子宫肿瘤-妇产科课件.ppt

Carcinomaoftheuterus子宫肿瘤 DepartmentofObstetricsandGynecology妇产科ZhangWei张蔚 Endometrialcarcinoma子宫内膜癌 Cervicaltumors宫颈肿瘤 Cervicalintraepithelialneoplasia CIN 宫颈上皮内瘤样变Cervicalcancer宫颈癌 Carcinomaoftheuterus子宫肿瘤 Cervicalintraepithelialneoplasia CIN 宫颈上皮内瘤样变 Definition Cervicalintraepithelialneoplasia CIN isapremalignantconditionofthecervix Itisusuallyasymptomaticandisdetectedbyroutinecytologicalscreening ThedegreeofseverityisgradedCIN toCIN 定义 宫颈上皮内瘤样变是宫颈组织的癌前病变 一般没有症状 通常在常规的细胞学筛查时发现 根据严重程度分为CIN CIN CIN TBStypes atypicalsquamouscells ASC 不典型鳞状上皮Low gradesquamousintraepitheliallesion LSIL 轻度鳞状上皮内病变High gradesquamousintraepitheliallesion HSIL 重度鳞状上皮内病变 Aetiology Theareaofpreviouslyexposedcolumnarepitheliumthatundergoessquamousmetaplasiaisknownasthetransformationzone TZ 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 Itisthepredilectionsiteofcervicalcarcinoma 移行带为宫颈癌好发部位 Ectropionandtransformationofthetransformationzone移行带区的外翻和转化 transformationmechanism转化机制 squamousmetaplasia鳞状上皮化生squamousepithelization鳞状上皮化 TheriskfactorsforCINandcervicalcarcinomaCIN和宫颈肿瘤的危险因素 Youngageatfirstintercourse初次性生活的年龄过小 Numberofsexualpartners性伙伴的数目 Smoking吸烟 Pooruptakeofscreeningprogramme筛查过少 Long termuseofthecontraceptivepill长期服用避孕药 Exposuretotumorpromotershasagreaterinfluenceonimmaturecells不成熟的细胞暴露于致癌因素会对其产生很大的影响 Increasestheriskofcervicalcancerfour fold theriskremainselevatedinex smokers吸烟的妇女患宫颈癌的危险性会提高4倍 曾经吸烟的妇女患宫颈癌的危险性仍然存在 Pilltakersdonotnecessarilyusebarriermethods increasingexposuretoseminalfluids服用药物而没有使用屏障的方法 会增加精液的刺激 Male relatedriskfactors与男性相关的危险因素 Thenumberofthepartner sprevioussexualrelationshipsisrelevant与以前性伙伴的数目有关 Cervicalcancerriskincreasedifpartnerhaspenilecancer性伙伴患阴茎癌会增加患宫颈癌的危险性 Cervicalcancerriskincreasedifpartner sprevioussexualcontacthadcervicalcancer性伙伴的前性伴患宫颈癌也会增加患宫颈癌的危险性 Immunosuppressant免疫抑制 Riskincreasedwithimmunesuppressedrenaltransplantpatients andinHIV positivewomen免疫抑制 肾移植 HIV阳性妇女患宫颈癌危险性增加 HPVinfectionHPV感染 Mainlysubtype16主要是16型 ScreeningforCINisbasedonacervicalsmear samplingsurfacecellsfromthecervixwithaspatula筛查CIN可以利用宫颈表皮细胞涂片 Screening 筛查 Toobtainacompletediagnosisthetriageofcytology colposcopyandhistologicalbiopsyareneeded assmearsareoftenunderreported 要想达到完整的细胞学分类诊断需要阴道镜和活检 因为细胞涂片常常取决于报告人的经验 Cytology 细胞学 dyskaryosisisacytologicaltermItdescribesfeaturesofindividualcellssuchassizeandstainingofnucleiandtheamountofcytoplasm 细胞核异常是细胞学特点 表现为各个细胞核的大小 染色和细胞质的数量的改变 Milddyskaryosis 轻度核异常 Moderatedyskaryosis Severedyskaryosis 中度核异常 重度核异常 Normal sizednucleus Mildnuclearabnormalities Nucleuslargerthannormalbut 50 ofcell 细胞核大于正常 但小于细胞的50 Nucleus 50 ofcell Nucleusirregular 细胞大小正常 轻度核异常 细胞核大于细胞的50 胞核不规则 Cellborderrounded 细胞边界变圆 Angularcellborders 细胞边界有角 Histology 组织学 Dysplasiaisahistologicalterm Itrequiresafull thicknessbiopsyfordiagnosis Carcinoma in situandCIN aremoreorlesssynonymous Thebasementmembraneremainsintact 组织学检查发现分化异常 需要取表皮全层活组织检查诊断 原位癌和CIN 在某种程度上是相同的 都没有突破基底膜 CIN CIN CIN Upper2 3ofepitheliumexhibits reasonabledifferentiation 