《子宫肿瘤-妇产科课件.ppt》由会员分享，可在线阅读，更多相关《子宫肿瘤-妇产科课件.ppt（57页珍藏版）》请在金锄头文库上搜索。
1、Carcinoma of the uterus 子宫肿瘤子宫肿瘤Department of Obstetrics and Gynecology妇妇 产产 科科Zhang Wei张张 蔚蔚Endometrial carcinoma 子宫内膜癌子宫内膜癌Cervical tumors 宫颈肿瘤宫颈肿瘤Cervical intraepithelial neoplasia (CIN)宫颈上皮内瘤样变宫颈上皮内瘤样变 Cervical cancer 宫颈癌宫颈癌 Carcinoma of the uterus 子宫肿瘤子宫肿瘤 Cervical intraepithelial neoplasia (CI
2、N)宫颈上皮内瘤样变宫颈上皮内瘤样变Definition：Cervical intraepithelial neoplasia (CIN) is a premalignant condition of the cervix. It is usually asymptomatic and is detected by routine cytological screening. The degree of severity is graded CIN、to CIN 定义定义: :宫颈上皮内瘤样变是宫宫颈上皮内瘤样变是宫颈组织的癌前病变。一般没有颈组织的癌前病变。一般没有症状症状, ,通常在常规的
3、细胞学筛查通常在常规的细胞学筛查时发现。根据严重程度分为时发现。根据严重程度分为CINCIN、CINCIN、CINCINTBS typesatypical squamous cells (ASC)不典型鳞状上皮不典型鳞状上皮Low-grade squamous intraepithelial lesion (LSIL)轻度鳞状上皮内病变轻度鳞状上皮内病变High-grade squamous intraepithelial lesion (HSIL) 重度鳞状上皮内病变重度鳞状上皮内病变Aetiology The area of previously exposed columnar epit
4、helium that undergoes squamous metaplasia is known as the transformation zone (TZ) 病因学病因学 原始鳞柱交接部和生理鳞柱交接部间的区域称为移行带原始鳞柱交接部和生理鳞柱交接部间的区域称为移行带 It is the predilection site of cervical carcinoma移行带为宫颈癌好发部位移行带为宫颈癌好发部位 Ectropion and transformation of the transformation zone 移行带区的外翻和转化移行带区的外翻和转化transformatio
5、n mechanism转化机制转化机制squamous metaplasia 鳞状上皮化生鳞状上皮化生squamous epithelization鳞状上皮化鳞状上皮化The risk factors for CIN and cervical The risk factors for CIN and cervical carcinomacarcinomaCINCIN和宫颈肿瘤的危险因素和宫颈肿瘤的危险因素Young age at first intercourse初次性生活的年龄过小初次性生活的年龄过小 Number of sexual partners性伙伴的数目性伙伴的数目 Smoking
6、 吸烟吸烟 Poor uptake of screening programme 筛查过少筛查过少 Long-term use of the contraceptive pill长期服用避孕药长期服用避孕药 Exposure to tumor promoters has a greater influence on immature cells不成熟的细胞暴露于致癌因素会对其产生不成熟的细胞暴露于致癌因素会对其产生很大的影响很大的影响 Increases the risk of cervical cancer four-fold; the risk remains elevated in ex
7、-smokers 吸烟的妇女患宫颈癌的危险性会吸烟的妇女患宫颈癌的危险性会提高提高4 4倍；曾经吸烟的妇女患宫颈癌的危险倍；曾经吸烟的妇女患宫颈癌的危险性仍然存在性仍然存在 Pill takers do not necessarily use barrier methods - increasing exposure to seminal fluids 服用药物而没有使用屏服用药物而没有使用屏障的方法，会增加精液的刺激障的方法，会增加精液的刺激 Male-related risk factors与男性相关的危险因素与男性相关的危险因素 The number of the partners pr
8、evious sexual relationships is relevant 与以前与以前性伙伴的数目有关性伙伴的数目有关 Cervical cancer risk increased if partner has penile cancer 性伙伴患阴性伙伴患阴茎癌会增加患宫颈癌的危险性茎癌会增加患宫颈癌的危险性 Cervical cancer risk increased if partners previous sexual contact had cervical cancer 性伙伴的前性伴患宫性伙伴的前性伴患宫颈癌也会增加患宫颈癌的危险性颈癌也会增加患宫颈癌的危险性 Immuno
