子宮腫瘤-婦產(chǎn)科課件

DepartmentofObstetricsandGynecology婦產(chǎn)科ZhangWei張蔚Definition：Cervicalintraepithelialneoplasia(CIN)isapremalignantconditionofthecervix.Itisusuallyasymptomaticandisdetectedbyroutinecytologicalscreening.ThedegreeofseverityisgradedCINⅠ、ⅡtoCINⅢTBStypesatypicalsquamouscells(ASC)不典型鱗狀上皮Low-gradesquamousintraepitheliallesion(LSIL)輕度鱗狀上皮內(nèi)病變High-gradesquamousintraepitheliallesion(HSIL)重度鱗狀上皮內(nèi)病變AetiologyTheareaofpreviouslyexposedcolumnarepitheliumthatundergoessquamousmetaplasiaisknownasthetransformationzone(TZ)

病因?qū)W

原始鱗柱交接部和生理鱗柱交接部間的區(qū)域稱為移行帶ItisthepredilectionsiteofcervicalcarcinomaEctropionandtransformationofthetransformationzone移行帶區(qū)的外翻和轉(zhuǎn)化transformation

mechanism

轉(zhuǎn)化機(jī)制squamousmetaplasia鱗狀上皮化生squamousepithelization鱗狀上皮化Youngageatfirstintercourse初次性生活的年齡過小

Numberofsexualpartners性伙伴的數(shù)目

Smoking吸煙

Pooruptakeofscreeningprogramme

篩查過少

Long-termuseofthecontraceptivepill長期服用避孕藥

Exposuretotumorpromotershasagreaterinfluenceonimmaturecells不成熟的細(xì)胞暴露于致癌因素會對其產(chǎn)生很大的影響Pilltakersdonotnecessarilyusebarriermethods-increasingexposuretoseminalfluids

服用藥物而沒有使用屏障的方法，會增加精液的刺激

Male-relatedriskfactors與男性相關(guān)的危險因素

Thenumberofthepartner'sprevioussexualrelationshipsisrelevant

與以前性伙伴的數(shù)目有關(guān)Immunosuppressant免疫抑制

HPVinfection

HPV感染

Mainlysubtype16

主要是16型

Screening(篩查)

Toobtainacompletediagnosisthetriageofcytology,colposcopyandhistologicalbiopsyareneeded,assmearsareoftenunderreported要想達(dá)到完整的細(xì)胞學(xué)分類診斷需要陰道鏡和活檢，因為細(xì)胞涂片常常取決于報告人的經(jīng)驗

Cytology

細(xì)胞學(xué)dyskaryosis

isacytologicaltermItdescribesfeaturesofindividualcellssuchassizeandstainingofnucleiandtheamountofcytoplasm

細(xì)胞核異常是細(xì)胞學(xué)特點(diǎn)。表現(xiàn)為各個細(xì)胞核的大小、染色和細(xì)胞質(zhì)的數(shù)量的改變Milddyskaryosis輕度核異常ModeratedyskaryosisSeveredyskaryosis中度核異常重度核異常Normal-sizednucleusMildnuclearabnormalitiesNucleuslargerthannormalbut<50%ofcell細(xì)胞核大于正常，但小于細(xì)胞的50％Nucleus>50%ofcellNucleusirregular細(xì)胞大小正常輕度核異常細(xì)胞核大于細(xì)胞的50％胞核不規(guī)則Cellborderrounded細(xì)胞邊界變圓Angularcellborders細(xì)胞邊界有角Histology

組織學(xué)

Dysplasia

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

組織學(xué)檢查發(fā)現(xiàn)分化異常。需要取表皮全層活組織檢查診斷，原位癌和CINⅢ在某種程度上是相同的，都沒有突破基底膜CINⅠ

CINⅡCINⅢ

Upper2/3ofepitheliumexhibitsreasonabledifferentiation2/3以上的上皮組織分化正常Upper1/2ofepitheliumwelldifferentiated1/2以上的上皮組織分化正常Maturationconfinedtosuperficial1/3(orabsent)分化成熟的組織局限于表皮1/3或沒有Colposcopy（陰道鏡檢查）Indysplastictissuethenormalpatternofbloodvesselsbecomesdistortedandpunctationand

mosaicismareseen

在異常的組織中可以看到正常結(jié)構(gòu)的血管變得彎曲、極細(xì)的點(diǎn)、血管網(wǎng)圍繞的鑲嵌現(xiàn)象（鑲嵌的白色或黃色的上皮塊）