2 3以上的上皮组织分化正常 Upper1 2ofepitheliumwelldifferentiated 1 2以上的上皮组织分化正常 Maturationconfinedtosuperficial1 3 orabsent 分化成熟的组织局限于表皮1 3或没有 Colposcopy 阴道镜检查 Indysplastictissuethenormalpatternofbloodvesselsbecomesdistortedandpunctationandmosaicismareseen 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 镶嵌的白色或黄色的上皮块 Colposcope阴道镜 Abnormaltissuestainswhitewithaceticacidbutwillnottakeupthebrowniodinestain Studyingthevesselpatternsandstainingreactions acolposcopistgaugesthedegreeofCINpresent 异常的组织 醋酸染色白色 不会被碘溶液染成棕色 根据血管的模式和染色反应 用阴道镜可以较精确地估计CIN的程度 CIN CIN CIN Localtreatment局部治疗 loopdiathermy环形电热疗法 runninganelectriccurrentthroughathinloopofvaryingsizeandshape电流可以通过不同大小和形状的细环 coldcoagulation冷凝法 carbondioxidelaser二氧化碳激光器 conebiopsy锥切 Loopdiathermyapparatus环形透热电疗仪 Theprocessofconebiopsy锥切的过程 LoopElectrosurgicalExcisionProcedure LEEP Cervicalcarcinoma宫颈肿瘤 normalcervix Cervicalcarcinoma roughanduneveninsurface smooth 凸凹不平 宫颈癌 正常宫颈 光滑 Epidemiology流行病学 cancerofthecervixisthesecondmostcommonmalignancyinwomenafterbreastcancer 77 ofcasesoccurindevelopingcountries 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 仅次于乳腺癌 77 Riskfactors危险因素 Themainaetiologicalagentisinfectionwithcertainsubtypesofhumanpapillomavirus HPV 主要的病原学因素是感染了人乳头瘤病毒的某一亚型 HPVsubtype16appearstobethemainoncologicalagentHPV16是肿瘤学的主要原因 Only5 ofcytologicallynormalwomen细胞学正常的妇女中HPV16阳性占5 Upto50 ofsmearscontainingCIN 在涂片异常含CIN 中HPV16阳性占50 Over90 ofinvasivecervicalcancer浸润性宫颈癌中90 以上患者HPV16阳性 PossibleaetiologicalpathwayforCINandcarcinomaCIN和宫颈癌可能的病原学途径 Pathology病理学 Malignanttumorsofthecervixmaybesquamous 85 90 orglandular 10 intype宫颈癌中约85 90 为鳞癌 10 为腺癌 exophytic 外生型 growingoutwardsinapapillaryorpolypoidalexcrescence endophytic 内生型 Ulceration 溃疡型 infiltratingthesurroundingstructures excavationfrequentlyoccur 向外呈乳头状生长或菜花状 向深部浸润周围的组织 常常形成凹陷 ulceration 颈管型 endocervical 常侵入宫颈及子宫狭部 infiltratingcervixandisthmusuteri Routeofmetastasis转移途径 Directmetastasis直接蔓延Lymphaticmetastasis淋巴转移Hematogenousmetastasis血行转移 Presentation临床表现 Symptoms症状 Signs体征 Confinedtocervix局限于宫颈 Atroutineexamination Postcoitalbleeding性交后出血 Cervixlookssuspiciousattimeofsmear宫颈刮片时可疑 Postmenopausalbleeding Abnormalcells indicativeofinvasivecarcinomaoncytology异常细胞 细胞学提示浸润癌 Intermenstrualbleeding月经间期出血 绝经后出血 常规检查 Offensive blood stainedvaginaldischarge血性白带 Atcolposcopy阴道镜检查 Spreadtoadjacentstructures侵犯临近组织 Heavy contactbleeding接触性出血 Fistulae passageofurine faecesorflatusvaginally ifbowel bladderinvolved 尿瘘 粪瘘形成 如果直肠膀胱受累 irregularsurfacecontour表面轮廓不规则 Renalfailure bilateraluretericobstruction肾衰竭 双侧输尿管梗阻 Atypicalvessels capillariesofirregularcalibreandbranchingpattern不典型血管 毛细血管口径 分支不规则 Deepvisceralornerverootpain ifsacralnerverootinvolved 内脏或神经根疼痛 如果骶神经根受累 Lowerlimboedema extensivepelvicsidewallinfiltration骨盆侧壁广泛浸润 下肢水肿 Staging分期 Clinicstageblockdiagramofcervicalcancer宫颈癌临床分期示意图 Clinicstageblockdiagramofcervicalcancer宫颈癌临床分期示意图 Treatmentoptions治疗方法选择 Microinvasivedisease微观浸润性病变 notyetcompletedherfamily conservativeapproach conebiopsy锥切 