宮頸癌標(biāo)準(zhǔn)治療選擇

1、3/24/2024,Dr.Xiaohua Wu,1,Standard Treatment Optionsfor Cervical Cancer,FIGO: Staging classifications and clinical practice guidelines of Cervical cancerNational Cancer Institute M.D. Anderson Cancer CenterPractical

2、 Gynecologic Oncology 4th Edition,3/24/2024,Dr.Xiaohua Wu,2,Cancers of the Female Reproductive Tract:Worldwide Statistics1,,Ferlay et al. GLOBOCAN 2000 IARC, WHO 2001 (www.dep.iarc.fr),3/24/2024,Dr.Xiaohua Wu,3,1974-200

3、0上海市居民婦科腫瘤發(fā)病率上海市腫瘤研究流行病研究室年報告,3/24/2024,Dr.Xiaohua Wu,4,3/24/2024,Dr.Xiaohua Wu,5,3/24/2024,Dr.Xiaohua Wu,6,Treatment Option Overview,Five randomized phase III trials have shown an overall survival advantage for cisplat

4、in-based therapy given concurrently with radiation therapy,[1-6] while 1 trial examining this regimen demonstrated no benefit.[7]The risk of death from cervical cancer was decreased by 30% to 50% by concurrent chemorad

5、iation. Based on these results, strong consideration should be given to the incorporation of concurrent cisplatin- based chemotherapy with radiation therapy in women who require radiation therapy for treatment of cervi

6、cal cancer.[1-8],3/24/2024,Dr.Xiaohua Wu,7,Treatment Option Overview,Surgery and radiation therapy are equally effective for early-stage small-volume disease.[9] Younger patients may benefit from surgery in regard to ov

7、arian preservation and avoidance of vaginal atrophy and stenosis. Patterns of care studies clearly demonstrate the negative prognostic effect of increasing tumor volume. Therefore, treatment may vary within each stage

8、as currently defined by FIGO, and will depend on tumor bulk and spread pattern.[10],3/24/2024,Dr.Xiaohua Wu,8,Treatment Option Overview,Therapy of patients with cancer of the cervical stump is effective, yielding results

9、 comparable to those seen in patients with an intact uterus.[11] During pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert colposcopy is recommended to

10、 exclude invasive cancer. Treatment of invasive cervical cancer during pregnancy depends on the stage of the cancer and gestational age at diagnosis.,3/24/2024,Dr.Xiaohua Wu,9,宮頸癌分期:臨床診斷分期,有經(jīng)驗的醫(yī)師、在麻醉下進(jìn)行檢查后來的發(fā)現(xiàn)不能改變已經(jīng)確定的

11、期別觸診、視診、陰道鏡、宮頸管診刮術(shù)(ECC)、宮腔鏡、膀胱鏡、直腸鏡、靜脈尿路造影、以及骨骼和肺部x線檢查膀胱和直腸懷疑病灶須經(jīng)活檢并有組織學(xué)證實淋巴管造影、動脈造影、靜脈造影、剖腹探查術(shù)、超聲探查、CT掃描和磁共振（MRI）等，故不能作為改變期別的根據(jù)對掃描檢查懷疑的淋巴結(jié)行細(xì)針穿刺，能幫助制定治療計劃,3/24/2024,Dr.Xiaohua Wu,10,宮頸癌分期:手術(shù)治療后病理分期,手術(shù)--病理檢查切除的標(biāo)本結(jié)果，是最

12、確切診斷腫瘤侵犯范圍這些結(jié)果不能改變臨床分期，但可將這些結(jié)果記錄在疾病的病理分期法則中，TNM分期正是符合情況首次診斷時確定分期，而且不能更改，即使在復(fù)發(fā)時也是如此只有在臨床分期的準(zhǔn)則嚴(yán)格執(zhí)行時，才有可能比較各個臨床單位和不同治療方式的結(jié)果,3/24/2024,Dr.Xiaohua Wu,11,3/24/2024,Dr.Xiaohua Wu,12,臨床分期檢查方法,臨床分期非損傷性診斷檢查雙足淋巴管X線照片（Bipedal l

13、ymphangiogram） 計算機(jī)斷層X線掃描術(shù)（CT, Computed Tomography） 超聲波掃描術(shù)（Ultrasonography） 磁共振成像（MRI, Magnetic Resonance Imaging） 正電子發(fā)射斷層掃描（PET, Positron Emission Tomography） 細(xì)針吸取細(xì)胞學(xué)檢查 手術(shù)分期： 治療前，腹主動脈旁LN，延伸放射野?剖腹探查術(shù)的方法腹腔鏡分期,3/24/

