《卵巢肿瘤》课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,卵巢肿瘤,(,Ovarian tumor),中国医科大学附属第四临床医院妇科,张 岩,卵巢肿瘤(Ovarian tumor)中国医科大学附属第四临,一、概论,Here comes your footer Page 2,一、概论Here comes your footer ,概论,女性生殖器常见肿瘤之一,组织学类型,为全身各脏器肿瘤中,最多,良性、交界性、恶性均可发生,不易早期发现,Here comes your footer Page 3,概论 女性生殖器常见肿瘤之一Here comes your,组织学分类,上皮性肿瘤：,50-70%,，占卵巢恶性肿瘤,85-90%,生殖细胞肿瘤：,20-40%,性索间质肿瘤：,5%,转移性肿瘤：,5-10%,Here comes your footer Page 4,组织学分类 上皮性肿瘤：50-70%，占卵巢恶性肿瘤85-9,（一）上皮性肿瘤,浆液性肿瘤,粘液性肿瘤,子宫内膜样肿瘤,透明细胞瘤（中肾样瘤）,勃勒纳瘤,混合性上皮瘤,未分化癌,良性、交界性、恶性,Here comes your footer Page 5,（一）上皮性肿瘤 浆液性肿瘤良性、交界性、恶性Here co,（二）生殖细胞肿瘤,无性细胞瘤,内胚窦瘤,胚胎癌,多胎瘤,绒毛膜癌,畸胎瘤,混合型,Here comes your footer Page 6,（二）生殖细胞肿瘤 无性细胞瘤Here comes your,（三）性索间质肿瘤,颗粒细胞,-,间质细胞肿瘤,支持细胞,-,间质细胞肿瘤（睾丸母细胞瘤）,两性母细胞瘤,Here comes your footer Page 7,（三）性索间质肿瘤 颗粒细胞-间质细胞肿瘤Here come,（四）转移性肿瘤,库肯勃瘤,Here comes your footer Page 8,（四）转移性肿瘤 库肯勃瘤Here comes your f,恶性肿瘤转移途径,转移特点：,外观局限的肿瘤，却在腹膜、大网膜、腹膜后淋巴结、横膈等部位已有亚临床转移。,Here comes your footer Page 9,恶性肿瘤转移途径转移特点：外观局限的肿瘤，却在腹膜、大网膜、,恶性肿瘤转移途径,直接蔓延及腹腔种植,淋巴转移,沿卵巢血管的淋巴管,-,腹主动脉淋巴结,卵巢门淋巴管,-,髂内、髂外淋巴结,-,腹主动脉淋巴结,圆韧带,-,髂外、腹股沟淋巴结,横膈,易转移，,右膈下淋巴丛,密集最易受侵犯,血行转移,Here comes your footer Page 10,恶性肿瘤转移途径直接蔓延及腹腔种植Here comes yo,恶性肿瘤临床分期,手术,病理分期,用以估计预后和比较疗效,Here comes your footer Page 11,恶性肿瘤临床分期手术病理分期Here comes your,表,32-2,原发性卵巢恶性肿瘤的临床分期（,FIGO,，,2000,）,期,:,肿瘤,局限于卵巢,a,肿瘤局限于一侧卵巢，包膜完整，表面无肿瘤，腹水或腹腔冲洗液中不含,恶性细胞,b,肿瘤局限于两侧卵巢，包膜完整，表面无肿瘤，腹水或腹腔冲洗液中不含,恶性细胞,c a,或,b,肿瘤伴以下任何一种情况：包膜破裂，卵巢表面有肿瘤，腹水或,腹腔冲洗液中含恶性细胞,期,:,一侧或双侧卵巢肿瘤，伴,盆腔内扩散,a,蔓延和（或）转移到子宫和（或）输卵管,b,蔓延到其他盆腔组织,c a,或, b,肿瘤，腹水或腹腔冲洗液中含恶性细胞,期,:,一侧或双侧卵巢肿瘤，伴显微镜下证实的,盆腔外的腹腔转移和（或）区域,淋巴结转移。肝表面转移,a,显微镜下证实的盆腔外的腹腔转移,b,腹腔转移灶直径 ,2cm,c,腹腔转移灶直径,2cm,，和（或）区域淋巴结转移,期,:,远处转移,（胸水有癌细胞，肝实质,),Here comes your footer Page 12,表32-2 原发性卵巢恶性肿瘤,组织学分级,WHO,分级标准主要依据组织结构，并参照,细胞分化程度而分为,3,级,分化,1,级,-,高分化,分化,2,级,-,中分化,分化,3,级,-,低分化,组织学分级：,对预后的影响,较组织学类型更重要，,组织分化越差，预后越差。,Here comes your footer Page 13,组织学分级WHO分级标准主要依据组织结构，并参照细胞分化程度,临床表现,良性肿瘤,发展缓慢，早期多无症状,恶性肿瘤,腹胀、腹部肿块及腹水,恶性肿瘤症状的轻重决定于：,（,1,）肿瘤的大小，位置，侵犯邻近器官的程度,（,2,）肿瘤的组织学类型,（,3,）有无并发症,Here comes your footer Page 14,临床表现良性肿瘤 发展缓慢，早期多无症状Here co,并发症,蒂扭转,破裂,感染,恶变,Here comes your footer Page 15,并发症 蒂扭转Here comes your footer,（一）蒂扭转,好发：蒂长、中等大、活动良、重心偏,蒂组成：,骨盆漏斗韧带、卵巢固有韧带、 输卵管,诱因：突然改变体位、妊娠、分娩,诊断：,治疗：确诊后尽快手术。