1、王建六北京大學人民醫院婦產科子宮內膜癌診治子宮內膜癌診治關注幾個問題關注幾個問題outlinefigo 2009新分期的臨床意義子宮切除范圍淋巴結切除指征子宮內膜癌09分期修訂（1）i腫瘤局限于子宮體 ia腫瘤局限于子宮內膜 ib腫瘤浸潤深度1/2肌層腫瘤局限于子宮體 a 腫瘤浸潤深度1/2肌層 b 腫瘤浸潤深度1/2肌層如何判斷侵肌深度？tvs：準確率84.6%，淺肌層為82.4% 深肌層為77.9%，無侵肌100%mri:90%術者肉眼剖視準確性89.7%病理醫生肉眼觀察 86.2%冰凍切片 91.4% 建議tvs+mri，注重術中剖視子宮內膜癌09分期修訂（2）ii腫瘤侵犯宮頸，但無宮體

2、外蔓延 iia僅宮頸內膜腺體受累 iib宮頸間質浸潤累及宮頸內膜腺體的預后和累及宮頸內膜腺體的預后和期無差異期無差異ii腫瘤侵犯宮頸間質，但無宮體外蔓延如何判定宮頸間質受侵？dc或或hs宮頸管陰性宮頸管陰性宮頸上皮浸潤宮頸上皮浸潤子宮切除術子宮切除術mri tvs局限于頸管內膜局限于頸管內膜侵犯宮頸間質侵犯宮頸間質廣泛子宮切除術廣泛子宮切除術宮頸間質浸潤宮頸間質浸潤子宮內膜癌09分期修訂(3)iii局部和(或)區域的擴散 iiia腫瘤侵犯漿膜層和(或)附件(直接蔓延或轉移)，和(或)腹水 或腹腔洗液有癌細胞 iiib陰道浸潤(直接蔓延或轉移)局部和(或)區域擴散 a 腫瘤累及漿膜層和(或)附件

3、 b 陰道和(或)宮旁受累0909分期刪去細胞學檢查結果分期刪去細胞學檢查結果 為什么要刪去細胞學檢查？腹水細胞學陽性和腹腔或淋巴結的轉移不相關，不影響預后沒有足夠的證據說明腹水細胞學陽性與復發風險和治療效果有何關系figofigo仍推薦進行細胞學檢查，并單獨報告結果仍推薦進行細胞學檢查，并單獨報告結果子宮內膜癌09分期修訂（4）iiic盆腔和(或)腹主動脈旁淋巴結轉移iiic盆腔和(或)腹主動脈旁淋巴結轉移 iiic1盆腔淋巴結陽性 iiic2腹主動脈旁淋巴結陽性(和盆腔淋巴結陽性)主動脈旁淋巴結轉移預后比盆腔淋巴結轉移差主動脈旁淋巴結轉移預后比盆腔淋巴結轉移差 163 case 35 (2

4、1.5%) nodal metastases positive pelvic 26 (16.0%) aortic 24 (27.3%) isolated aortic 17 (19.3%) the recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases all those who recurred died of disease within seven to 28 months. eur j gynaecol oncol. 2007;28(2):98-102is aor

5、tic lymphadenectomy necessary?子宮內膜癌如何切除子宮？子宮內膜癌如何切除子宮？筋膜內子宮切除術全宮切除術 筋膜外子宮切除術定義？手術中要點？與全子宮切除術異同？筋膜外子宮切除術 現代婦產科手術與技巧史常旭 主編 人民軍醫 2004 婦產科臨床解剖學蘇應寬 等主編 山東科技出版社 2001 實用婦科腹腔鏡手術學李廣儀主編 人民衛生2006 婦科手術學萬小平主譯 人民衛生2003 均無描述15i i期子宮內膜癌期子宮內膜癌子宮切除范圍：比較明確，存在混淆子宮切除范圍：比較明確，存在混淆筋膜外子宮切除術？筋膜外子宮切除術？全子宮切除術？全子宮切除術？二者異同？二者異同？

