Standard Treatment Optionsfor Cervical Cancer FIGO: Staging classifications and clinical practice guidelines of Cervical cancerNational Cancer Institute M.D. Anderson Cancer CenterPractical Gynecologic Oncology 4th Edition宫颈癌标准治疗选择Cancers of the Female Reproductive Tract:Worldwide Statistics11.1. Ferlay Ferlay et al.et al. GLOBOCAN 2000 IARC, WHO 2001 ( GLOBOCAN 2000 IARC, WHO 2001 () ) CancerCancerNew CasesNew CasesDeathsDeathsCervical470,000230,000Endometrial189,00045,000Ovarian192,000114,000USANorthern EuropeSouthern Europe23,80010,00010,20015,6007,2006,200宫颈癌标准治疗选择1974-2000上海市居民妇科肿瘤发病率上海市肿瘤研究流行病研究室年报告宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择Treatment Option Overview nFive randomized phase III trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy,1-6 while 1 trial examining this regimen demonstrated no benefit.7nThe risk of death from cervical cancer was decreased by 30% to 50% by concurrent chemoradiation. nBased 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 cervical cancer.1-8宫颈癌标准治疗选择Treatment Option OverviewnSurgery and radiation therapy are equally effective for early-stage small-volume disease.9 nYounger patients may benefit from surgery in regard to ovarian preservation and avoidance of vaginal atrophy and stenosis. nPatterns of care studies clearly demonstrate the negative prognostic effect of increasing tumor volume. nTherefore, treatment may vary within each stage as currently defined by FIGO, and will depend on tumor bulk and spread pattern.10 宫颈癌标准治疗选择Treatment Option OverviewnTherapy of patients with cancer of the cervical stump is effective, yielding results comparable to those seen in patients with an intact uterus.11 nDuring pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert colposcopy is recommended to exclude invasive cancer. nTreatment of invasive cervical cancer during pregnancy depends on the stage of the cancer and gestational age at diagnosis.宫颈癌标准治疗选择宫颈癌分期:临床诊断分期临床诊断分期q有经验的医师、在麻醉下进行检查有经验的医师、在麻醉下进行检查q后来的发现不能改变已经确定的期别后来的发现不能改变已经确定的期别q触诊、视诊、阴道镜、宫颈管诊刮术触诊、视诊、阴道镜、宫颈管诊刮术(ECC)、宫腔镜、膀胱镜、直、宫腔镜、膀胱镜、直肠镜、静脉尿路造影、以及骨骼和肺部肠镜、静脉尿路造影、以及骨骼和肺部x线检查线检查q膀胱和直肠怀疑病灶须经活检并有组织学证实膀胱和直肠怀疑病灶须经活检并有组织学证实q淋巴管造影、动脉造影、静脉造影、剖腹探查术、超声探查、淋巴管造影、动脉造影、静脉造影、剖腹探查术、超声探查、CT扫描和磁共振（扫描和磁共振（MRI）等，故不能作为改变期别的根据）等，故不能作为改变期别的根据q对扫描检查怀疑的淋巴结行细针穿刺，能帮助制定治疗计划对扫描检查怀疑的淋巴结行细针穿刺，能帮助制定治疗计划宫颈癌标准治疗选择宫颈癌分期:手术治疗后病理分期手术治疗后病理分期q手术手术-病理检查切除的标本结果，是最确切诊断肿瘤侵犯范围病理检查切除的标本结果，是最确切诊断肿瘤侵犯范围q这些结果不能改变临床分期，但可将这些结果记录在疾病的病理分这些结果不能改变临床分期，但可将这些结果记录在疾病的病理分期法则中，期法则中，TNM分期正是符合情况分期正是符合情况q首次诊断时确定分期，而且不能更改，即使在复发时也是如此首次诊断时确定分期，而且不能更改，即使在复发时也是如此q只有在临床分期的准则严格执行时，才有可能比较各个临床单位和只有在临床分期的准则严格执行时，才有可能比较各个临床单位和不同治疗方式的结果不同治疗方式的结果宫颈癌标准治疗选择宫颈癌标准治疗选择临床分期检查方法n临床分期临床分期q非损伤性诊断检查非损伤性诊断检查n双足淋巴管双足淋巴管X线照片（线照片（Bipedal lymphangiogram） n计算机断层计算机断层X线扫描术（线扫描术（CT, Computed Tomography） n超声波扫描术（超声波扫描术（Ultrasonography） n磁共振成像（磁共振成像（MRI, Magnetic Resonance Imaging） n正电子发射断层扫描（正电子发射断层扫描（PET, Positron Emission Tomography） n细针吸取细胞学检查细针吸取细胞学检查 q手术分期手术分期： 治疗前，腹主动脉旁治疗前，腹主动脉旁LN，延伸放射野，延伸放射野?n剖腹探查术的方法n腹腔镜分期宫颈癌标准治疗选择Surgical StagingnPretreatment surgical staging is the most accurate method to determine extent of disease. nBecause there is little evidence to demonstrate overall improved survival with routine surgical staging, it usually should be performed only as part of a clinical trial. nPretreatment surgical staging in bulky, but locally curable, disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. nIf abnormal nodes are detected by CT scan or lymphangiography, fine needle aspiration should be negative before a surgical staging procedure is performed. 