,不回复扭转，于蒂下方钳夹切除患侧附件。,Here comes your footer Page 16,（一）蒂扭转好发：蒂长、中等大、活动良、重心偏Here co,Here comes your footer Page 17,Here comes your footer Pag,（二）破裂,原因：外伤性（重击、性交）、自发性,症状：破口大小、囊液流出性质及数量,治疗原则：,立即手术,Here comes your footer Page 18,（二）破裂原因：外伤性（重击、性交）、自发性Here com,（三）感染,多发生于：扭转后、破裂后,临床表现：,治疗：,先抗生素、后手术,Here comes your footer Page 19,（三）感染多发生于：扭转后、破裂后Here comes yo,（四）恶变,早期不易发现,良性卵瘤可恶变,因此，确诊的卵巢肿瘤应尽快手术。,Here comes your footer Page 20,（四）恶变早期不易发现Here comes your foo,诊断,影像学：超声、,X-ray,、,CT,、,MRI,、,PET,肿瘤标志物：,CA125,-,上皮性肿瘤,AFP,-,卵黄囊瘤,HCG,-,卵巢绒癌,腹腔镜检查,细胞学检查,Here comes your footer Page 21,诊断影像学：超声、X-ray、CT、MRI、PETHere,鉴别诊断,鉴别内容,良性肿瘤,恶性肿瘤,病史,病程长，逐渐增大,病程短，迅速增大,体征,单侧,多，活动，,囊性,，表面光滑；通常无腹水,双侧,多，固定，,实性或半实半囊,，表面结节状不平；常伴,腹水，多为血性,，可能查到癌细胞,一般情况,良好,逐渐出现恶病质,B,型超声,为液性暗区，可有间隔光带，边缘清晰,液性暗区内有杂乱光区、光点，肿块界限不清,（一）,良性肿瘤与恶性肿瘤的鉴别,Here comes your footer Page 22,鉴别诊断鉴别内容良性肿瘤恶性肿瘤病史病程长，逐渐增大病程短，,（二）良性肿瘤的鉴别诊断,卵巢瘤样病变：,5cm,，,2-3m,可自行消失,输卵管卵巢囊肿,子宫肌瘤,妊娠子宫,腹水,Here comes your footer Page 23,（二）良性肿瘤的鉴别诊断 卵巢瘤样病变：5cm，2-3m可,（三）恶性卵巢肿瘤的鉴别诊断,子宫内膜异位症：,CA125,可轻度增高,盆腔结缔组织炎,结核性腹膜炎,生殖道以外的肿瘤,转移性卵巢肿瘤,Here comes your footer Page 24,（三）恶性卵巢肿瘤的鉴别诊断子宫内膜异位症：CA125可轻度,随访,随访时间,术后,1,年内,1,次,/3,月,第二年,1,次,/4-6,月,5,年以上,1,次,/,年,Here comes your footer Page 25,随访随访时间Here comes your footer,监测,监测内容：,症状、体征,全身及盆腔检查,各种辅助检查（影像学、肿瘤标志物测定,),Here comes your footer Page 26,监测监测内容：Here comes your footer,预防,高危因素的预防,开展普查普治,早期发现及处理：,实性肿块；囊肿直径,8cm,；青春期前、绝经后期；口服避孕药妇女；囊肿持续存在,2m,-,腹腔镜探查,Here comes your footer Page 27,预防 高危因素的预防Here comes your foot,妊娠合并卵巢肿瘤,肿瘤对妊娠的影响：,流产、胎位异常、难产,妊娠对肿瘤的影响：,蒂扭转、破裂、迅速增大、恶性肿瘤扩散,手术时机,：,妊早期，待妊娠,3,个月后,妊晚期，可待足月，剖宫产同时,疑恶性者，尽早手术,Here comes your footer Page 28,妊娠合并卵巢肿瘤肿瘤对妊娠的影响：流产、胎位异常、难产Her,二、卵巢上皮性肿瘤（,epithelial ovaian tumor,）,Here comes your footer Page 29,二、卵巢上皮性肿瘤（epithelial ovaian t,概述,最常见,好发年龄：,30-60,岁,良性、交界性、恶性,恶性上皮性肿瘤约占卵巢肿瘤的,90%,Here comes your footer Page 30,概述最常见Here comes your footer ,发病的高危因素,持续排卵：未产、未孕、初潮早、绝经晚（排卵、,HRT-,促排卵）,遗传和家族因素,遗传性乳癌,-,卵巢癌综合征（,BRCA1,、,BRCA2,基因突变）,部位特异性卵巢癌综合征,型,Lynch,综合征（常染色体显性遗传）,环境因素（有机粉尘、芳香胺、滑石粉、吸烟、高动物蛋白饮食）,Here comes your footer Page 31,发病的高危因素持续排卵：未产、未孕、初潮早、绝经晚（排卵、H,发病的抑制因素,口服避孕药,生育、哺乳,非甾体抗炎药,VitA,，胡萝卜素,低脂饮食,子宫切除及输卵管结扎,预防性卵巢切除,Here comes your footer Page 32,发病的抑制因素 口服避孕药Here comes your f,（一） 浆液性囊腺瘤,1,）良性：,常见，,占良性卵巢瘤,25%,。