1、子宮內膜癌治療相關問題北京大學人民醫院婦產科 王建六子宮內膜癌新分期子宮內膜癌淋巴結切除必要性子宮內膜癌子宮切除的范圍子宮內膜癌09分期修訂1I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 2cm 15% entire uterine cavity 35%5-y survival: 2cm - 98% 2cm - 84% entire uterine cavity - 64% 建議有指征的行腹膜后淋巴結切除術腹膜后淋巴結切除指征術前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

2、1/2術中發現宮腔50%以上有病灶累及子宮內膜漿乳癌、透明細胞癌等一定要切除腹主動脈旁淋巴結嗎？Eur J Gynaecol Oncol. 2007;28(2):98-102. Prince of Wales Hospital, Shatin, Hong Kong Is aortic lymphadenectomy necessary in the management of endometrial carcinoma?75 (46.0%) pelvic lymphadenectomy alone 88 (54.0%) had both pelvic and aortic lymphadene

3、ctomy35 (21.5%) nodal metastases positive pelvic 26 (16.0%)positive aortic 24 (27.3%) Isolated aortic metastases 17 cases (19.3%) 35 patients with nodal metastases recurrence developed in 15 (42.9%) and all except one died within five to 50 monthsThe recurrence rate was higher (63.6%) among patients

4、 with upper aortic lymph node metastasesall those who recurred died of disease within seven to 28 months. CONCLUSIONSaortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metastatic risk. Todo Y et al.Survival effect of para-aortic

5、 lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet. 2010 Apr 3;375(9721):1165-72 671 patients with endometrial carcinomasystematic pelvic lymphadenectomy (n=325)pelvic and para-aortic lymphadenectomy (n=346) INTERPRETATION: Combined pelvic and para-aortic l

6、ymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. 期子宮內膜癌子宮切除范圍33I期子宮內膜癌子宮切除范圍： 全子宮切除術？筋膜外子宮切除術？二者異同？ 次廣泛子宮切除術？FIGO 2009 子宮內膜癌分期改變影響子宮內膜癌子宮切除范圍的選擇嗎？局限于子宮的內膜癌手術選擇爭議：局限于子宮，宮頸累及？廣泛子宮切除術？子宮切除范圍值得探討 內膜癌病變局限于子宮-手術方式Disease limited

7、 to uterusMedically inoperable operableTumor directed RTTotal hysterectomy and bilateral salpingo-oophorectomyLympho nodes dissection pelvic+para aorticThe current NCCN Clinical Practice Guideline recommendspracticing radical hysterectomy only when cervical infiltrationis suspected on MRI or when co

8、nfirmed by cervical biopsy.2009NCCNFIGO: 筋膜外子宮切除術GOG2010:Women with endometrial cancers should undergo total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-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：全子宮切除術中國婦產科學（曹澤毅主編）：筋膜外子宮切除術 I 期子宮內膜癌-手術方式 I 期子宮內膜癌-手術方式Gan To

9、Kagaku Ryoho. 1995 Aug;22(9):1163-8. Total hysterectomy is done for cases of stage 0, modified radical hysterectomy for stage I, radical hysterectomy for stage II, and radical hysterectomy combined with resection of the metastatic lesions for stage III and IV Zhonghua Fu Chan Ke Za Zhi. 2002 Feb;37(

10、2):90-3. Surgical method is not the main factor influenced the survive of stage I endometrial carcinoma. 為什么不行廣泛或次廣泛子宮切除術 MauroSignorelli, et al. Gynecologic Oncology 2009Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer Recurrence Class I

11、hysterectomy(n =263)Class II hysterectomy(n=257)NO recurrence231(87.8)228 (88.7)WIth recurrence32 (12.2)29 (11.3)DFS HR (95% CI) 87.7%(1.0 ref) 89.7%(0.91) (0.551.51) OS HR (95% CI)88.9% (1.0 ref) 92.2%(0.77) (0.441.33) 筋膜外子宮切除術目的 to ensure that the cervix is entirely removed適應癥：子宮內膜癌，早期宮頸癌與全子宮切除術異同

12、？定義？手術中要點？ 筋膜外子宮切除術方法：The position of the ureters is determined by palpation without freeing the ureters from their beds. The parametrium is transected medial to the ureter, but lateral to the cervix, keeping the paracervical ring intact. The uterosacral and vesicouterine ligaments are transected cl

13、ose to the uterus. There is no removal of paracolpos and a minimal part of vagina is resected at fornix level. 病變累及宮頸手術范圍的選擇 II期子宮內膜癌子宮切除范圍首選廣泛子宮切除術（IIIII型子宮根治術）累及宮頸粘膜，現在歸為I期，子宮切除范圍？累及粘膜和間質如果應該選擇不同的手術范圍，如何術前鑒別診斷之？宮頸是否累及？是否間質浸潤？術前診斷困難40分期改變帶來的新問題累及宮頸粘膜（I期）？OLD：IC差于IIANEW：II差于所有I期IIA期宮旁累及？ 宮頸癌早期手術范圍如何

14、識別粘膜累及還是間質浸潤FIGO1988FIGO 2009I期IAIBIC(56757)91%89%77% 90%78%IIIAIIIBIIICIIIC1IIIC259%36%54%(3120)56%36%-57%49% 累及宮頸粘膜（ 一期）？診斷和鑒別宮頸粘膜累及還是間質浸潤分段診刮或宮腔鏡檢查宮頸管陰性宮頸上皮浸潤I 型子宮切除術MR局限于頸管內膜侵犯宮頸間質II或III型子宮切除術宮頸間質浸潤 宮頸累及時子宮切除范圍選擇指 南：廣泛子宮切除術 局限于子宮歸為一類II期子宮內膜癌: 筋膜外或廣泛子宮切除術KOREA， JAPAN： Choose the surgical extent o

15、f 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 regarding the preoperative status of cervical involvement (Watanabe)NORTH AMERICAN：20-30% center II期子宮內膜癌RH 手術的必要性II期子宮內膜癌手術方式的選擇II期子宮內膜癌RH 手術的必要性Depth of myometrial invasion and pelvic or paraaortic lymph node