NCCN子宫内膜癌疗指南解读

1、 *省肿瘤医院2011.5.31概要l1.2009年子宫内膜癌figo分期变更l2.2011年nccn指南解读l 子宫内膜样腺癌的初始治疗l 完备分期手术后的辅助治疗l 不全手术分期后的处置惩罚l 复发的治疗l 特殊类型子宫内膜癌的治疗l 激素治疗和化疗23312312l正常子宫内膜周期性再生、分化、剥脱，依赖女性激素作用。l无排卵、排卵不规则妇女因雌激素刺激，子宫内膜持续增生this is the microscopic appearance of normal proliferative endometrium in the menstrual cycle. the proliferati

2、ve phase is the variable part of the cycle. in this phase, tubular glands with columnar cells and surrounding dense stroma are proliferating to build up the endometrium following shedding with previous menstruation.here is early secretory endometrium. the appearance with prominent subnuclear vacuole

3、s in cells forming the glands is consistent with post-ovulatory day 2. the histologic changes following ovulation are quite constant over the 14 days to menstruation and can be utilized to date the endometrium. 正常子宫内膜正常子宫内膜 增生期增生期 早期分泌期早期分泌期(proliferative endometrium) (early secretory endometrium)th

4、is is normal secretory phase endometrium. note the larger tortuous glands with secretions. the secretory phase follows a set 14 day course leading to either implantation of a fertilized ovum or menstruation.晚期分泌期（月经前期）晚期分泌期（月经前期）(secretory phase endometrium) this is endometrial cystic hyperplasia in

5、 which the amount of endometrium is abnormally increased and not cycling as it should. the glands are enlarged and irregular with columnar cells that have some atypia. simple endometrial hyperplasias can cause bleeding, but are not thought to be premalignant. however, adenomatous hyperplasia is prem

6、alignant.子宫内膜非典型增生子宫内膜非典型增生（40岁） 年代 例 癌变率 年限gusberg 1963 68 12 % 1.5-9chamlian 1970 97 14 % 1-14wentz 1974 22 81.8 % 2-8sheman 1978 91 57.1% 2-15盖铭英 1981 41 9.7 % 3-15kurman 1985 48 23 % 1-11 l绝经后5059岁妇女最多;l60%绝经后, 30%绝经前;l高发年龄58岁，中间年龄61岁;l40岁以下患者仅占2% 5%;l25岁以下患者极少 。 this adenocarcinoma of the endom

7、etrium is more obvious. irregular masses of white tumor are seen over the surface of this uterus that has been opened anteriorly. the cervix is at the bottom of the picture. this enlarged uterus was no doubt palpable on physical examination. such a neoplasm often present with abnormal bleeding.the e

8、ndometrial adenocarcinoma is present on the lumenal surface of this cross section of uterus. note that the neoplasm is superficially invasive. the cervix is at the right. 子宫内膜癌子宫内膜癌 iii 期期 侵肌全层、宫颈、附件侵肌全层、宫颈、附件 侵肌侵肌 this is endometrial adenocarcinoma which can be seen invading into the smooth muscle

9、bundles of the myometrial wall of the uterus. this neoplasm has a higher stage than a neoplasm that is just confined to the endometrium or is superficially invasive.子宫内膜癌侵肌子宫内膜癌侵肌the endometrial adenocarcinoma in the polyp at the left is moderately differentiated, as a glandular structure can still

10、be discerned. note the hyperchromatism and pleomorphism of the cells, compared to the underlying endometrium with cystic atrophy at the right. 子宫内膜增生子宫内膜增生子宫内膜子宫内膜 癌（息肉样）癌（息肉样） 子宫内膜增生子宫内膜增生 。 normal cavityhysteroscopypolyp 阴道流血、排液或宫腔积脓、积液者阴道流血、排液或宫腔积脓、积液者 妇科检查妇科检查 细胞学检查细胞学检查 腹部或阴道腹部或阴道b b超检查超检查 宫腔镜检

11、查宫腔镜检查 分段刮宫分段刮宫 病理组织学检查确诊病理组织学检查确诊 图图 子宫内膜癌的诊断步骤子宫内膜癌的诊断步骤 全子宫切除全子宫切除筋膜外子宫切除筋膜外子宫切除次广泛子宫切除次广泛子宫切除广泛子宫切除广泛子宫切除。组织学形态l常见的形态依次为乳头状、腺样、实性、管状l通常至少由上述两种形态组成l可见嗜酸性细胞，“鞋钉”样细胞l核多形性通常很明显透明细胞癌、组织类型、治疗 临床分期：l局部复发与分期无关。l远处复发则与淋巴结受累（iii期）密切相关。l有无淋巴血管浸润是唯一预测子宫内膜癌复发的因素。 组织类型：l局部复发以腺癌为多。l近年来未见组织类型与复发关系研究的报道。 治疗方式：l 术后放疗可降低局部复发率，l 但增加远距离复发。l 其远距离复发率高的原因： 可能与接受放疗患者的高危因素有关， 而与治疗方式无关。l我院早期子宫内膜癌中复发病例11/112例（9.82%）。l临床分期：ib期2例，ic期7例，ii a期1例，iib期1例；l病理类型：子宫内膜腺癌9例，腺棘癌1例，浆液性乳头状腺癌1例；l组织分级： g1：4例 ， g2：5例， g3：2例；l肌层浸润：2例侵犯浅肌层，9例至少侵肌1/2。l首次治疗：l复发组8例(72.73%)行分期手术，l3例未行淋巴结切除术或活检术；l术后放疗9例；l在发现复发前均未行术后辅助化疗；l2例术后应用