宫颈癌标准治疗选择腹主动脉旁淋巴结腹主动脉旁淋巴结CT阴性患者中生存率曲线与阴性患者中生存率曲线与PET扫描结果的关系扫描结果的关系 J Clin Oncol 2001;19: 37453749.)宫颈癌标准治疗选择IB期宫颈癌盆腔淋巴结转移率期宫颈癌盆腔淋巴结转移率宫颈癌标准治疗选择 II 和和 III期宫颈癌腹主动脉旁淋巴结转移率期宫颈癌腹主动脉旁淋巴结转移率宫颈癌标准治疗选择宫颈癌治疗：根据期别选择1.0期2.微小浸润癌3.B1期和早A癌4.B至至A期宫颈癌期宫颈癌宫颈癌标准治疗选择Stage 0 Cervical Cancer Standard treatment options: Methods to treat ectocervical lesions include: nLoop electrosurgical excision procedure (LEEP).7,8 nLaser therapy.9 nConization. nCryotherapy.10 nWhen 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. nTotal abdominal or vaginal hysterectomy is an accepted therapy for the postreproductive age group and is particularly indicated when the neoplastic process extends to the inner cone margin.nFor medically inoperable patients, a single intracavitary insertion with tandem and ovoids for 5,000 milligram hours (8,000 cGy vaginal surface dose) may be used.11 宫颈癌标准治疗选择对异常对异常Pap 涂片或活检示涂片或活检示微小浸润癌微小浸润癌处理步骤处理步骤Pap涂片异常或钳取活检“微小浸润癌”锥切活检微小浸润5mml切缘阴性lECC阴性ECC阴性切缘和/或ECC示非典型增生lA1期l无广泛LVSIl如有生育愿望者锥切l筋膜外子宫切除再次锥切活检如锥切不便行改良RH盆腔淋巴结切除术l广泛LVSI的A1期lA2期l如有生育愿望者盆腔淋巴结切除加锥切，或广泛宫颈切除l改良RH和盆腔淋巴结切除宫颈癌标准治疗选择Stage IA Cervical Cancer Equivalent treatment options: nIntracavitary radiation alone: nIf 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 low that external beam radiation is not required.n 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 nRadiation should be reserved for women who are not surgical candidates. 宫颈癌标准治疗选择IB 和早和早 IIA期宫颈癌的治疗步骤期宫颈癌的治疗步骤l期l早期（阴道前壁侵犯）除外l根治性子宫切除l盆腔淋巴结切除l切除任何增大腹主动脉旁淋巴结l淋巴结阴性l高危险（GOG分数120）多个阳性淋巴结或增大阳性淋巴结l淋巴结阴性l低危险观察小野盆腔放疗l延伸野放疗l顺铂周疗宫颈癌标准治疗选择Stage IIB Cervical Cancer Stage III Cervical Cancer Stage IVA Cervical Cancer Radiation therapy plus chemotherapy: Intracavitary radiation and external-beam pelvic irradiation combined with cisplatin or cisplatin/fluorouracil.7-12 宫颈癌标准治疗选择晚期宫颈癌的诊治步骤B-A宫颈癌腹、盆腔CT盆、腹腔阴性l盆腔或腹腔淋巴结1.5cml附件包块胸部CT胸部CT阴性胸部CT阳性l切除附件包块l肿大淋巴结腹膜外切除l延伸野放疗和DDP周疗姑息性盆腔放疗预防性延伸野放疗和DDP周疗宫颈癌标准治疗选择Recurrent Cervical Cancer nStandard treatment options: nFor 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 nChemotherapy can be used for palliation. Tested drugs include: qCisplatin (15%-25% response rate).4 qIfosfamide (15%-30% response rate).5,6 qIfosfamide-cisplatin.7,8 qPaclitaxel (17% response rate).9 qIrinotecan (21% response rate in patients previously treated with chemotherapy).10 qPaclitaxel/cisplatin (46% response rate).11 qCisplatin/gemcitabine (41% response rate).12 宫颈癌标准治疗选择术后放射治疗：术后放射治疗：范围及适应症范围及适应症n 标准野标准野 ：1.阳性盆腔淋巴结阳性阳性盆腔淋巴结阳性2.宫旁组织阳性宫旁组织阳性3.手术切缘阳性患者手术切缘阳性患者n小野：淋巴结阴性小野：淋巴结阴性+高危因素高危因素1.临床肿瘤大小临床肿瘤大小2.淋巴管腔侵犯淋巴管腔侵犯3.肿瘤浸润深度肿瘤浸润深度宫颈癌标准治疗选择宫颈癌根治子宫和双侧盆腔淋巴结切除后无病生存率宫颈癌根治子宫和双侧盆腔淋巴结切除后无病生存率宫颈癌标准治疗选择盆腔放射的标准野和小野之间的比较盆腔放射的标准野和小野之间的比较宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择宫颈癌标准治疗选择谢谢 谢谢宫颈癌标准治疗选择