9、suppressant 免疫抑制免疫抑制 Risk increased with immune suppressed renal transplant patients, and in HIV-positive women 免疫抑制、免疫抑制、肾移植、肾移植、HIVHIV阳性妇女患宫颈癌危险性阳性妇女患宫颈癌危险性增加增加 HPV infection HPVHPV感染感染 Mainly subtype 16 主要是主要是1616型型 Screening for CIN is based on a cervical smear - sampling surface cells from the
10、cervix with a spatula筛查筛查CINCIN可以利用宫颈表皮细胞涂片可以利用宫颈表皮细胞涂片Screening(筛查筛查) To obtain a complete diagnosis the triage of cytology, colposcopy and histological biopsy are needed, as smears are often under reported 要想达到完整的细胞要想达到完整的细胞学分类诊断需要阴道学分类诊断需要阴道镜和活检，因为细胞镜和活检，因为细胞涂片常常取决于报告涂片常常取决于报告人的经验人的经验 Cytology 细胞
11、学细胞学 dyskaryosis is a cytological termIt describes features of individual cells such as size and staining of nuclei and the amount of cytoplasm 细胞核异常是细胞细胞核异常是细胞学特点。表现为各学特点。表现为各个细胞核的大小、个细胞核的大小、染染色和细胞质的数色和细胞质的数量的改变量的改变 Mild dyskaryosis轻度核异常轻度核异常Moderate dyskaryosisSevere dyskaryosis中度核异常中度核异常重度核异常重度核异
12、常Normal-sized nucleusMild nuclear abnormalitiesNucleus larger than normalbut 50% of cellNucleus irregular细胞大小正常细胞大小正常轻度核异常轻度核异常细胞核大于细胞的细胞核大于细胞的50胞核不规则胞核不规则Cell border rounded细胞边界变圆细胞边界变圆Angular cell borders细胞边界有角细胞边界有角Histology 组织学组织学 Dysplasia is a histological term. It requires a full-thickness bi
13、opsy for diagnosis. Carcinoma-in-situ and CINare more or less synonymous. The basement membrane remains intact 组织学检查发现分化异常。需组织学检查发现分化异常。需要取表皮全层活组织检查诊要取表皮全层活组织检查诊断，原位癌和断，原位癌和CINCIN在某种程在某种程度上是相同的，都没有突破基度上是相同的，都没有突破基底膜底膜 CIN CIN CIN Upper 2/3 of epithelium exhibitsreasonable differentiation2/32/3以上的上皮组
14、以上的上皮组织分化正常织分化正常Upper 1/2 of epithelium welldifferentiated1/21/2以上的上皮组织以上的上皮组织分化正常分化正常Maturation confined tosuperficial 1/3 (or absent)分化成熟的组分化成熟的组织局限于表皮织局限于表皮1/31/3或没有或没有Colposcopy（阴道镜检查）（阴道镜检查）In dysplastic tissue the normal pattern of blood vessels becomes distorted and punctation and mosaicism a
15、re seen 在异常的组织中可以看到正常结构的血管变在异常的组织中可以看到正常结构的血管变得弯曲、极细的点、血管网围绕的镶嵌现象得弯曲、极细的点、血管网围绕的镶嵌现象（镶嵌的白色或黄色的上皮块）（镶嵌的白色或黄色的上皮块） Colposcope 阴道镜阴道镜Abnormal tissue stains white with acetic acid but will not take up the brown iodine stain. Studying the vessel patterns and staining reactions, a colposcopist gauges the
16、degree of CIN present 异常的组织（醋酸染色白色）不异常的组织（醋酸染色白色）不会被碘溶液染成棕色，根据血管会被碘溶液染成棕色，根据血管的模式和染色反应，用阴道镜可的模式和染色反应，用阴道镜可以较精确地估计以较精确地估计CINCIN的程度的程度 CINCIN CIN Local treatment 局部治疗局部治疗 loop diathermy环形电热疗法环形电热疗法 running an electric current through a thin loop of varying size and shape 电流可以通过不同大小和形状的细环电流可以通过不同大小和形状的
17、细环cold coagulation 冷凝法冷凝法carbon dioxide laser 二氧化碳激光器二氧化碳激光器cone biopsy锥切锥切Loop diathermy apparatus 环形透热电疗仪环形透热电疗仪The process of cone biopsy 锥切的过程锥切的过程Loop Electrosurgical Excision Procedure (LEEP)Cervical carcinoma 宫颈肿瘤宫颈肿瘤normal cervix Cervical carcinoma rough and uneven in surface smooth 凸凹不平凸凹不平
