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1、*Dr.Xiaohua Wu 1Standard Treatment Options for Cervical Cancer FIGO: Staging classifications and clinical practice guidelines of Cervical cancer National Cancer Institute M.D. Anderson Cancer Center Practical Gynecologic Oncology 4th Edition*Dr.Xiaohua Wu 2Cancers of the Female Reproductive Tract: W
2、orldwide Statistics11.1. Ferlay Ferlay et al.et al. GLOBOCAN 2000 IARC, WHO 2001 (www.dep.iarc.fr GLOBOCAN 2000 IARC, WHO 2001 (www.dep.iarc.fr) ) CancerCancerNew CasesNew CasesDeathsDeathsCervical470,000230,000Endometrial189,00045,000Ovarian192,000114,000USA Northern Europe Southern Europe23,800 10
3、,000 10,20015,600 7,200 6,200*Dr.Xiaohua Wu 31974-2000上海市居民妇科肿瘤发病率上海市肿瘤研究流行病研究室年报告*Dr.Xiaohua Wu 4*Dr.Xiaohua Wu 5*Dr.Xiaohua Wu 6Treatment Option Overview nFive randomized phase III trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy
4、,1-6 while 1 trial examining this regimen demonstrated no benefit.7nThe risk of death from cervical cancer was decreased by 30% to 50% by concurrent chemoradiation. nBased on these results, strong consideration should be given to the incorporation of concurrent cisplatin- based chemotherapy with rad
5、iation therapy in women who require radiation therapy for treatment of cervical cancer.1-8*Dr.Xiaohua Wu 7Treatment Option OverviewnSurgery and radiation therapy are equally effective for early-stage small-volume disease.9 nYounger patients may benefit from surgery in regard to ovarian preservation
6、and avoidance of vaginal atrophy and stenosis. nPatterns of care studies clearly demonstrate the negative prognostic effect of increasing tumor volume. nTherefore, treatment may vary within each stage as currently defined by FIGO, and will depend on tumor bulk and spread pattern.10 *Dr.Xiaohua Wu 8T
7、reatment Option OverviewnTherapy of patients with cancer of the cervical stump is effective, yielding results comparable to those seen in patients with an intact uterus.11 nDuring pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert c
8、olposcopy is recommended to exclude invasive cancer. nTreatment of invasive cervical cancer during pregnancy depends on the stage of the cancer and gestational age at diagnosis.*Dr.Xiaohua Wu 9宫颈癌分期:临床诊断分期q有经验的医师、在麻醉下进行检查q后来的发现不能改变已经确定的期别q触诊、视诊、阴道镜、宫颈管诊刮术(ECC)、宫腔镜、膀胱镜、直肠镜、静脉尿路造影、以及骨骼和肺部x线检查q膀胱和直肠怀疑病
9、灶须经活检并有组织学证实q淋巴管造影、动脉造影、静脉造影、剖腹探查术、超声探查、CT扫描和磁共振（MRI）等，故不能作为改变期别的根据q对扫描检查怀疑的淋巴结行细针穿刺，能帮助制定治疗计划*Dr.Xiaohua Wu 10宫颈癌分期:手术治疗后病理分期q手术-病理检查切除的标本结果，是最确切诊断肿瘤侵犯范围q这些结果不能改变临床分期，但可将这些结果记录在疾病的病理分期法则中，TNM分期正是符合情况q首次诊断时确定分期，而且不能更改，即使在复发时也是如此q只有在临床分期的准则严格执行时，才有可能比较各个临床单位和不同治疗方式的结果*Dr.Xiaohua Wu 11*Dr.Xiaohua Wu 1
10、2临床分期检查方法n临床分期q非损伤性诊断检查n双足淋巴管X线照片（Bipedal lymphangiogram） n计算机断层X线扫描术（CT, Computed Tomography） n超声波扫描术（Ultrasonography） n磁共振成像（MRI, Magnetic Resonance Imaging） n正电子发射断层扫描（PET, Positron Emission Tomography） n细针吸取细胞学检查 q手术分期： 治疗前，腹主动脉旁LN，延伸放射野?n剖腹探查术的方法n腹腔镜分期*Dr.Xiaohua Wu 13Surgical StagingnPretreatm
11、ent surgical staging is the most accurate method to determine extent of disease. nBecause 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. nPretreatment surgical staging in bulky, but loc
12、ally curable, disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. nIf abnormal nodes are detected by CT scan or lymphangiography, fine needle aspiration should be negative before a surgical staging procedure is performed. *Dr.Xiaohua Wu 14腹主动脉旁淋巴结CT
13、阴性患者中生存率曲线与PET扫描结果的关系 J Clin Oncol 2001;19: 37453749.)*Dr.Xiaohua Wu 15IB期宫颈癌盆腔淋巴结转移率 *Dr.Xiaohua Wu 16II 和 III期宫颈癌腹主动脉旁淋巴结转移率 *Dr.Xiaohua Wu 17宫颈癌治疗：根据期别选择1.0期2.微小浸润癌3.B1期和早A癌4.B至A期宫颈癌*Dr.Xiaohua Wu 18Stage 0 Cervical Cancer Standard treatment options: Methods to treat ectocervical lesions include:
14、 nLoop electrosurgical excision procedure (LEEP).7,8 nLaser therapy.9 nConization. nCryotherapy.10 nWhen the endocervical canal is involved, laser or cold-knife conization may be used for selected patients to preserve the uterus and avoid radiation therapy and/or more extensive surgery. nTotal abdom
15、inal 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.nFor medically inoperable patients, a single intracavitary insertion with tandem and ovoids for 5,000 milligram hours (8,0
16、00 cGy vaginal surface dose) may be used.11 *Dr.Xiaohua Wu 19对异常Pap 涂片或活检示微小浸润癌处理步骤 Pap涂片异常或钳取活检“微小 浸润癌”锥切活检微小浸润5mml切缘阴性 lECC阴性ECC阴性切缘和/或ECC示非典型增生lA1期 l无广泛LVSIl如有生育愿望者锥切 l筋膜外子宫切除再次锥切活检 如锥切不便行改良RH盆 腔淋巴结切除术l广泛LVSI的A1期 lA2期l如有生育愿望者盆腔 淋巴结切除加锥切，或 广泛宫颈切除 l改良RH和盆腔淋巴结切除*Dr.Xiaohua Wu 20Stage IA Cervical Cancer Equivalent treatment options: nIntracavitary radiation alone: nIf the depth of invasion is less than 3 millimeters and no capillary lymphatic space invasion is noted