,单侧、光滑、囊性、壁薄,、内为淡黄色液体,分型：单纯性、乳头性,镜下：囊壁为纤维结缔组织,Here comes your footer Page 33,（一） 浆液性囊腺瘤1）良性：Here comes your,Here comes your footer Page 34,Here comes your footer Pag,Here comes your footer Page 35,Here comes your footer Pag,Here comes your footer Page 36,Here comes your footer Pag,2,）交界性,中等大、双侧、囊外乳头状生长,低度潜在恶性、生长缓慢、转移率低、复发迟,Here comes your footer Page 37,2）交界性Here comes your footer ,Here comes your footer Page 38,Here comes your footer Pag,Here comes your footer Page 39,Here comes your footer Pag,Here comes your footer Page 40,Here comes your footer Pag,3,）浆液性囊腺癌,最常见,，,40%-50%,双侧,、体积较大、,半实质性,结节性、分叶性，多房，,腔内充满乳头,、质脆、出血、坏死、囊液混浊,镜下：囊壁上皮明显增生，复层排列，细胞异型明显，向间质浸润,Here comes your footer Page 41,3）浆液性囊腺癌Here comes your footer,Here comes your footer Page 42,Here comes your footer Pag,Here comes your footer Page 43,Here comes your footer Pag,Here comes your footer Page 44,Here comes your footer Pag,（二）粘液性囊腺瘤,1,）良性：,占,20%,、,单侧、圆形或卵圆形、表面光滑、灰白色、,体积较大或巨大,切面：,多房,、内充满,胶冻状粘液,恶变率：,5%-10%,Here comes your footer Page 45,（二）粘液性囊腺瘤1）良性：Here comes your,Here comes your footer Page 46,Here comes your footer Pag,Here comes your footer Page 47,Here comes your footer Pag,Here comes your footer Page 48,Here comes your footer Pag,2,）交界性：,较大、表面光滑、多房,切面：,囊壁厚、实质区和乳头,形成,镜下：细胞轻度异型，细胞核大、染色深，少量核分裂,Here comes your footer Page 49,2）交界性：Here comes your footer,Here comes your footer Page 50,Here comes your footer Pag,Here comes your footer Page 51,Here comes your footer Pag,3,）粘液性囊腺癌,:,占,10%,，,单侧多见、较大、,囊壁可见乳头或实性区、切面,半实半囊、囊液混浊,或,血性,镜下：腺上皮超过,3,层，细胞明显异型，间质浸润,Here comes your footer Page 52,3）粘液性囊腺癌:Here comes your foote,Here comes your footer Page 53,Here comes your footer Pag,Here comes your footer Page 54,Here comes your footer Pag,（三）卵巢子宫内膜样肿瘤,良性：少,单房、光滑,恶性：单侧、中等大、囊性或实性、有乳头、囊液血性,Here comes your footer Page 55,（三）卵巢子宫内膜样肿瘤 良性：少Here comes yo,Here comes your footer Page 56,Here comes your footer Pag,Here comes your footer Page 57,Here comes your footer Pag,治疗,治疗原则：首选手术治疗,良性肿瘤,一经确诊，即应手术治疗,疑为卵巢瘤样病变可作短期观察,恶性肿瘤,治疗原则：,以手术为主，加用化疗放疗的综合治疗,Here comes your footer Page 58,治疗治疗原则：首选手术治疗Here comes your f,治疗,（,一）良性肿瘤,-,患侧卵巢肿瘤剥出术或患侧附件切除术,-,子宫及双侧附件切除术,*术中尽可能完整取出，防止肿瘤破裂、囊液流出，巨大良性囊肿可先穿刺放液，再取出。