14、2024,Dr.Xiaohua Wu,13,Surgical Staging,Pretreatment surgical staging is the most accurate method to determine extent of disease. Because there is little evidence to demonstrate overall improved survival with routine sur

15、gical staging, it usually should be performed only as part of a clinical trial. Pretreatment surgical staging in bulky, but locally curable, disease may be indicated in select cases when a nonsurgical search for metasta

16、tic disease is negative. If abnormal nodes are detected by CT scan or lymphangiography, fine needle aspiration should be negative before a surgical staging procedure is performed.,3/24/2024,Dr.Xiaohua Wu,14,腹主動脈旁淋巴結(jié)CT陰性

17、患者中生存率曲線與PET掃描結(jié)果的關(guān)系 J Clin Oncol 2001;19: 3745–3749.),3/24/2024,Dr.Xiaohua Wu,15,IB期宮頸癌盆腔淋巴結(jié)轉(zhuǎn)移率,3/24/2024,Dr.Xiaohua Wu,16,II 和 III期宮頸癌腹主動脈旁淋巴結(jié)轉(zhuǎn)移率,3/24/2024,Dr.Xiaohua Wu,17,宮頸癌治療：根據(jù)期別選擇,0期微小浸潤癌ⅠB1期和早ⅡA癌ⅡB至ⅣA期宮頸癌,3/2

18、4/2024,Dr.Xiaohua Wu,18,Stage 0 Cervical Cancer,Standard treatment options: Methods to treat ectocervical lesions include: Loop electrosurgical excision procedure (LEEP).[7,8] Laser therapy.[9] Conization. Cryothera

19、py.[10] When 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. Total abdominal or vag

20、inal hysterectomy is an accepted therapy for the postreproductive age group and is particularly indicated when the neoplastic process extends to the inner cone margin.For medically inoperable patients, a single intracav

21、itary insertion with tandem and ovoids for 5,000 milligram hours (8,000 cGy vaginal surface dose) may be used.[11],3/24/2024,Dr.Xiaohua Wu,19,對異常Pap 涂片或活檢示微小浸潤癌處理步驟,3/24/2024,Dr.Xiaohua Wu,20,Stage IA Cervical Cancer Eq

22、uivalent treatment options:,Intracavitary radiation alone: If the depth of invasion is less than 3 millimeters and no capillary lymphatic space invasion is noted, the frequency of lymph node involvement is sufficiently

23、low that external beam radiation is not required. One or 2 insertions with tandem and ovoids for 6,500 to 8,000 milligram hours (10,000-12,500 cGy vaginal surface dose) are recommended.[4] Radiation should be reserved

24、for women who are not surgical candidates.,3/24/2024,Dr.Xiaohua Wu,21,IB 和早 IIA期宮頸癌的治療步驟,3/24/2024,Dr.Xiaohua Wu,22,Stage IIB Cervical Cancer Stage III Cervical Cancer Stage IVA Cervical Cancer,Radiation therapy plus

25、chemotherapy: Intracavitary radiation and external-beam pelvic irradiation combined with cisplatin or cisplatin/fluorouracil.[7-12],3/24/2024,Dr.Xiaohua Wu,23,晚期宮頸癌的診治步驟,3/24/2024,Dr.Xiaohua Wu,24,Recurrent Cervical Canc

26、er,Standard treatment options: For recurrence in the pelvis following radical surgery, radiation in combination with chemotherapy (fluorouracil with or without mitomycin) may cure 40% to 50% of patients.[3] Chemotherap

27、y can be used for palliation. Tested drugs include: Cisplatin (15%-25% response rate).[4] Ifosfamide (15%-30% response rate).[5,6] Ifosfamide-cisplatin.[7,8] Paclitaxel (17% response rate).[9] Irinotecan (21% respon

28、se rate in patients previously treated with chemotherapy).[10] Paclitaxel/cisplatin (46% response rate).[11] Cisplatin/gemcitabine (41% response rate).[12],3/24/2024,Dr.Xiaohua Wu,25,術(shù)后放射治療：范圍及適應(yīng)癥,標(biāo)準(zhǔn)野 ：陽性盆腔淋巴結(jié)陽性宮旁組織陽

29、性手術(shù)切緣陽性患者小野：淋巴結(jié)陰性+高危因素臨床腫瘤大小淋巴管腔侵犯腫瘤浸潤深度,3/24/2024,Dr.Xiaohua Wu,26,宮頸癌根治子宮和雙側(cè)盆腔淋巴結(jié)切除后無病生存率,3/24/2024,Dr.Xiaohua Wu,27,盆腔放射的標(biāo)準(zhǔn)野和小野之間的比較,3/24/2024,Dr.Xiaohua Wu,28,3/24/2024,Dr.Xiaohua Wu,29,3/24/2024,Dr.Xiaohua Wu,3