子宫肿瘤-妇产科课件

DepartmentofObstetricsandGynecology妇产科ZhangWei张蔚Definition：Cervicalintraepithelialneoplasia(CIN)isapremalignantconditionofthecervix.Itisusuallyasymptomaticandisdetectedbyroutinecytologicalscreening.ThedegreeofseverityisgradedCINⅠ、ⅡtoCINⅢTBStypesatypicalsquamouscells(ASC)不典型鳞状上皮Low-gradesquamousintraepitheliallesion(LSIL)轻度鳞状上皮内病变High-gradesquamousintraepitheliallesion(HSIL)重度鳞状上皮内病变AetiologyTheareaofpreviouslyexposedcolumnarepitheliumthatundergoessquamousmetaplasiaisknownasthetransformationzone(TZ)

病因学

原始鳞柱交接部和生理鳞柱交接部间的区域称为移行带ItisthepredilectionsiteofcervicalcarcinomaEctropionandtransformationofthetransformationzone移行带区的外翻和转化transformation

mechanism

转化机制squamousmetaplasia鳞状上皮化生squamousepithelization鳞状上皮化Youngageatfirstintercourse初次性生活的年龄过小

Numberofsexualpartners性伙伴的数目

Smoking吸烟

Pooruptakeofscreeningprogramme

筛查过少

Long-termuseofthecontraceptivepill长期服用避孕药

Exposuretotumorpromotershasagreaterinfluenceonimmaturecells不成熟的细胞暴露于致癌因素会对其产生很大的影响Pilltakersdonotnecessarilyusebarriermethods-increasingexposuretoseminalfluids

服用药物而没有使用屏障的方法，会增加精液的刺激

Male-relatedriskfactors与男性相关的危险因素

Thenumberofthepartner'sprevioussexualrelationshipsisrelevant

与以前性伙伴的数目有关Immunosuppressant免疫抑制

HPVinfection

HPV感染

Mainlysubtype16

主要是16型

Screening(筛查)

Toobtainacompletediagnosisthetriageofcytology,colposcopyandhistologicalbiopsyareneeded,assmearsareoftenunderreported要想达到完整的细胞学分类诊断需要阴道镜和活检，因为细胞涂片常常取决于报告人的经验

Cytology

细胞学dyskaryosis

isacytologicaltermItdescribesfeaturesofindividualcellssuchassizeandstainingofnucleiandtheamountofcytoplasm

细胞核异常是细胞学特点。表现为各个细胞核的大小、染色和细胞质的数量的改变Milddyskaryosis轻度核异常ModeratedyskaryosisSeveredyskaryosis中度核异常重度核异常Normal-sizednucleusMildnuclearabnormalitiesNucleuslargerthannormalbut<50%ofcell细胞核大于正常，但小于细胞的50％Nucleus>50%ofcellNucleusirregular细胞大小正常轻度核异常细胞核大于细胞的50％胞核不规则Cellborderrounded细胞边界变圆Angularcellborders细胞边界有角Histology

组织学

Dysplasia

isahistologicalterm.Itrequiresafull-thicknessbiopsyfordiagnosis.Carcinoma-in-situandCINⅢaremoreorlesssynonymous.Thebasementmembraneremainsintact

组织学检查发现分化异常。需要取表皮全层活组织检查诊断，原位癌和CINⅢ在某种程度上是相同的，都没有突破基底膜CINⅠ

CINⅡCINⅢ

Upper2/3ofepitheliumexhibitsreasonabledifferentiation2/3以上的上皮组织分化正常Upper1/2ofepitheliumwelldifferentiated1/2以上的上皮组织分化正常Maturationconfinedtosuperficial1/3(orabsent)分化成熟的组织局限于表皮1/3或没有Colposcopy（阴道镜检查）Indysplastictissuethenormalpatternofbloodvesselsbecomesdistortedandpunctationand

mosaicismareseen

在异常的组织中可以看到正常结构的血管变得弯曲、极细的点、血管网围绕的镶嵌现象（镶嵌的白色或黄色的上皮块）

Colposcope

阴道镜Abnormaltissuestainswhitewithaceticacidbutwillnottakeupthebrowniodinestain.Studyingthevesselpatternsandstainingreactions,acolposcopistgaugesthedegreeofCINpresent