,Here comes your footer Page 59,治疗（一）良性肿瘤Here comes your foote,治疗,（二）交界性肿瘤,参照卵巢癌手术治疗,期、年轻、要求保留生育功能,患侧附件切除术,化疗：有残留病灶、复发,Here comes your footer Page 60,治疗（二）交界性肿瘤Here comes your foot,治疗,（二）恶性肿瘤,手术目的：诊断与分期、切除病灶、评价,手术方式,分期手术,肿瘤细胞减灭术,间歇性肿瘤细胞减灭术,再分期手术,再次肿瘤细胞减灭术,二探,Here comes your footer Page 61,治疗（二）恶性肿瘤Here comes your foote,治疗,手术：卵巢癌治疗的,关键作用,低危：,a-b,，高分化，,5,年生存率,90%,高危：,c- ,，低分化，透明细胞癌，约,30%,复发,Here comes your footer Page 62,治疗手术：卵巢癌治疗的关键作用Here comes your,早期卵巢癌手术治疗,分期手术,-,-,期,腹水细胞学检查,彻底盆腹腔探查,全子宫及双附件切除,切除所有明显肿瘤病灶,大网膜切除,盆腔及腹主动脉旁淋巴结切除,Here comes your footer Page 63,早期卵巢癌手术治疗分期手术-期Here comes,早期卵巢癌手术治疗,年轻要求保留生育功能、,a,、高分化、对侧卵巢外观正常、可随访,患侧附件切除术,Here comes your footer Page 64,早期卵巢癌手术治疗年轻要求保留生育功能、a、高分化、对侧卵,晚期卵巢癌手术治疗,肿瘤细胞减灭术,：晚期（,期以上）的患者,应尽量切除原发病灶及转移灶，使肿瘤残余病灶直径,2cm,，,必要时切除部分肠区，行结肠造瘘、切除胆囊或脾等。,满意的肿瘤细胞减灭术,残余瘤灶,2cm,，无论手术多大，都不能改变预后,Here comes your footer Page 65,晚期卵巢癌手术治疗肿瘤细胞减灭术：晚期（期以上）的患者He,术后辅助治疗,期、无高危因素,-,随访,期有高危因素（肿瘤破裂、分化差、核分裂相多）、,期以上、复发,-,化疗,化疗方案：,PVB,、,PEB,Here comes your footer Page 66,术后辅助治疗期、无高危因素-随访Here comes y,手术彻底性生存期,残余瘤灶, 2cm 5,年生存率,2.6%,残余瘤灶,2cm,平均生存,6,个月,Here comes your footer Page 67,手术彻底性生存期残余瘤灶2cm 5年生存率31%,化疗,最基本原则：足量、及时、正规,以,顺铂,为主的联合化疗,（,PC,、,PP,、,VBP,）,腹腔内化疗,Here comes your footer Page 68,化疗最基本原则：足量、及时、正规 Here c,化疗,常用药物,:,铂类：,顺铂、卡铂,烷化剂：环磷酰胺、塞替派等,抗代谢类：氟尿嘧啶,抗瘤抗生素类：放线菌素,D,、平阳霉素等,抗肿瘤植物成分类：长春新碱类、,紫杉醇,等,Here comes your footer Page 69,化疗常用药物:Here comes your footer,放疗,手术和化疗的辅助治疗,内照射,外照射,Here comes your footer Page 70,放疗手术和化疗的辅助治疗Here comes your fo,三、卵巢非上皮性肿瘤,Here comes your footer Page 71,三、卵巢非上皮性肿瘤Here comes your foot,卵巢非上皮性肿瘤,生殖细胞肿瘤（,ovarian germcell tumor,）,性索间质肿瘤,(ovarian sex cord stromal tumor),转移性肿瘤,Here comes your footer Page 72,卵巢非上皮性肿瘤生殖细胞肿瘤（ovarian germcel,(,一,),卵巢生殖细胞肿瘤,畸胎瘤,(teratoma),1,）成熟畸胎瘤,(mature teratoma):,又称,皮样囊肿,(dermoid cyst),2,）未成熟畸胎瘤,(immature teratoma),Here comes your footer Page 73,(一)卵巢生殖细胞肿瘤畸胎瘤(teratoma)Here c,Here comes your footer Page 74,Here comes your