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1、王建六 北京大学人民医院妇产科,子宫内膜癌诊治关注几个问题,OUTLINE,FIGO 2009新分期的临床意义 子宫切除范围 淋巴结切除指征,子宫内膜癌09分期修订（1）,如何判断侵肌深度？,TVS：准确率84.6%，浅肌层为82.4%深肌层为77.9%，无侵肌100% MRI:90% 术者肉眼剖视准确性89.7% 病理医生肉眼观察 86.2% 冰冻切片 91.4%建议TVS+MRI，注重术中剖视,子宫内膜癌09分期修订（2）,累及宫颈内膜腺体的预后和期无差异,如何判定宫颈间质受侵？,子宫内膜癌09分期修订(3),09分期删去细胞学检查结果,为什么要删去细胞学检查？,腹水细胞学阳性和腹腔或淋巴
2、结的转移不相关，不影响预后 没有足够的证据说明腹水细胞学阳性与复发风险和治疗效果有何关系,FIGO仍推荐进行细胞学检查，并单独报告结果,子宫内膜癌09分期修订（4）,主动脉旁淋巴结转移预后比盆腔淋巴结转移差,163 case 35 (21.5%) 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 meta
3、stases all those who recurred died of disease within seven to 28 months. Eur J Gynaecol Oncol. 2007;28(2):98-102,Is aortic lymphadenectomy necessary?,子宫内膜癌标准术式 I期筋膜外子宫切除术？ II期广泛（改良的）子宫切除术？,子宫内膜癌如何切除子宫？,筋膜内子宫切除术,全宫切除术,筋膜外子宫切除术？,筋膜外子宫切除术,定义？ 手术中要点？ 与全子宫切除术异同？,筋膜外子宫切除术,现代妇产科手术与技巧史常旭 主编 人民军医 2004 妇产科临床解
4、剖学苏应宽 等主编 山东科技出版社 2001 实用妇科腹腔镜手术学李广仪主编 人民卫生2006 妇科手术学万小平主译 人民卫生2003均无描述,15,I期子宫内膜癌 子宫切除范围：比较明确，存在混淆 筋膜外子宫切除术？ 全子宫切除术？ 二者异同？ 次广泛子宫切除术？,子宫切除范围值得探讨,子宫内膜癌子宫切除的范围,I期子宫内膜癌 GOG2010:Women with endometrial cancers should undergo total abdominal hysterectomy and BSO), pelvic/paraaortic dissection 妇科常见恶性肿瘤治疗指南
5、：筋膜外子宫切除术 林巧稚妇科肿瘤学：全子宫切除术 妇产科学第七版（林仲秋）：筋膜外子宫切除术,筋膜外子宫切除术？ 标准全子宫切除术？,仁者见仁，智者见智下推膀胱至宫颈外口水平下较低水平主韧带：宫颈旁切除（贴而略离开）宫骶韧带：单独处理阴道切除1cm,17,广泛子宫切除术 必要性？ 改良广泛（根治）子宫切除术 缩小的广泛子宫切除术？ （II型子宫切除术）,广泛子宫切除术目的：切除宫旁可能的转移 文献：样本例数较多的回顾性研究 Sartori E, et al. Int J Gynecol Cancer 2001;11(6):430437203 cases：10-Y OS 74% (TAH) v
6、s 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 cases：5-Y OS 84% (TAH) vs 93%(RH) OP alone5-Y OS 83% (TAH) vs 88%(RH) OP+RT,KOREA， JAPAN：Choose the surgical extent of hysterectomy through their own di
7、sposition and do not strictly adhere the results of pre operative evaluation. JAPANESE groupmore than 70% of institutes never perform RH without regarding the preoperative status of cervical involvement (Watanabe) NORTH AMERICAN：20%-30% center,宫颈累及一定要行广泛子宫切除术吗？,THIS IS AN AREA OF CONTINUED DEBATE！,2
8、1,J Korean Med Sci 2010; 25: 552-6,原因：Current pre-operative evaluation method is not sensitive enough to detect cervical invasion Medical status cervical stromal invasion should be followed by adjuvant radiotherapy and thus, the prognosis would not be changed by performing a high morbidity producing
9、 surgery considering the low incidence of PMI,原因：4.Metastasis characteristics: different from cervical cancer PMI: low incidence 6% PMI(+): LN(+) 80% LN(+): PMI(+)45% Metastasis patterns:direct invasion of cancer cells to the parametrial connective tissuesparametrial lymphvascularspace invasion freq
10、uently seen in patients with deep myometrial involvement without cervical involvement,妇科常见肿瘤诊治指南 妇科肿瘤分会 p49 I期子宫内膜癌应行手术分期 术式为筋膜外子宫切除术及双附件切除术盆腔及腹主动脉旁淋巴结切除和（或）取样术 腹主动脉旁淋巴结切除/取样指征：可疑淋巴结转移 特殊组织类型 CA125显著升高 宫颈受累深肌层受累 低分化,I期子宫内膜癌淋巴结切除必要性？,全国高等院校教材 妇产科学 乐杰主编 林仲秋编写 p275 I期子宫内膜癌应行筋膜外子宫切除术及双附件切除术盆腔及腹主动脉旁淋巴结切除
11、和（或）取样术 下列情况之一，应行盆腔及腹主动脉旁淋巴结切除 和（或）取样术 可疑淋巴结增大 宫颈受累 CA125显著升高 特殊组织类型 低分化 深肌层受累 癌灶累及宫腔面积超过50%,Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007585. Lymphadenectomy for the management of endometrial cancer. May K, Bryant A, Dickinson HO, Kehoe S, Morrison JUniversity of Oxford, Womens Centre,No eviden
12、ce that lymphadenectomy decreases the risk of death or disease recurrence compared with no lymphadenectomy in women with presumed stage I disease.The evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgically related systemic morbidity
13、 or lymphoedema/lymphocyst formation.,国外近2年的文献报道,Lancet. 2009 Jan 10;373(9658):125-36. Epub 2008 Dec 16. Efficacy of systematic 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
14、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, Mook 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, F
15、ish A, Lamb M, Goodfellow C, Tahir S, Smith JR, Gornall R, Kerr-Wilson R, Swingler GR, Lavery BA, Chan KK, Kehoe S, Flavin A, 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 M
16、R, Nordin A, Smart G, Cowie V, Katesmark M, Murray P, Eddy J, Gornall R, Swingler GR, Finn CB, Moloney M, Farthing A, Hanoch 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, Kings
17、ton 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, 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, M
18、onaghan JM, Naik R, Evans J, Gillespie A, Paterson ME, Tidy J, Ind T, Lane J, Oates S, Redford D, Ford M, Fish A, Larsen-Disney 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
19、 EM, Woolas R, Anderson R, Murdoch JB, Niven PA, Kerr-Wilson R, Chin K, Flynn P, Freites O, Newman GH, McNally O, Cullimore J, 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.,
