.Inaddition,geneexpressionofhigh-gradeserouscarcinomasismorecloselyrelatedtothefallopiantubemorphologythantheovariansurfaceepithelium.High-gradeserouscarcinomasexpressamüllerianmarker(PAX8)butnotamesothelialmarker(calretinin).12委員會(huì)認(rèn)為，大約75%的卵巢癌和90%的卵巢癌導(dǎo)致的死亡是由上皮性卵巢癌造成的。目前沒有可靠的卵巢癌篩查方案。傳統(tǒng)觀點(diǎn)認(rèn)為上皮性卵巢癌起因于卵巢的一小部分，最新研究表明，上皮性卵巢癌源自輸卵管和子宮內(nèi)膜的一部分。研究還指出輸卵管結(jié)扎對(duì)子宮內(nèi)膜透明細(xì)胞癌起預(yù)防作用。13

總結(jié)：基于女性中卵巢癌的人口風(fēng)險(xiǎn)比例，外科醫(yī)生應(yīng)該對(duì)輸卵管切除術(shù)的潛在好處進(jìn)行討論。在全子宮切除時(shí)，對(duì)于有卵巢癌風(fēng)險(xiǎn)，希望保留卵巢的患者，討論切除輸卵管的利弊。3.醫(yī)生應(yīng)該告知考慮腹腔鏡絕育手術(shù)的女性，雙側(cè)輸卵管切術(shù)可以提供有效避孕，并應(yīng)該指出這個(gè)手術(shù)還可以避免輸卵管扭轉(zhuǎn)這個(gè)疾病。4.對(duì)于一些患者而言，預(yù)防性輸卵管切除術(shù)可能預(yù)防卵巢癌。

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