footer Pag,Here comes your footer Page 75,Here comes your footer Pag,Here comes your footer Page 76,Here comes your footer Pag,Here comes your footer Page 77,Here comes your footer Pag,Here comes your footer Page 78,Here comes your footer Pag,Here comes your footer Page 79,Here comes your footer Pag,Here comes your footer Page 80,Here comes your footer Pag,Here comes your footer Page 81,Here comes your footer Pag,Here comes your footer Page 82,Here comes your footer Pag,Here comes your footer Page 83,Here comes your footer Pag,Here comes your footer Page 84,Here comes your footer Pag,无性细胞瘤,(dysgerminoma) :,中等恶性、实性,好发,青春期、生育期,对,放疗敏感,Here comes your footer Page 85,无性细胞瘤(dysgerminoma) :Here come,Here comes your footer Page 86,Here comes your footer Pag,卵黄囊瘤,(yolk sac tumor),又称,内胚窦瘤,(endodermal sinus tumor),较罕见,恶性度高，预后差,血清,AFP,高,Here comes your footer Page 87,卵黄囊瘤(yolk sac tumor) 又称内胚窦瘤(en,Here comes your footer Page 88,Here comes your footer Pag,Here comes your footer Page 89,Here comes your footer Pag,治疗,恶性肿瘤,手术：,年轻要求保留生育功能,-,无论期别、如子宫及对侧卵巢正常，可保留,化疗：,放疗：,无性细胞瘤敏感,Here comes your footer Page 90,治疗恶性肿瘤 Here comes your foote,（二）卵巢性索间质肿瘤,颗粒细胞,间质细胞瘤,1.,颗粒细胞瘤,(granulosa cell tumor),：,低度恶性、可分泌雌激素,2.,卵泡膜细胞瘤,(theca cell tumor),：,良性、内分泌功能,3.,纤维瘤,(fibroma):,可伴有腹水、胸腔积液,梅格斯综合症（,Meigs syndrome,）,支持细胞,间质细胞瘤,:,又称睾丸母细胞瘤,(androblastoma),Here comes your footer Page 91,（二）卵巢性索间质肿瘤颗粒细胞间质细胞瘤Here come,Here comes your footer Page 92,Here comes your footer Pag,Here comes your footer Page 93,Here comes your footer Pag,Here comes your footer Page 94,Here comes your footer Pag,Here comes your footer Page 95,Here comes your footer Pag,（三）卵巢转移性肿瘤,常见的原发癌：乳腺、肠、胃、生殖道、泌尿道等。,库肯勃瘤（,krukenberg tumor),：,为卵巢特殊性腺癌。,原发胃肠道,双侧,印戒细胞,预后极差,Here comes your footer Page 96,（三）卵巢转移性肿瘤常见的原发癌：乳腺、肠、胃、生殖道、泌尿,Here comes your footer Page 97,Here comes your footer Pag,Here comes your footer Page 98,Here comes your footer Pag,Here comes your footer Page 99,Here comes your footer Pag,Here comes your footer Page 100,Here comes your footer Pag,本课重点,良、恶肿瘤的鉴别诊断,常见的并发症及诊断,处理原则,Here comes your footer Page 101,本课重点 良、恶肿瘤的鉴别诊断 Here comes you,卵巢肿瘤课件,