18、宫颈癌宫颈癌正常宫颈正常宫颈光滑光滑Epidemiology 流行病学流行病学cancer of the cervix is the second most common malignancy in women after breast cancer - 77% of cases occur in developing countries在发展中国家，宫颈癌的发病在发展中国家，宫颈癌的发病率位于妇女恶性肿瘤的第二位，率位于妇女恶性肿瘤的第二位，仅次于乳腺癌（仅次于乳腺癌（7777）Risk factors危险因素危险因素The main aetiological agent is infect
19、ion with certain subtypes of human papilloma virus (HPV) 主要的病原学因素主要的病原学因素是感染了人乳头瘤是感染了人乳头瘤病毒的某一亚型病毒的某一亚型HPV subtype 16 appears to be the main oncological agent HPV16是肿瘤学的主要原因是肿瘤学的主要原因 Only 5% of cytologically normal women细胞学正常的妇女中细胞学正常的妇女中HPV16阳性占阳性占5 Up to 50% of smears containing CIN在涂片异常含在涂片异常含CIN
20、 中中HPV16阳性占阳性占50 Over 90% of invasive cervical cancer浸润性宫颈癌中浸润性宫颈癌中90以上患者以上患者HPV16阳性阳性Possible aetiological pathway for CIN and carcinoma CIN和宫颈癌可能的病原学途径和宫颈癌可能的病原学途径Pathology 病理学病理学Malignant tumors of the cervix maybe squamous (8590%) or glandular (10%) in type 宫颈癌中约宫颈癌中约8590为鳞癌，为鳞癌，10为腺癌为腺癌 exophyt
21、ic外生型外生型growing outwards in a papillary or polypoidal excrescence endophytic 内生型内生型Ulceration 溃疡型溃疡型infiltrating the surrounding structures excavation frequently occur 向外呈乳头状生长或菜花状向外呈乳头状生长或菜花状 向深部浸润周围的组织向深部浸润周围的组织 常常形成凹陷常常形成凹陷 ulceration颈管型颈管型endocervical常侵入宫颈及子宫狭部常侵入宫颈及子宫狭部infiltrating cervix and i
22、sthmus uteriRoute of metastasis转移途径转移途径Direct metastasis 直接蔓延直接蔓延Lymphatic metastasis 淋巴转移淋巴转移 Hematogenous metastasis 血行转移血行转移Presentation 临床表现临床表现Symptoms 症状症状Signs 体征体征Confined to cervix 局限于宫颈局限于宫颈At routine examinationPostcoital bleeding 性交后出血性交后出血Cervix looks suspicious at time of smear 宫颈刮片时可疑
23、宫颈刮片时可疑Postmenopausal bleedingAbnormal cells, indicative of invasive carcinoma on cytology 异常细胞，细胞学提示浸润癌异常细胞，细胞学提示浸润癌Intermenstrual bleeding 月经间期出血月经间期出血绝经后出血绝经后出血常规检查常规检查Offensive, blood-stained vaginal discharge血性白带血性白带At colposcopy 阴道镜检查阴道镜检查Spread to adjacent structures 侵犯临近组织侵犯临近组织Heavy, contac
24、t bleeding 接触性出血接触性出血Fistulae - passage of urine, faeces or flatus vaginally (if bowel/ bladder involved) （尿瘘、粪瘘形成）如果直肠膀胱受累（尿瘘、粪瘘形成）如果直肠膀胱受累irregular surface contour表面轮廓不规则表面轮廓不规则Renal failure - bilateral ureteric obstruction 肾衰竭双侧输尿管梗阻肾衰竭双侧输尿管梗阻Atypical vessels - capillaries of irregular calibre an
25、d branching pattern 不典型血管毛细血管口径、不典型血管毛细血管口径、分支不规则分支不规则Deep visceral or nerve root pain (if sacral nerve root involved) 内脏或神经根疼痛（如果骶神经根受累）内脏或神经根疼痛（如果骶神经根受累）Lower limb oedema - extensive pelvic side wall infiltration 骨盆侧壁广泛浸润下肢水肿骨盆侧壁广泛浸润下肢水肿Staging 分期分期Staging 分期分期Stage 1: Tumor confined to the cervix
26、期期 肿瘤局限于宫颈肿瘤局限于宫颈 a Microinvasive carcinoma a 微浸润肿瘤微浸润肿瘤 a1 stromal invasion 3 mm depth and 7 mm horizontal spread a1 间质浸浸润深度深度3 mm 宽度度7 mm a2 Lesions with a depth 3 mm, but 5 mm, and a horizontal spread 7 mm a2 浸浸润深度深度3 mm 5 mm，宽度度7 mm b Clinical lesions confined to the cervix b 肿瘤损害局限于宫颈肿瘤损害局限于宫颈b
