宫颈癌标准治疗选择课件

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上海市居民妇科肿瘤发病率

上海市肿瘤研究流行病研究室年报告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2/6/2023Dr.XiaohuaWu10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2/6/2023Dr.XiaohuaWu112/6/2023Dr.XiaohuaWu13SurgicalStagingPretreatmentsurgicalstagingisthemostaccuratemethodtodetermineextentofdisease.Becausethereislittleevidencetodemonstrateoverallimprovedsurvivalwithroutinesurgicalstaging,itusuallyshouldbeperformedonlyaspartofaclinicaltrial.Pretreatmentsurgicalstaginginbulky,butlocallycurable,diseasemaybeindicatedinselectcaseswhenanonsurgicalsearchformetastaticdiseaseisnegative.IfabnormalnodesaredetectedbyCTscanorlymphangiography,fineneedleaspirationshouldbenegativebeforeasurgicalstagingprocedureisperformed.2/6/2023Dr.XiaohuaWu14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

JClinOncol2001;19:3745–3749.)2/6/2023Dr.XiaohuaWu15IB期宫颈癌盆腔淋巴结转移率

2/6/2023Dr.XiaohuaWu17宫颈癌治疗：根据期别选择0期微小浸润癌ⅠB1期和早ⅡA癌ⅡB至ⅣA期宫颈癌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ⅠA1期无广泛LVSI如有生育愿望者锥切筋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ⅠA1期ⅠA2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2/6/2023Dr.XiaohuaWu21IB

和早

IIA期宫颈癌的治疗步骤Ⅰ期早Ⅱ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2/6/2023Dr.XiaohuaWu22StageIIBCervicalCancer

StageIIICervicalCancer

StageIVACervicalCancer

Radiationtherapypluschemotherapy:Intracavitaryradiationandexternal-beampelvicirradiationcombinedwithcisplatinorcisplatin/fluorouracil.[7-12]2/6/2023Dr.XiaohuaWu23晚期宫颈癌的诊治步骤ⅡB-ⅣA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2/6/2023Dr.XiaohuaWu25术后放射治疗：范围及适应症

标准野：阳性盆腔淋巴结阳性宫旁组织阳性手术切缘阳性患者