异常的组织（醋酸染色白色）不会被碘溶液染成棕色，根据血管的模式和染色反应，用阴道镜可以较精确地估计CIN的程度CINⅡCINⅠ

CINⅢ

Localtreatment

局部治疗

loopdiathermy环形电热疗法

runninganelectriccurrentthroughathinloopofvaryingsizeandshape

电流可以通过不同大小和形状的细环coldcoagulation冷凝法carbondioxidelaser二氧化碳激光器conebiopsy锥切Loopdiathermyapparatus环形透热电疗仪Theprocessofconebiopsy

锥切的过程LoopElectrosurgicalExcisionProcedure(LEEP)normalcervix

Cervicalcarcinomaroughanduneveninsurface

smooth凸凹不平光滑Epidemiology

流行病学cancerofthecervixisthesecondmostcommonmalignancyinwomenafterbreastcancer-77%ofcasesoccurindevelopingcountriesRiskfactors危险因素Themainaetiologicalagentisinfectionwithcertainsubtypesofhumanpapillomavirus(HPV)主要的病原学因素是感染了人乳头瘤病毒的某一亚型HPVsubtype16appearstobethemainoncologicalagentHPV16是肿瘤学的主要原因Pathology

病理学

exophytic外生型growingoutwardsinapapillaryorpolypoidalexcrescenceendophytic

内生型Ulceration

溃疡型infiltratingthesurroundingstructures

excavationfrequentlyoccur

向外呈乳头状生长或菜花状

向深部浸润周围的组织

常常形成凹陷

ulceration颈管型endocervicalinfiltratingcervixandisthmusuteriRouteofmetastasis转移途径Directmetastasis直接蔓延Lymphaticmetastasis淋巴转移Hematogenousmetastasis血行转移Presentation临床表现Symptoms症状Signs体征AtroutineexaminationPostmenopausalbleedingAbnormalcells,indicativeofinvasivecarcinomaoncytology

异常细胞，细胞学提示浸润癌Intermenstrualbleeding

月经间期出血绝经后出血常规检查Offensive,blood-stainedvaginaldischarge血性白带Atcolposcopy阴道镜检查Heavy,contactbleeding接触性出血Fistulae-passageofurine,faecesorflatusvaginally(ifbowel/bladderinvolved)

（尿瘘、粪瘘形成）如果直肠膀胱受累irregularsurfacecontour表面轮廓不规则Renalfailure-bilateraluretericobstruction肾衰竭－双侧输尿管梗阻Atypicalvessels-capillariesofirregularcalibreandbranchingpattern不典型血管－毛细血管口径、分支不规则Deepvisceralornerverootpain(ifsacralnerverootinvolved)内脏或神经根疼痛（如果骶神经根受累）Lowerlimboedema-extensivepelvicsidewallinfiltration骨盆侧壁广泛浸润－下肢水肿Staging分期Staging

分期Stage1:TumorconfinedtothecervixⅠ期肿瘤局限于宫颈

aMicroinvasivecarcinomaa微浸润肿瘤a1stromalinvasion≤3mmdepthand≤7mmhorizontalspread

a1间质浸润深度≤3mm宽度≤7mma2Lesionswithadepth>3mm,but≤5mm,andahorizontalspread≤7mm

a2浸润深度>3mm≤

5mm，宽度≤7mm

bClinicallesionsconfinedtothecervix

b肿瘤损害局限于宫颈blTumordiameter≤4cm

b1肿瘤直径≤4cmb2Tumordiameter>4cm

b2肿瘤直径>4cmStage2:Spreadbeyondthecervix,butnottothepelvicsidewall,withinvolvementofuppertwo-thirdsofthevagina