Colposcope

陰道鏡Abnormaltissuestainswhitewithaceticacidbutwillnottakeupthebrowniodinestain.Studyingthevesselpatternsandstainingreactions,acolposcopistgaugesthedegreeofCINpresent

異常的組織（醋酸染色白色）不會被碘溶液染成棕色，根據(jù)血管的模式和染色反應(yīng)，用陰道鏡可以較精確地估計CIN的程度CINⅡCINⅠ

CINⅢ

Localtreatment

局部治療

loopdiathermy環(huán)形電熱療法

runninganelectriccurrentthroughathinloopofvaryingsizeandshape

電流可以通過不同大小和形狀的細(xì)環(huán)coldcoagulation冷凝法carbondioxidelaser二氧化碳激光器conebiopsy錐切Loopdiathermyapparatus環(huán)形透熱電療儀Theprocessofconebiopsy

錐切的過程LoopElectrosurgicalExcisionProcedure(LEEP)normalcervix

Cervicalcarcinomaroughanduneveninsurface

smooth凸凹不平光滑Epidemiology

流行病學(xué)cancerofthecervixisthesecondmostcommonmalignancyinwomenafterbreastcancer-77%ofcasesoccurindevelopingcountriesRiskfactors危險因素Themainaetiologicalagentisinfectionwithcertainsubtypesofhumanpapillomavirus(HPV)主要的病原學(xué)因素是感染了人乳頭瘤病毒的某一亞型HPVsubtype16appearstobethemainoncologicalagentHPV16是腫瘤學(xué)的主要原因Pathology

病理學(xué)

exophytic外生型growingoutwardsinapapillaryorpolypoidalexcrescenceendophytic

內(nèi)生型Ulceration

潰瘍型infiltratingthesurroundingstructures

excavationfrequentlyoccur

向外呈乳頭狀生長或菜花狀

向深部浸潤周圍的組織

常常形成凹陷

ulceration頸管型endocervicalinfiltratingcervixandisthmusuteriRouteofmetastasis轉(zhuǎn)移途徑Directmetastasis直接蔓延Lymphaticmetastasis淋巴轉(zhuǎn)移Hematogenousmetastasis血行轉(zhuǎn)移Presentation臨床表現(xiàn)Symptoms癥狀Signs體征AtroutineexaminationPostmenopausalbleedingAbnormalcells,indicativeofinvasivecarcinomaoncytology

異常細(xì)胞，細(xì)胞學(xué)提示浸潤癌Intermenstrualbleeding

月經(jīng)間期出血絕經(jīng)后出血常規(guī)檢查Offensive,blood-stainedvaginaldischarge血性白帶Atcolposcopy陰道鏡檢查Heavy,contactbleeding接觸性出血Fistulae-passageofurine,faecesorflatusvaginally(ifbowel/bladderinvolved)

（尿瘺、糞瘺形成）如果直腸膀胱受累irregularsurfacecontour表面輪廓不規(guī)則Renalfailure-bilateraluretericobstruction腎衰竭－雙側(cè)輸尿管梗阻Atypicalvessels-capillariesofirregularcalibreandbranchingpattern不典型血管－毛細(xì)血管口徑、分支不規(guī)則Deepvisceralornerverootpain(ifsacralnerverootinvolved)內(nèi)臟或神經(jīng)根疼痛（如果骶神經(jīng)根受累）Lowerlimboedema-extensivepelvicsidewallinfiltration骨盆側(cè)壁廣泛浸潤－下肢水腫Staging分期Staging

分期Stage1:TumorconfinedtothecervixⅠ期腫瘤局限于宮頸

aMicroinvasivecarcinomaa微浸潤腫瘤a1stromalinvasion≤3mmdepthand≤7mmhorizontalspread

a1間質(zhì)浸潤深度≤3mm寬度≤7mma2Lesionswithadepth>3mm,but≤5mm,andahorizontalspread≤7mm

a2浸潤深度>3mm≤

5mm，寬度≤7mm

bClinicallesionsconfinedtothecervix

b腫瘤損害局限于宮頸blTumordiameter≤4cm

b1腫瘤直徑≤4cmb2Tumordiameter>4cm

b2腫瘤直徑>4cmStage2:Spreadbeyondthecervix,butnottothepelvicsidewall,withinvolvementofuppertwo-thirdsofthevagina

