宮頸癌標準治療選擇課件

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宮頸癌標準治療選擇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宮頸癌標準治療選擇Cancers of the Female Reproduc1974-2000上海市居民婦科腫瘤發(fā)病率上海市腫瘤研究流行病研究室年報告

3、宮頸癌標準治療選擇1974-2000上海市居民婦科腫瘤發(fā)病率上海市腫瘤研究流宮頸癌標準治療選擇宮頸癌標準治療選擇宮頸癌標準治療選擇宮頸癌標準治療選擇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宮頸癌標準治療選擇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 宮頸癌標準治療選擇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.宮頸癌標準治療選擇Treatment Option OverviewThera宮頸癌分期:臨床診斷分期有經(jīng)驗的醫(yī)師、在麻醉下進行檢查后來的發(fā)現(xiàn)不能改變已經(jīng)確定的期別觸診、視診、陰道鏡、宮頸管診刮術(ECC)、宮腔鏡、膀胱鏡、直腸鏡、靜脈尿路造影、以及骨骼和肺部x線檢查膀胱和直腸懷疑病灶

9、須經(jīng)活檢并有組織學證實淋巴管造影、動脈造影、靜脈造影、剖腹探查術、超聲探查、CT掃描和磁共振（MRI）等，故不能作為改變期別的根據(jù)對掃描檢查懷疑的淋巴結行細針穿刺，能幫助制定治療計劃宮頸癌標準治療選擇宮頸癌分期:臨床診斷分期有經(jīng)驗的醫(yī)師、在麻醉下進行檢查宮頸宮頸癌分期:手術治療后病理分期手術-病理檢查切除的標本結果，是最確切診斷腫瘤侵犯范圍這些結果不能改變臨床分期，但可將這些結果記錄在疾病的病理分期法則中，TNM分期正是符合情況首次診斷時確定分期，而且不能更改，即使在復發(fā)時也是如此只有在臨床分期的準則嚴格執(zhí)行時，才有可能比較各個臨床單位和不同治療方式的結果宮頸癌標準治療選擇宮頸癌分期:手術治療

10、后病理分期手術-病理檢查切除的標本結宮頸癌標準治療選擇宮頸癌標準治療選擇臨床分期檢查方法臨床分期非損傷性診斷檢查雙足淋巴管X線照片（Bipedal lymphangiogram） 計算機斷層X線掃描術（CT, Computed Tomography） 超聲波掃描術（Ultrasonography） 磁共振成像（MRI, Magnetic Resonance Imaging） 正電子發(fā)射斷層掃描（PET, Positron Emission Tomography） 細針吸取細胞學檢查 手術分期： 治療前，腹主動脈旁LN，延伸放射野?剖腹探查術的方法腹腔鏡分期宮頸癌標準治療選擇臨床分期檢查方法臨床

11、分期宮頸癌標準治療選擇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. 宮頸癌標準治療選擇Surgical StagingPretreatment s腹主動脈旁淋巴結CT陰性患者中生存率曲線與PET掃描結果的關系 J Clin Oncol 2001;19: 37453749.)宮頸癌標準治療選擇腹主動脈旁淋巴結CT陰性患者中生存率曲線與PET掃描結果的關IB期宮頸癌盆腔淋巴結轉移率 宮頸癌標準治療選擇IB期宮頸癌盆腔淋巴結轉移率 宮頸癌標準治療選擇 II 和 III期宮頸癌腹主動脈旁淋巴結轉移率 宮頸癌標準治療選擇 II 和 III期宮頸癌腹主動脈旁淋巴結轉移率 宮頸癌標準宮頸癌治療：根據(jù)期別選擇0期微小浸潤癌B1期和早A癌B至A期宮頸癌宮頸癌標準治療

14、選擇宮頸癌治療：根據(jù)期別選擇0期宮頸癌標準治療選擇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 宮頸癌標準治療選擇Stage 0 Cervical Cancer Standa對異常Pap 涂片或活檢示微小浸潤癌處理步驟 Pap涂片異常或鉗取活檢“微小浸潤癌”錐切活檢微小浸潤5mm切緣陰性ECC陰性ECC陰性切緣和/或ECC示非典型增生A1期無廣泛LVSI如有生育愿望者錐切筋

17、膜外子宮切除再次錐切活檢如錐切不便行改良RH盆腔淋巴結切除術廣泛LVSI的A1期A2期如有生育愿望者盆腔淋巴結切除加錐切，或廣泛宮頸切除改良RH和盆腔淋巴結切除宮頸癌標準治療選擇對異常Pap 涂片或活檢示微小浸潤癌處理步驟 Pap涂片異常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. 宮頸癌標準治療選擇Stage IA Cervical Cancer EquiIB 和早 IIA期宮頸癌的治療步驟期早期（陰道前壁侵犯）除外根治性子宮切除盆腔淋巴結切除切除任何增大腹主動脈旁淋巴結淋巴結陰性高危險（GOG分數(shù)120）多個陽性淋巴結或增大陽性淋巴結淋巴結陰性低危險觀察小野盆腔放療延伸野放療順鉑周療宮頸癌標準治療選擇IB 和早 IIA期宮頸癌的治療步驟期根治性子宮切除淋巴結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 宮頸癌標準治療選擇Stage IIB Cervical Cancer St晚期宮頸癌的診治步驟B-A宮頸癌腹、盆腔CT盆、腹腔陰性盆腔或腹腔淋巴結1.5cm附件包塊胸部CT胸部CT陰性胸部CT陽性切除附件包塊腫大淋巴結腹膜外切除延伸野放療和DDP周療姑息性盆腔放療預防性延伸野放療和DDP周療宮頸癌標準治

21、療選擇晚期宮頸癌的診治步驟B-A宮頸癌腹、盆腔CT盆、腹腔陰性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