Ⅱ期超越宫颈但未达盆壁，侵犯阴道，但未及下1/3aVaginalspread,butnoobviousparametrialspreada侵犯阴道，无明显盆壁浸润bParametrialspread,butnotasfaraspelvicsidewallb宫旁浸润，但未达盆壁Stage3:SpreadinthepelvisⅢ期侵犯骨盆aInvolvementoflowerone-thirdofthevagina

a侵犯阴道的下1/3bExtensiontothepelvicsidewallorhydronephrosis

b扩散至骨盆壁或肾盂积水Stage4:DistantspreadⅣ期远处转移aSpreadtoinvolveadjacentorgans[bladder,rectum]

a侵犯临近组织（膀胱、直肠）bDistantspread

b远处转移Treatmentoptions

治疗方法选择Microinvasivedisease

微观浸润性病变notyetcompletedherfamily

conservativeapproach

conebiopsy锥切

completedherfamily

Invasivedisease

浸润癌stagesIb,Ⅱaandsomecasesof2b

①whensurgicalexpertiseisnotavailable②inwomenwithatumorgreaterthan4cmindiameter③inwomenwhoarenotmedicallyfitforsurgeryRadiotherapy放疗Advanceddisease(stage4)

Combinationsofchemo-andradiotherapy

联合放化疗保守治疗RadicaltreatmentisindicatedforstagesIb,ⅡaandsomecasesofⅡb

Wertheim'sradicalhysterectomy

pelviclymphadenectomy

3cmvaginalcuff

切除阴道上端3厘米

Squamouscarcinoma

conservedtheovaries鳞状细胞癌保留卵巢Adenocarcinoma

腺癌OophorectomySquamouscarcinomadoesnotspreaddirectlytotheovaries

腺癌卵巢转移发生率约5％～10％

thereisa5-10%incidenceofovarianmetastases

Advanceddisease(stage4)

晚期患者－Ⅳ期

Combinationsofchemo-andradiotherapy

联合放化疗

survivalrateisverypoor

存活率很低

Carcinomaoftheendometriumformsthemostcommontypeofuterinecancer.Thesearemainlyadenocarcinomasderivedfromendometrialglandularcells

Riskfactors

危险因素Obesity肥胖Impairedglucosetolerance糖耐量下降Nulliparity从未生育的妇女Latemenopause绝经迟Unopposedoestrogentherapy无对抗的雌激素治疗Functioningovariantumors[granulosa-thecacelltumor]功能性卵巢肿瘤[颗粒－卵泡膜细胞瘤]Familyhistoryofcarcinomaofbreast、ovaryorcolon家族性乳腺癌、卵巢癌、结肠癌

Pathology病理学thecommonestistheendometrioidadenocarcinoma

(a)Viewofcutsurfaceoftheuterus

(b)High-powerviewofGrade1cancerRouteofmetastasis

转移途径Directmetastasis直接蔓延Lymphaticmetastasis淋巴转移Hematogenousmetastasis血行转移SymptomsandSigns

症状和体征postmenopausalbleeding

绝经后出血Discharge

阴道排液Metastaticdisease

转移Pain疼痛UltrasonographyandcolorDopplerblood-flowimagingprovideusefulscreeningtools超声和彩色多普勒血流显像图是有效的检查工具irregularand/orheavyregularbleedinginthepremenopausalgroup绝经前患者中不规则的和/或量较多的规则的出血

Renalandhepaticfunctiontests,tumormarkers,chestX-rayandpossiblyanintravenousurogramwillneedtobeundertaken

Beforetheoperation检查肝肾功能，肿瘤标记物，胸部X线检查，必要时进行静脉尿路造影

Treatment

治疗histologyshowsapoorlydifferentiatedhigh-gradetumor

Radiotherapy

放疗晚期组织学显示低分化

ifthenodesareinvolved

如果淋巴结受累stagingatthetimeofsurgeryscoresmorethanaIb

Thestage3patient

3期病人