宫颈癌标准治疗选择课件

1、Standard Treatment Optionsfor Cervical Cancer FIGO: Staging classifications and clinical practice guidelines of Cervical cancerNational Cancer Institute M.D. Anderson Cancer CenterPractical Gynecologic Oncology 4th Edition宫颈癌标准治疗选择Standard Treatment OptionsforCancers of the Female Reproductive Tract

2、:Worldwide Statistics1 Ferlay et al. GLOBOCAN 2000 IARC, WHO 2001 () CancerNew CasesDeathsCervical470,000230,000Endometrial189,00045,000Ovarian192,000114,000USANorthern EuropeSouthern Europe23,80010,00010,20015,6007,2006,200宫颈癌标准治疗选择Cancers of the Female Reproduc1974-2000上海市居民妇科肿瘤发病率上海市肿瘤研究流行病研究室年报告

3、宫颈癌标准治疗选择1974-2000上海市居民妇科肿瘤发病率上海市肿瘤研究流宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择Treatment Option Overview Five randomized phase III trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy,1-6 while 1 trial examining this regimen demonstrated no

4、 benefit.7The risk of death from cervical cancer was decreased by 30% to 50% by concurrent chemoradiation. Based on these results, strong consideration should be given to the incorporation of concurrent cisplatin- based chemotherapy with radiation therapy in women who require radiation therapy for t

5、reatment of cervical cancer.1-8宫颈癌标准治疗选择Treatment Option Overview FiveTreatment Option OverviewSurgery and radiation therapy are equally effective for early-stage small-volume disease.9 Younger patients may benefit from surgery in regard to ovarian preservation and avoidance of vaginal atrophy and s

6、tenosis. Patterns of care studies clearly demonstrate the negative prognostic effect of increasing tumor volume. Therefore, treatment may vary within each stage as currently defined by FIGO, and will depend on tumor bulk and spread pattern.10 宫颈癌标准治疗选择Treatment Option OverviewSurgeTreatment Option O

7、verviewTherapy of patients with cancer of the cervical stump is effective, yielding results comparable to those seen in patients with an intact uterus.11 During pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert colposcopy is recomm

8、ended to exclude invasive cancer. Treatment of invasive cervical cancer during pregnancy depends on the stage of the cancer and gestational age at diagnosis.宫颈癌标准治疗选择Treatment Option OverviewThera宫颈癌分期:临床诊断分期有经验的医师、在麻醉下进行检查后来的发现不能改变已经确定的期别触诊、视诊、阴道镜、宫颈管诊刮术(ECC)、宫腔镜、膀胱镜、直肠镜、静脉尿路造影、以及骨骼和肺部x线检查膀胱和直肠怀疑病灶

9、须经活检并有组织学证实淋巴管造影、动脉造影、静脉造影、剖腹探查术、超声探查、CT扫描和磁共振（MRI）等，故不能作为改变期别的根据对扫描检查怀疑的淋巴结行细针穿刺，能帮助制定治疗计划宫颈癌标准治疗选择宫颈癌分期:临床诊断分期有经验的医师、在麻醉下进行检查宫颈宫颈癌分期:手术治疗后病理分期手术-病理检查切除的标本结果，是最确切诊断肿瘤侵犯范围这些结果不能改变临床分期，但可将这些结果记录在疾病的病理分期法则中，TNM分期正是符合情况首次诊断时确定分期，而且不能更改，即使在复发时也是如此只有在临床分期的准则严格执行时，才有可能比较各个临床单位和不同治疗方式的结果宫颈癌标准治疗选择宫颈癌分期:手术治疗

10、后病理分期手术-病理检查切除的标本结宫颈癌标准治疗选择宫颈癌标准治疗选择临床分期检查方法临床分期非损伤性诊断检查双足淋巴管X线照片（Bipedal lymphangiogram） 计算机断层X线扫描术（CT, Computed Tomography） 超声波扫描术（Ultrasonography） 磁共振成像（MRI, Magnetic Resonance Imaging） 正电子发射断层扫描（PET, Positron Emission Tomography） 细针吸取细胞学检查 手术分期： 治疗前，腹主动脉旁LN，延伸放射野?剖腹探查术的方法腹腔镜分期宫颈癌标准治疗选择临床分期检查方法临床

11、分期宫颈癌标准治疗选择Surgical StagingPretreatment surgical staging is the most accurate method to determine extent of disease. Because there is little evidence to demonstrate overall improved survival with routine surgical staging, it usually should be performed only as part of a clinical trial. Pretreatment

12、surgical staging in bulky, but locally curable, disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. If abnormal nodes are detected by CT scan or lymphangiography, fine needle aspiration should be negative before a surgical staging procedure is perfo

