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1、,子宫内膜癌治疗相关问题 北京大学人民医院妇产科 王建六,子宫内膜癌新分期 子宫内膜癌淋巴结切除必要性 子宫内膜癌子宫切除的范围,子宫内膜癌09分期修订1,和II期有关的新证据（修订2）,累及宫颈内膜腺体的预后和期无差异,09分期把累及宫颈内膜腺体归入期,和III期有关的新证据,腹水或腹腔冲洗液细胞学阳性88分期为A期 多项大样本病例对照研究结果，腹水细胞学阳性和腹腔或淋巴结的转移不相关，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 针对腹水细胞学阳性的治疗尚有争议：不处理？化疗？放疗？激素治疗？,子宫内膜癌09分期修订3,09分期删去细胞学检查结果,子宫内膜癌09
2、分期修订4,资料表明主动脉旁淋巴结转移预后比盆腔淋巴结转移差。,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 术中如无明显淋巴结肿大，应系统切除淋巴结 术中有可疑淋巴结肿大，取样明确有无转移即可 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,子宫内膜癌淋巴结切除的必要性？,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和（或）取样术 下列情
3、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 癌灶累及宫腔面积超过50%低分化 深肌层受累,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 evidence that lymp
4、hadenectomy 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 or lymphoed
5、ema/lymphocyst formation.,J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16. Epub 2008 Nov 25 Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. Rome, Italy,CONCLUSION: Although systematic pelvic lymphadenectomy statistically signif
6、icantly improved surgical staging, it did not improve disease-free or overall survival.,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, B
7、uckley CH, Redman CW, Shepherd J, Dunn 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 R
8、J, Price JH, Chan KK, Mann C, Rand R, Fish 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, Yian
9、nakis D, Alloub MI, Gilbert L, Heslip MR, 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, Irela
10、nd D, Kirwan P, Davies Q, Lamb M, Kingston 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, De
11、aley R, Godfrey K, Hatem MM, Lopes A, Monaghan 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,
12、 Kitchener H, Beynon JL, Hogston P, Low 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, Gi
13、les J, Leeson S, Nevin J, van Wijk AL, Karolewski K, Klimek M, Blecharz P, McConnell D.,Hysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease a
14、nd as a therapeutic procedure,median follow-up of 37 months (IQR 24-58) 191 women had died: 88/704 standard surgery group103/704 lymphadenectomy group251Recurrent disease 107/704 standard surgery group144/704 lymphadenectomy group),INTERPRETATION no evidence of benefit in terms of overall or recurre
15、nce-free survival for pelvic lymphadenectomy in women with early endometrial cancer. Pelvic lymphadenectomy cannot berecommended as routine procedurefor therapeutic purposes outsideof clinical trials.,子宫内膜癌淋巴结切除利与弊 争论“由来已久”！,早期：淋巴结转移率较低,国内 中山肿瘤：临床7.9%,8.6%, 38.4% 浙江肿瘤：临床4.4%,14%，34.8% 国外 Stageb（a）G1
16、-2 或 IaG3：转移率 0-2% Stageb（a）G3或 Ic（b）G1：转移率16%-20%,早期：LND并未降低复发 改善生存,1996年10月到2006年3月 意大利多个中心的514例术前FIGO分期为期子宫内膜癌患者 随机分配接受盆腔淋巴结切除术（n=264）或者不进行此手术（n=250）,“冲锋在前”的意大利研究,生存上没有差异,5年DFS 5年OS 未接受淋巴结切除术 81.7% 90.0% 接受淋巴结切除术 81% 85.9%,复发时间和复发率相似,复发时间 复发率（mth） （49mth） 未进行淋巴结切除 13mth 33例（13.2%） 淋巴结切除术者为 14mth 34例（12.9%）,复发部位相似,LND手术并发症明显增加,在手术时间和住院时间上，两组有显著的统计学差异 接受盆腔淋巴结切除术的患者有较高的早期和晚期术后并发症率，两组出现并发症的患者分别为81例和34例。,改变观念 无容置疑,