completedherfamily Hysterectomy子宫全切 Invasivedisease浸润癌 stagesIb aandsomecasesof2b Radicaltreatment根治术 whensurgicalexpertiseisnotavailable inwomenwithatumorgreaterthan4cmindiameter inwomenwhoarenotmedicallyfitforsurgery Radiotherapy放疗 Advanceddisease stage4 Combinationsofchemo andradiotherapy联合放化疗 保守治疗 RadicaltreatmentisindicatedforstagesIb aandsomecasesof b 子宫根治术适合于Ib a和某些 b患者 Wertheim sradicalhysterectomy Wertheim子宫根治术 pelviclymphadenectomy 盆腔淋巴结清扫术 3cmvaginalcuff 切除阴道上端3厘米 Squamouscarcinoma conservedtheovaries 鳞状细胞癌 保留卵巢 Adenocarcinoma 腺癌 Oophorectomy 卵巢切除术 Squamouscarcinomadoesnotspreaddirectlytotheovaries 宫颈鳞癌不会直接蔓延至卵巢 腺癌卵巢转移发生率约5 10 thereisa5 10 incidenceofovarianmetastases Advanceddisease stage4 晚期患者 期 Combinationsofchemo andradiotherapy 联合放化疗 survivalrateisverypoor 存活率很低 Endometrialcarcinoma子宫内膜癌 Carcinomaoftheendometriumformsthemostcommontypeofuterinecancer Thesearemainlyadenocarcinomasderivedfromendometrialglandularcells 子宫内膜癌是子宫恶性肿瘤中最常见的一种类型 主要是来源于子宫内膜腺体的腺癌 Riskfactors危险因素 Pathology病理学 thecommonestistheendometrioidadenocarcinoma 最常见的为子宫内膜样腺癌 a Viewofcutsurfaceoftheuterus b High powerviewofGrade1cancer 大体观子宫切面 高倍镜下看 期子宫内膜癌 Routeofmetastasis转移途径 Directmetastasis直接蔓延Lymphaticmetastasis淋巴转移Hematogenousmetastasis血行转移 SymptomsandSigns症状和体征 postmenopausalbleeding绝经后出血 Discharge阴道排液 pyometra子宫积脓 Metastaticdisease转移 Pain疼痛 UltrasonographyandcolorDopplerblood flowimagingprovideusefulscreeningtools超声和彩色多普勒血流显像图是有效的检查工具 irregularand orheavyregularbleedinginthepremenopausalgroup 绝经前患者中不规则的和 或量较多的规则的出血 Renalandhepaticfunctiontests tumormarkers chestX rayandpossiblyanintravenousurogramwillneedtobeundertaken Beforetheoperation 手术前 检查肝肾功能 肿瘤标记物 胸部X线检查 必要时进行静脉尿路造影 Treatment治疗 Operation手术 Theoperationofchoiceisatotalabdominalhysterectomyandbilateralsalpingo oophorectomy手术选择 腹式子宫全切加双侧输卵管卵巢切除 Thepelvicandthepara aorticnodesshouldberemovedifthecervixoradnexaareinvolved orifthemyometriumisobviouslydeeplyinfiltrated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脉旁淋巴结清扫 histologyshowsapoorlydifferentiated high gradetumor Radiotherapy放疗 晚期 组织学显示低分化 ifthenodesareinvolved 如果淋巴结受累 stagingatthetimeofsurgeryscoresmorethanaIb 手术时分期在Ib期以上 Thestage3patient3期病人 determinewhetherthediseaseisconfinedtothepelvis 确定病灶是否局限于盆腔 radicalsurgery 根治性手术 radiotherapy 放疗 Stage4disease4期病人 Radiotherapy 放疗 mostcommonlyspreadstothelungs常有肺转移 spreadstoperipherallymphnodes外周淋巴结转移 spreadstothebladder转移至膀胱 greatvalueforpalliation 放疗对减轻症状很有价值 Prognosis预后 Thestageandgradeofthediseaseareofparamountimportance分期是影响预后的首要因素 Lymphnodeinvolvementandevidenceofvascularspreadreducethesurvivalrate淋巴结和血管受累明显降低生存率 Questions 1 WhataretheriskfactorsforCINandcervicalcacinoma 2 Cancervicalcancerbeprevented Howtopreventit 3 Whichdiseasescaninducethepostmenopausaluterinebleeding 4 Howtotreatthediseaseendometrialcarcinoma MainReference 1 JoanP AlisonB P BrianA M etal ObstetricsandGynaecology M EdinburghLondonNewYorkOxfordPhiladelphiaStLouisSydneyToronto 2003 134 1392 丰有吉 沈铿 马丁 妇产科学 M 人民卫生出版社 2005 316 328 谢谢