13、rmed. 宫颈癌标准治疗选择Surgical StagingPretreatment s腹主动脉旁淋巴结CT阴性患者中生存率曲线与PET扫描结果的关系 J Clin Oncol 2001;19: 37453749.)宫颈癌标准治疗选择腹主动脉旁淋巴结CT阴性患者中生存率曲线与PET扫描结果的关IB期宫颈癌盆腔淋巴结转移率 宫颈癌标准治疗选择IB期宫颈癌盆腔淋巴结转移率 宫颈癌标准治疗选择 II 和 III期宫颈癌腹主动脉旁淋巴结转移率 宫颈癌标准治疗选择 II 和 III期宫颈癌腹主动脉旁淋巴结转移率 宫颈癌标准宫颈癌治疗：根据期别选择0期微小浸润癌B1期和早A癌B至A期宫颈癌宫颈癌标准治疗

14、选择宫颈癌治疗：根据期别选择0期宫颈癌标准治疗选择Stage 0 Cervical Cancer Standard treatment options: Methods to treat ectocervical lesions include: Loop electrosurgical excision procedure (LEEP).7,8 Laser therapy.9 Conization. Cryotherapy.10 When the endocervical canal is involved, laser or cold-knife conization may be use

15、d for selected patients to preserve the uterus and avoid radiation therapy and/or more extensive surgery. Total abdominal or vaginal hysterectomy is an accepted therapy for the postreproductive age group and is particularly indicated when the neoplastic process extends to the inner cone margin.For m

16、edically inoperable patients, a single intracavitary insertion with tandem and ovoids for 5,000 milligram hours (8,000 cGy vaginal surface dose) may be used.11 宫颈癌标准治疗选择Stage 0 Cervical Cancer Standa对异常Pap 涂片或活检示微小浸润癌处理步骤 Pap涂片异常或钳取活检“微小浸润癌”锥切活检微小浸润5mm切缘阴性ECC阴性ECC阴性切缘和/或ECC示非典型增生A1期无广泛LVSI如有生育愿望者锥切筋

17、膜外子宫切除再次锥切活检如锥切不便行改良RH盆腔淋巴结切除术广泛LVSI的A1期A2期如有生育愿望者盆腔淋巴结切除加锥切，或广泛宫颈切除改良RH和盆腔淋巴结切除宫颈癌标准治疗选择对异常Pap 涂片或活检示微小浸润癌处理步骤 Pap涂片异常Stage IA Cervical Cancer Equivalent treatment options: Intracavitary radiation alone: If the depth of invasion is less than 3 millimeters and no capillary lymphatic space invasion i

18、s noted, the frequency of lymph node involvement is sufficiently low that external beam radiation is not required. One or 2 insertions with tandem and ovoids for 6,500 to 8,000 milligram hours (10,000-12,500 cGy vaginal surface dose) are recommended.4 Radiation should be reserved for women who are n

19、ot surgical candidates. 宫颈癌标准治疗选择Stage IA Cervical Cancer EquiIB 和早 IIA期宫颈癌的治疗步骤期早期（阴道前壁侵犯）除外根治性子宫切除盆腔淋巴结切除切除任何增大腹主动脉旁淋巴结淋巴结阴性高危险（GOG分数120）多个阳性淋巴结或增大阳性淋巴结淋巴结阴性低危险观察小野盆腔放疗延伸野放疗顺铂周疗宫颈癌标准治疗选择IB 和早 IIA期宫颈癌的治疗步骤期根治性子宫切除淋巴结Stage IIB Cervical Cancer Stage III Cervical Cancer Stage IVA Cervical Cancer Radia

20、tion therapy plus chemotherapy: Intracavitary radiation and external-beam pelvic irradiation combined with cisplatin or cisplatin/fluorouracil.7-12 宫颈癌标准治疗选择Stage IIB Cervical Cancer St晚期宫颈癌的诊治步骤B-A宫颈癌腹、盆腔CT盆、腹腔阴性盆腔或腹腔淋巴结1.5cm附件包块胸部CT胸部CT阴性胸部CT阳性切除附件包块肿大淋巴结腹膜外切除延伸野放疗和DDP周疗姑息性盆腔放疗预防性延伸野放疗和DDP周疗宫颈癌标准治

21、疗选择晚期宫颈癌的诊治步骤B-A宫颈癌腹、盆腔CT盆、腹腔阴性Recurrent Cervical Cancer Standard treatment options: For recurrence in the pelvis following radical surgery, radiation in combination with chemotherapy (fluorouracil with or without mitomycin) may cure 40% to 50% of patients.3 Chemotherapy can be used for palliation. Tested drugs include