最新子宫肿瘤-妇产科课件PPT课件 58页

'子宫肿瘤-妇产科课件 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 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ModeratedyskaryosisSeveredyskaryosis中度核异常重度核异常Normal-sizednucleusMildnuclearabnormalitiesNucleuslargerthannormalbut<50%ofcell细胞核大于正常，但小于细胞的50％Nucleus>50%ofcellNucleusirregular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-situandCINⅢaremoreorlesssynonymous.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CINⅢ在某种程度上是相同的，都没有突破基底膜 CINⅠCINⅡCINⅢUpper2/3ofepitheliumexhibitsreasonabledifferentiation2/3以上的上皮组织分化正常Upper1/2ofepitheliumwelldifferentiated1/2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 CINⅡCINⅠCINⅢ 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 normalcervixCervicalcarcinomaroughanduneveninsurfacesmooth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%ofsmearscontainingCINⅠ在涂片异常含CINⅠ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growingoutwardsinapapillaryorpolypoidalexcrescenceendophytic内生型Ulceration溃疡型infiltratingthesurroundingstructuresexcavationfrequentlyoccur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AtroutineexaminationPostcoitalbleeding性交后出血Cervixlookssuspiciousattimeofsmear宫颈刮片时可疑PostmenopausalbleedingAbnormalcells,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Staging分期Stage1:TumorconfinedtothecervixⅠ期肿瘤局限于宫颈aMicroinvasivecarcinomaa微浸润肿瘤a1stromalinvasion≤3mmdepthand≤7mmhorizontalspreada1间质浸润深度≤3mm宽度≤7mma2Lesionswithadepth>3mm,but≤5mm,andahorizontalspread≤7mma2浸润深度>3mm≤5mm，宽度≤7mmbClinicallesionsconfinedtothecervixb肿瘤损害局限于宫颈blTumordiameter≤4cmb1肿瘤直径≤4cmb2Tumordiameter>4cmb2肿瘤直径>4cmStage2:Spreadbeyondthecervix,butnottothepelvicsidewall,withinvolvementofuppertwo-thirdsofthevaginaⅡ期超越宫颈但未达盆壁，侵犯阴道，但未及下1/3aVaginalspread,butnoobviousparametrialspreada侵犯阴道，无明显盆壁浸润bParametrialspread,butnotasfaraspelvicsidewallb宫旁浸润，但未达盆壁 Stage3:SpreadinthepelvisⅢ期侵犯骨盆aInvolvementoflowerone-thirdofthevaginaa侵犯阴道的下1/3bExtensiontothepelvicsidewallorhydronephrosisb扩散至骨盆壁或肾盂积水Stage4:DistantspreadⅣ期远处转移aSpreadtoinvolveadjacentorgans[bladder,rectum]a侵犯临近组织（膀胱、直肠）bDistantspreadb远处转移 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notyetcompletedherfamilyconservativeapproachconebiopsy锥切completedherfamilyHysterectomy子宫全切Invasivedisease浸润癌stagesIb,Ⅱaandsomecasesof2bRadicaltreatment根治术①whensurgicalexpertiseisnotavailable②inwomenwithatumorgreaterthan4cmindiameter③inwomenwhoarenotmedicallyfitforsurgeryRadiotherapy放疗Advanceddisease(stage4)Combinationsofchemo-andradiotherapy联合放化疗保守治疗 RadicaltreatmentisindicatedforstagesIb,ⅡaandsomecasesofⅡb子宫根治术适合于Ib,Ⅱa和某些Ⅱb患者Wertheim"sradicalhysterectomyWertheim子宫根治术pelviclymphadenectomy盆腔淋巴结清扫术3cmvaginalcuff切除阴道上端3厘米 Squamouscarcinomaconservedtheovaries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－Ⅳ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Obesity肥胖Impairedglucosetolerance糖耐量下降Nulliparity从未生育的妇女Latemenopause绝经迟Unopposedoestrogentherapy无对抗的雌激素治疗Functioningovariantumors[granulosa-thecacelltumor]功能性卵巢肿瘤[颗粒－卵泡膜细胞瘤]Familyhistoryofcarcinomaofbreast、ovaryorcolon家族性乳腺癌、卵巢癌、结肠癌 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Ⅰ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-rayandpossiblyanintravenousurogramwillneedtobeundertakenBeforetheoperation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 histologyshowsapoorlydifferentiatedhigh-gradetumorRadiotherapy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 Questions1.WhataretheriskfactorsforCINandcervicalcacinoma?2.Cancervicalcancerbeprevented?Howtopreventit?3.Whichdiseasescaninducethepostmenopausaluterinebleeding?4.Howtotreatthediseaseendometrialcarcinoma? MainReference1.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 '