6、次廣泛子宮切除術？次廣泛子宮切除術？ i期子宮內膜癌gog2010:women with endometrial cancers should undergo total abdominal hysterectomy and bso), pelvic/paraaortic dissection婦科常見惡性腫瘤治療指南：筋膜外子宮切除術林巧稚婦科腫瘤學：全子宮切除術婦產科學第七版（林仲秋）：筋膜外子宮切除術 筋膜外子宮切除術？ 標準全子宮切除術？ 仁者見仁，智者見智仁者見仁，智者見智 下推膀胱至宮頸外口水平下較低水平 主韌帶：宮頸旁切除（貼而略離開） 宮骶韌帶：單獨處理 陰道切除1cm17廣泛子

7、宮切除術目的：切除宮旁可能的轉移廣泛子宮切除術目的：切除宮旁可能的轉移文獻：樣本例數較多的回顧性研究文獻：樣本例數較多的回顧性研究sartori e, et al. int j gynecol cancer 2001;11(6):430437 203 cases：10-y os 74% (tah) vs 94%(rh)boente mp,et al. gynecol oncol 1993;51(3):316322. 202 cases：5-y os 77% (tah) vs 86%(rh)cornelison tl, gynecol oncol 1999;74(3):350355. 932 c

8、ases：5-y os 84% (tah) vs 93%(rh) op alone 5-y os 83% (tah) vs 88%(rh) op+rt korea， japan： choose the surgical extent of hysterectomy through their own disposition and do not strictly adhere the results of pre operative evaluation.japanese group more than 70% of institutes never perform rh without re

9、garding the preoperative status of cervical involvement (watanabe)north american：20%-30% center 宮頸累及一定要行廣泛子宮切除術嗎？宮頸累及一定要行廣泛子宮切除術嗎？this is an area of continued debate！ 21j korean med sci 2010; 25: 552-6：1. current pre-operative evaluation method is not sensitive enough to detect cervical invasion2. m

10、edical status3. cervical stromal invasion should be followed by adjuvant radiotherapy and thus, the prognosis would not be changed by performing a high morbidity producing surgery considering the low incidence of pmi：4.metastasis characteristics: different from cervical cancerpmi: low incidence 6%pm

11、i(+): ln(+) 80%ln(+): pmi(+)45%metastasis patterns: direct invasion of cancer cells to the parametrial connective tissues parametrial lymphvascular space invasion frequently seen in patients with deep myometrial involvement without cervical involvement婦科常見腫瘤診治指南 中華醫學會婦科腫瘤分會 p49i期子宮內膜癌應行手術分期術式為筋膜外子宮切

12、除術及雙附件切除術 盆腔及腹主動脈旁淋巴結切除和（或）取樣術腹主動脈旁淋巴結切除/取樣指征： 可疑淋巴結轉移 特殊組織類型 ca125顯著升高 宮頸受累 深肌層受累 低分化i期子宮內膜癌淋巴結切除必要性？期子宮內膜癌淋巴結切除必要性？全國高等院校教材 婦產科學 樂杰主編 林仲秋編寫 p275i期子宮內膜癌應行筋膜外子宮切除術及雙附件切除術 盆腔及腹主動脈旁淋巴結切除和（或）取樣術下列情況之一，應行盆腔及腹主動脈旁淋巴結切除和（或）取樣術可疑淋巴結增大 宮頸受累 ca125顯著升高特殊組織類型 低分化 深肌層受累 癌灶累及宮腔面積超過50%cochrane database syst rev.

