期子宫内膜癌子宫切除的范围北京大学第三医院妇产科 郭红燕,2,I期子宫内膜癌 子宫切除范围：比较明确，存在混淆全子宫切除术？筋膜外子宫切除术？二者异同？次广泛子宫切除术？,FIGO 2009 子宫内膜癌分期改变 影响子宫内膜癌子宫切除范围的选择吗？,局限于子宫的内膜癌手术选择 争议：局限于子宫，宫颈累及？广泛子宫切除术？,子宫切除范围值得探讨,子宫内膜癌分期改变,筋膜外子宫切除术？,II 期子宫内膜癌子宫切除范围？,子宫切除范围探讨OUTLINE,I期子宫内膜癌次广泛子宫切除术？,内膜癌病变局限于子宫-手术方式,Disease limited to uterus,Medically inoperable,operable,Tumor directed RT,Total hysterectomy and bilateral salpingo-oophorectomy Lympho nodes dissection pelvic+para aortic,The current NCCN Clinical Practice Guideline recommends practicing radical hysterectomy only when cervical infiltration is suspected on MRI or when confirmed by cervical biopsy.,2009NCCN,FIGO: 筋膜外子宫切除术 GOG2010:Women with endometrial cancers should undergo total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO), pelvic/paraaortic dissection 妇科常见恶性肿瘤治疗指南：筋膜外子宫切除术 林巧稚妇科肿瘤学：全子宫切除术 中国妇产科学（曹泽毅主编）：筋膜外子宫切除术,I 期子宫内膜癌-手术方式,I 期子宫内膜癌-手术方式,Gan To Kagaku Ryoho. 1995 Aug;22(9):1163-8.Total hysterectomy is done for cases of stage 0, modified radical hysterectomy for stage I, radical hysterectomy for stage II, and radical hysterectomy combined with resection of the metastatic lesions for stage III and IV Zhonghua Fu Chan Ke Za Zhi. 2002 Feb;37(2):90-3. Surgical method is not the main factor influenced the survive of stage I endometrial carcinoma. Zhonghua Fu Chan Ke Za Zhi. 2004 Mar;39(3):156-8. The patients with stage I endometrial carcinoma who were treated with simple hysterectomy and salpingo-oophorectomy did almost as well as those who underwent radical hysterectomy.,为什么不行广泛或次广泛子宫切除术,Mauro Signorelli, et al. Gynecologic Oncology 2009 Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer,宫颈癌宫旁切除范围分类,子宫切除范围类型,Piver-Rutledge: 5类 LANCET 2008 ：Denis Querleu, et al: Classification of radical hysterectomy,Extrafacial hysterectomy Modified hysterectomy Radical hysterectomy Laterally extended resection Extenteration,筋膜外子宫切除术,目的to ensure that the cervix is entirely removed 适应症：子宫内膜癌，早期宫颈癌 与全子宫切除术异同？定义？ 手术中要点？,筋膜外子宫切除术,方法：The position of the ureters is determined by palpation without freeing the ureters from their beds. The parametrium is transected medial to the ureter, but lateral to the cervix, keeping the paracervical ring intact. The uterosacral and vesicouterine ligaments are transected close to the uterus. There is no removal of paracolpos and a minimal part of vagina is resected at fornix level.,10,筋膜外子宫切除术,仁者见仁，智者见智我们：膀胱抚摸返折：下推膀胱至宫颈外口水平下较低水平子宫动脉：峡部水平以下主韧带：贴而略离开宫骶韧带：单独处理,11,宫颈癌,子宫肉瘤,子宫内膜癌,FIGO 2009,外阴癌,FIGO 2009 年肿瘤分期改变,FIGO 子宫内膜癌分期 （1988年）, 期 a （G1,2,3） 癌瘤局限于子宫内膜 b （G1,2,3） 癌瘤浸润深度 1/2 肌层 期 a （G1,2,3） 宫颈内膜腺体受累 b （G1,2,3） 宫颈间质受累 期 a （G1,2,3） 病变累及子宫浆膜和(或)附件和(或)腹腔细胞学阳性 b （G1,2,3） 阴道转移 c （G1,2,3） 盆腔淋巴结和(或)腹主动脉淋巴结 期 a （G1,2,3） 癌瘤侵及膀胱或直肠粘膜 b （G1,2,3） 远处转移，包括腹腔内和(或)腹股沟淋巴结转移,OLD,FIGO 子宫内膜癌分期 （2009年）,*累及宫颈腺体为期，不再定为期 *腹水细胞学结果单独报告，但是不改变分期,NEW,子宫内膜癌分期修订的原因和主要修订内容,1988分期中Ia及Ib期患者预后差异不大，将原Ia和Ib期合并。 Ia期/G1、 Ib期/G1、 Ia期/G2、 Ib期/G2的5年生存率分别为93.4%、91.2%、91.3%、93.4%，无显著差异 宫颈粘膜受累作为上皮内癌，归为I期。 腹膜后淋巴结转移是预后不良的独立因素，伴有腹主动脉旁淋巴结转移者预后更差。因此将原IIIc期分为IIIC1和IIIC2。 腹腔冲洗液细胞学阳性是其它危险因素的潜在结果，而不是独立的危险因素。因而不改变分期。,病变累及宫颈手术范围的选择,II期子宫内膜癌子宫切除范围首选广泛子宫切除术（IIIII型子宫根治术） 累及宫颈粘膜，现在归为I期，子宫切除范围？ 累及粘膜和间质如果应该选择不同的手术范围，如何术前鉴别诊断之？ 宫颈是否累及？是否间质浸润？术前诊断困难,16,分期改变带来的新问题,累及宫颈粘膜（I期）？,OLD：IC差于IIA NEW：II差于所有I期 IIA期宫旁累及？宫颈癌早期手术范围 如何识别粘膜累及还是间质浸润,累及宫颈粘膜（ 一期）？,诊断和鉴别宫颈粘膜累及还是间质浸润,宫颈累及一定要行广泛子宫切除术吗？,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) vs 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,宫颈累及时子宫切除范围选择,指 南：广泛子宫切除术局限于子宫归为一类 II期子宫内膜癌: 筋膜外或广泛子宫切除术现 状KOREA， JAPAN：Choose the surgical extent of hysterectomy through their own disposition 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,II期子宫内膜癌RH 手术的必要性,II期子宫内膜癌手术方式的选择,II期子宫内膜癌RH 手术的必要性,Depth of myometrial invasion and pelvic or paraaortic lymph node positivity were significantly correlated with paramatrial involvement. Of the 19 patients with pelvic lymph node metastasis, 8 patients (42.1%) had concomitant PMI. Conversely, of the 10 patients with PMI, 8(80.0%) had lymph node metastasis.,THIS IS AN AREA OF CONTINUED DEBATE,23,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 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 frequently seen in patients with deep myometrial involvement without cervical involvement,