27、 l Tumor diameter 4 cm b1 肿瘤直径瘤直径4 cmb2 Tumor diameter 4 cm b2 肿瘤直径肿瘤直径4 cmStage 2: Spread beyond the cervix, but not to the pelvic side wall, with involvement of upper two-thirds of the vagina 期期 超越宫颈但未达盆壁，超越宫颈但未达盆壁，侵犯阴道，但未及下侵犯阴道，但未及下1/3a Vaginal spread, but no obvious parametrial spreada 侵犯阴道，无明侵犯
28、阴道，无明显盆壁浸盆壁浸润b Parametrial spread, but not as far as pelvic side wallb 宫旁浸旁浸润，但未达盆壁，但未达盆壁Stage 3: Spread in the pelvis期期 侵犯骨盆侵犯骨盆a Involvement of lower one-third of the vagina a a 侵犯阴道的下侵犯阴道的下1/31/3b Extension to the pelvic side wall or hydronephrosis b b 扩散至骨盆壁或散至骨盆壁或肾盂盂积水水Stage 4: Distant spread期期
29、 远处转移远处转移a Spread to involve adjacent organs bladder, rectum a a 侵犯临近组织（膀胱、侵犯临近组织（膀胱、直肠）直肠）b Distant spread b b 远处转移移Clinic stage block diagram of cervical cancer宫颈癌临床分期示意图宫颈癌临床分期示意图Clinic stage block diagram of cervical cancer宫颈癌临床分期示意图宫颈癌临床分期示意图Treatment options 治疗方法选择治疗方法选择Microinvasive disease 微
30、观浸润性病变微观浸润性病变not yet completed her family conservative approach cone biopsy锥切锥切 completed her family Hysterectomy子宫全切子宫全切 Invasive disease 浸润癌浸润癌stages I b, a and some cases of 2b Radical treatment 根治术根治术when surgical expertise is not available in women with a tumor greater than 4 cm in diameter in
31、women who are not medically fit for surgery Radiotherapy放疗放疗 Advanced disease (stage 4) Combinations of chemo- and radiotherapy 联合放化疗联合放化疗保守治疗保守治疗Radical treatment is indicated for stages I b, a and some cases of b 子宫根治术适合于子宫根治术适合于IbIb, , a a 和某些和某些bb患者患者 Wertheims radical hysterectomy Wertheim子宫根治术
32、子宫根治术 pelvic lymphadenectomy 盆腔淋巴结清扫术盆腔淋巴结清扫术 3 cm vaginal cuff 切除阴道上端切除阴道上端3 3厘米厘米 Squamous carcinoma conserved the ovaries 鳞状细胞癌鳞状细胞癌保留卵巢保留卵巢Adenocarcinoma 腺癌腺癌Oophorectomy卵巢切除术卵巢切除术Squamous carcinoma does not spread directly to the ovaries 宫颈鳞癌不会直接蔓延至卵巢宫颈鳞癌不会直接蔓延至卵巢 腺癌卵巢转移发生率约腺癌卵巢转移发生率约5 51010 th
33、ere is a 5-10% incidence of ovarian metastases Advanced disease (stage 4) 晚期患者晚期患者期期 Combinations of chemo- and radiotherapy 联合放化疗联合放化疗 survival rate is very poor 存活率很低存活率很低 Endometrial carcinoma子宫内膜癌子宫内膜癌Carcinoma of the endometrium forms the most common type of uterine cancer. These are mainly ade
34、nocarcinomas derived from endometrial glandular cells 子宫内膜癌是子宫恶性肿瘤中子宫内膜癌是子宫恶性肿瘤中最常见的一种类型，主要是来最常见的一种类型，主要是来源于子宫内膜腺体的腺癌源于子宫内膜腺体的腺癌 Risk factors 危险因素危险因素Obesity 肥胖肥胖 Impaired glucose tolerance 糖耐量下降糖耐量下降Nulliparity 从未生育的从未生育的妇女女Late menopause 绝经迟Unopposed oestrogen therapy 无无对抗的雌激素治抗的雌激素治疗Functioning o