13、2010 jan 20;(1):cd007585.lymphadenectomy for the management of endometrial cancer.may k, bryant a, dickinson ho, kehoe s, morrison j university of oxford, womens centre no evidence that lymphadenectomy decreases the risk of death or disease recurrence compared with no lymphadenectomy in women with p

14、resumed stage i disease. the evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgically related systemic morbidity or lymphoedema/lymphocyst formation.國外近2年的文獻報道lancet. 2009 jan 10;373(9658):125-36. epub 2008 dec 16.efficacy of systema

15、tic pelvic lymphadenectomy in endometrial cancer (mrc astec trial): a randomised study.collaborators (180) amos c, blake p, branson a, buckley ch, redman cw, shepherd j, dunn g, heintz p, yarnold j, johnson p, mason m, rudd r, badman p, begum s, chadwick n, collins s, goodall k, jenkins j, law k, mo

16、ok p, sandercock j, goldstein c, uscinska b, cruickshank m, parkin de, crawford ra, latimer j, michel m, clarke j, dobbs s, mcclelland rj, price jh, chan kk, mann c, rand r, fish a, lamb m, goodfellow c, tahir s, smith jr, gornall r, kerr-wilson r, swingler gr, lavery ba, chan kk, kehoe s, flavin a,

17、 eddy j, davies-humphries j, hocking m, sant-cassia lj, pearson s, chapman rl, hodgkins j, scott i, guthrie d, persic m, daniel fn, yiannakis d, alloub mi, gilbert l, heslip mr, nordin a, smart g, cowie v, katesmark m, murray p, eddy j, gornall r, swingler gr, finn cb, moloney m, farthing a, hanoch

18、j, mason pw, mcindoe a, soutter wp, tebbutt h, morgan js, vasey d, cruickshank dj, nevin j, kehoe s, mckenzie iz, gie c, davies q, ireland d, kirwan p, davies q, lamb m, kingston r, kirwan j, herod j, fiander a, lim k, head ac, lynch cb, browning aj, cox c, murphy d, duncan id, mckenzie c, crocker s

19、, nieto j, paterson me, tidy j, duncan a, chan s, williamson km, weekes a, adeyemi oa, henry r, laurence v, dean s, poole d, lind mj, dealey r, godfrey k, hatem mm, lopes a, monaghan jm, naik r, evans j, gillespie a, paterson me, tidy j, ind t, lane j, oates s, redford d, ford m, fish a, larsen-disn

20、ey p, johnson n, bolger a, keating p, martin-hirsch p, richardson l, murdoch jb, jeyarajah a, lamb m, mcwhinney n, farthing a, mason pw, kitchener h, beynon jl, hogston p, low em, woolas r, anderson r, murdoch jb, niven pa, kerr-wilson r, chin k, flynn p, freites o, newman gh, mcnally o, cullimore j

21、, olaitan a, mould t, menon v, redman cw, george m, hatem mh, evans a, fiander a, howells r, lim k, cawdell g, warwick ap, eustace d, giles j, leeson s, nevin j, van wijk al, karolewski k, klimek m, blecharz p, mcconnell d. median follow-up of 37 months (iqr 24-58) 191 women had died: 88/704 standar

22、d surgery group 103/704 lymphadenectomy group251recurrent disease 107/704 standard surgery group 144/704 lymphadenectomy group)no evidence of benefit：or or dfs for pelvic lymphadenectomy in early endometrial cancer.pelvic lymphadenectomy cannot be recommended as routine procedure for therapeutic pur

23、poses outside of clinical trials.術前b超、mri等估計深肌層受侵術前病理分級為g3術前臨床分期ii期以上術中探查腹膜后淋巴結可疑轉移術中發現侵肌1/2術中發現宮腔50%以上有病灶累及子宮內膜漿乳癌、透明細胞癌等todoy et al. survival effect of para-aortic lymphadenectomy in endometrial cancer (sepal study): a retrospective cohort analysis. lancet. 2010 apr 3;375(9721):1165-72 combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. 一定要切除腹主動脈旁淋巴結嗎？esmo2009 intermediate-risk group: aged 60 yrs deeply invasive g1 or g2 superfic