Ⅱ期超越宮頸但未達(dá)盆壁，侵犯陰道，但未及下1/3aVaginalspread,butnoobviousparametrialspreada侵犯陰道，無明顯盆壁浸潤bParametrialspread,butnotasfaraspelvicsidewallb宮旁浸潤，但未達(dá)盆壁Stage3:SpreadinthepelvisⅢ期侵犯骨盆aInvolvementoflowerone-thirdofthevagina

a侵犯陰道的下1/3bExtensiontothepelvicsidewallorhydronephrosis

b擴(kuò)散至骨盆壁或腎盂積水Stage4:DistantspreadⅣ期遠(yuǎn)處轉(zhuǎn)移aSpreadtoinvolveadjacentorgans[bladder,rectum]

a侵犯臨近組織（膀胱、直腸）bDistantspread

b遠(yuǎn)處轉(zhuǎn)移Treatmentoptions

治療方法選擇Microinvasivedisease

微觀浸潤性病變notyetcompletedherfamily

conservativeapproach

conebiopsy錐切

completedherfamily

Invasivedisease

浸潤癌stagesIb,Ⅱaandsomecasesof2b

①whensurgicalexpertiseisnotavailable②inwomenwithatumorgreaterthan4cmindiameter③inwomenwhoarenotmedicallyfitforsurgeryRadiotherapy放療Advanceddisease(stage4)

Combinationsofchemo-andradiotherapy

聯(lián)合放化療保守治療RadicaltreatmentisindicatedforstagesIb,ⅡaandsomecasesofⅡb

Wertheim'sradicalhysterectomy

pelviclymphadenectomy

3cmvaginalcuff

切除陰道上端3厘米

Squamouscarcinoma

conservedtheovaries鱗狀細(xì)胞癌保留卵巢Adenocarcinoma

腺癌OophorectomySquamouscarcinomadoesnotspreaddirectlytotheovaries

腺癌卵巢轉(zhuǎn)移發(fā)生率約5％～10％

thereisa5-10%incidenceofovarianmetastases

Advanceddisease(stage4)

晚期患者－Ⅳ期

Combinationsofchemo-andradiotherapy

聯(lián)合放化療

survivalrateisverypoor

存活率很低

Carcinomaoftheendometriumformsthemostcommontypeofuterinecancer.Thesearemainlyadenocarcinomasderivedfromendometrialglandularcells

Riskfactors

危險因素Obesity肥胖Impairedglucosetolerance糖耐量下降Nulliparity從未生育的婦女Latemenopause絕經(jīng)遲Unopposedoestrogentherapy無對抗的雌激素治療Functioningovariantumors[granulosa-thecacelltumor]功能性卵巢腫瘤[顆粒－卵泡膜細(xì)胞瘤]Familyhistoryofcarcinomaofbreast、ovaryorcolon家族性乳腺癌、卵巢癌、結(jié)腸癌

Pathology病理學(xué)thecommonestistheendometrioidadenocarcinoma

(a)Viewofcutsurfaceoftheuterus

(b)High-powerviewofGrade1cancerRouteofmetastasis

轉(zhuǎn)移途徑Directmetastasis直接蔓延Lymphaticmetastasis淋巴轉(zhuǎn)移Hematogenousmetastasis血行轉(zhuǎn)移SymptomsandSigns

癥狀和體征postmenopausalbleeding

絕經(jīng)后出血Discharge

陰道排液Metastaticdisease

轉(zhuǎn)移Pain疼痛UltrasonographyandcolorDopplerblood-flowimagingprovideusefulscreeningtools超聲和彩色多普勒血流顯像圖是有效的檢查工具irregularand/orheavyregularbleedinginthepremenopausalgroup絕經(jīng)前患者中不規(guī)則的和/或量較多的規(guī)則的出血

Renalandhepaticfunctiontests,tumormarkers,chestX-rayandpossiblyanintravenousurogramwillneedtobeundertaken

Beforetheoperation檢查肝腎功能，腫瘤標(biāo)記物，胸部X線檢查，必要時進(jìn)行靜脈尿路造影

Treatment

治療histologyshowsapoorlydifferentiatedhigh-gradetumor

Radiotherapy

放療晚期組織學(xué)顯示低分化

ifthenodesareinvolved

如果淋巴結(jié)受累stagingatthetimeofsurgeryscoresmorethanaIb

Thestage3patient

3期病人