35、varian tumors granulosa-theca cell tumor 功能性卵巢功能性卵巢肿瘤瘤颗粒卵泡膜粒卵泡膜细胞瘤胞瘤Family history of carcinoma of breast、ovary or colon 家族性乳腺癌、卵巢癌、家族性乳腺癌、卵巢癌、结肠癌癌 Pathology 病理学病理学the commonest is the endometrioid adenocarcinoma最常见的为子最常见的为子宫内膜样腺癌宫内膜样腺癌 (a) View of cut surface of the uterus (b) High-power view of Gr
36、ade 1 cancer大体观子宫切面大体观子宫切面 高倍镜下看高倍镜下看期子宫内膜癌期子宫内膜癌 Route of metastasis转移途径转移途径Direct metastasis 直接蔓延直接蔓延Lymphatic metastasis 淋巴转移淋巴转移Hematogenous metastasis 血行转移血行转移Symptoms and Signs 症状和体征症状和体征postmenopausal bleeding 绝经后出血绝经后出血 Discharge 阴道排液阴道排液 pyometra 子宫积脓子宫积脓 Metastatic disease 转移转移Pain 疼痛疼痛Ult
37、rasonography and color Doppler blood-flow imaging provide useful screening tools 超声和彩色多普勒血流显像图是有效的检查工具超声和彩色多普勒血流显像图是有效的检查工具irregular and/or heavy regular bleeding in the premenopausal group 绝经前患者中不规则的和绝经前患者中不规则的和/ /或量较多或量较多的规则的出血的规则的出血 Renal and hepatic function tests, tumor markers, chest X-ray and
38、 possibly an intravenous urogram will need to be undertaken Before the operation手术前手术前检查肝肾功能，肿瘤标记物，检查肝肾功能，肿瘤标记物，胸部胸部X X线检查，必要时进行线检查，必要时进行静脉尿路造影静脉尿路造影 Treatment 治疗治疗Operation 手术手术The operation of choice is a total abdominal hysterectomy and bilateral salpingo-oophorectomy手术选择腹式手术选择腹式子宫全切加双侧子宫全切加双侧输卵管
39、卵巢切除输卵管卵巢切除The pelvic and the para-aortic nodes should be removed if the cervix or adnexa are involved, or if the myometrium is obviously deeply infiltrated 如果侵犯宫颈、附件或明显的浸如果侵犯宫颈、附件或明显的浸润子宫深肌层需要行盆腔和主动润子宫深肌层需要行盆腔和主动脉旁淋巴结清扫脉旁淋巴结清扫histology shows a poorly differentiatedhigh-grade tumor Radiotherapy 放疗放疗
40、晚期晚期组织学显示低分化组织学显示低分化 if the nodes are involved 如果淋巴结受累如果淋巴结受累staging at the time of surgery scores more than a I b 手术时分期在手术时分期在 I b I b 期以上期以上The stage 3 patient 3 3期病人期病人determine whether the disease is confined to the pelvis 确定病灶是否确定病灶是否局限于盆腔局限于盆腔radical surgery 根治性手术根治性手术 radiotherapy 放疗放疗Stage 4
41、 disease 4 4期病人期病人Radiotherapy 放疗放疗 most commonly spreads to the lungs 常有肺转移常有肺转移 spreads to peripheral lymph nodes 外周淋巴外周淋巴结转移结转移 spreads to the bladder 转移至膀胱转移至膀胱 great value for palliation 放疗对减轻症状很有价值放疗对减轻症状很有价值 Prognosis 预后预后The stage and grade of the disease are of paramount importance 分期是影响预后的
42、首要因素分期是影响预后的首要因素Lymph node involvement and evidence of vascular spread reduce the survival rate 淋巴结和血管受累明显降低生存率淋巴结和血管受累明显降低生存率Questions1.What are the risk factors for CIN and cervical cacinoma?2. Can cervical cancer be prevented? How to prevent it? 3.Which diseases can induce the postmenopausal uter
43、ine bleeding? 4. How to treat the disease endometrial carcinoma?Main Reference1.Joan P,Alison B.P,Brian A.M,et al,Obstetrics and GynaecologyM.Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto,2003;134-1392.丰有吉丰有吉, ,沈铿沈铿, ,马丁马丁, ,妇产科学妇产科学M.M.人民卫生出版社人民卫生出版社,2005,316-,2005,316-328328
