1、Carcinoma of the uterus 子宫肿瘤,Department of Obstetrics and Gynecology 妇 产 科 Zhang Wei 张 蔚,Endometrial carcinoma 子宫内膜癌,Cervical tumors 宫颈肿瘤,Cervical intraepithelial neoplasia (CIN) 宫颈上皮内瘤样变Cervical cancer 宫颈癌,Carcinoma of the uterus 子宫肿瘤,Cervical intraepithelial neoplasia (CIN) 宫颈上皮内瘤样变,Definition：Cer
2、vical intraepithelial neoplasia (CIN) is a premalignant condition of the cervix. It is usually asymptomatic and is detected by routine cytological screening. The degree of severity is graded CIN、 to CIN ,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,TBS types,atypical squamous
3、cells (ASC) 不典型鳞状上皮Low-grade squamous intraepithelial lesion (LSIL) 轻度鳞状上皮内病变High-grade squamous intraepithelial lesion (HSIL) 重度鳞状上皮内病变,Aetiology,The area of previously exposed columnar epithelium that undergoes squamous metaplasia is known as the transformation zone (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
4、行带,It is the predilection site of cervical carcinoma,移行带为宫颈癌好发部位,Ectropion and transformation of the transformation zone 移行带区的外翻和转化,transformation mechanism 转化机制,squamous metaplasia 鳞状上皮化生squamous epithelization 鳞状上皮化,The risk factors for CIN and cervical carcinoma CIN和宫颈肿瘤的危险因素,Young age at first i
5、ntercourse 初次性生活的年龄过小,Number of sexual partners 性伙伴的数目,Smoking 吸烟,Poor uptake of screening programme 筛查过少,Long-term use of the contraceptive pill 长期服用避孕药,Exposure to tumor promoters has a greater influence on immature cells 不成熟的细胞暴露于致癌因素会对其产生很大的影响,Increases the risk of cervical cancer four-fold; the
6、 risk remains elevated in ex-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,Pill takers do not necessarily use barrier methods - increasing exposure to seminal fluids 服用药物而没有使用屏障的方法，会增加精液的刺激,Male-related risk factors 与男性相关的危险因素,The number of the partners previous sexual relationships is relevant 与以前
7、性伙伴的数目有关,Cervical cancer risk increased if partner has penile cancer 性伙伴患阴茎癌会增加患宫颈癌的危险性,Cervical cancer risk increased if partners previous sexual contact had cervical cancer 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,Risk increased with immune suppressed renal transplant patients, and in HIV-po
8、sitive women 免疫抑制、肾移植、HIV阳性妇女患宫颈癌危险性增加,HPV infection HPV感染,Mainly subtype 16 主要是16型,Screening for CIN is based on a cervical smear - sampling surface cells from the cervix with a spatula 筛查CIN可以利用宫颈表皮细胞涂片,Screening(筛查),To obtain a complete diagnosis the triage of cytology, colposcopy and histologica
9、l biopsy are needed, as smears are often under reported,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,dyskaryosis is a cytological termIt describes features of individual cells such as size and staining of nuclei and the amount of cytoplasm,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,Mild dyskaryos
10、is,轻度核异常,Moderate dyskaryosis,Severe dyskaryosis,中度核异常,重度核异常,Normal-sized nucleus,Mild nuclear abnormalities,Nucleus larger than normal but 50% of cell,细胞核大于正常，但小于细胞的50,Nucleus 50% of cell,Nucleus irregular,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,Cell border rounded,细胞边界变圆,Angular cell borders,细胞边界有角,Histolog
11、y,组织学,Dysplasia is a histological term. It requires a full-thickness biopsy for diagnosis. Carcinoma-in-situ and CINare more or less synonymous. The basement membrane remains intact,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,Upper 2/3 of epithelium exhibits,reasonable differen
12、tiation,2/3以上的上皮组织分化正常,Upper 1/2 of epithelium well differentiated,1/2以上的上皮组织分化正常,Maturation confined to superficial 1/3 (or absent),分化成熟的组织局限于表皮1/3或没有,Colposcopy（阴道镜检查）,In dysplastic tissue the normal pattern of blood vessels becomes distorted and punctation and mosaicism are seen,在异常的组织中可以看到正常结构的血
13、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,Abnormal tissue stains white with acetic acid but will not take up the brown iodine stain. Studying the vessel patterns and staining reactions, a colposcopist gauges the degree of CIN present,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,C
14、IN,CIN,CIN,Local treatment 局部治疗,loop diathermy 环形电热疗法,running an electric current through a thin loopof varying size and shape 电流可以通过不同大小和形状的细环,cold coagulation冷凝法,carbon dioxide laser 二氧化碳激光器,cone biopsy 锥切,Loop diathermy apparatus环形透热电疗仪,The process of cone biopsy锥切的过程,Loop Electrosurgical Excisio
15、n Procedure (LEEP),Cervical carcinoma 宫颈肿瘤,normal cervix,Cervical carcinoma,rough and uneven in surface,smooth,凸凹不平,宫颈癌,正常宫颈,光滑,Epidemiology 流行病学,cancer of the cervix is the second most common malignancy in women after breast cancer - 77% of cases occur in developing countries,在发展中国家，宫颈癌的发病率位于妇女恶性肿瘤
16、的第二位，仅次于乳腺癌（77）,Risk factors 危险因素,The main aetiological agent is infection with certain subtypes of human papilloma virus (HPV),主要的病原学因素是感染了人乳头瘤病毒的某一亚型,HPV subtype 16 appears to be the main oncological agent HPV16是肿瘤学的主要原因,Only 5% of cytologically normal women 细胞学正常的妇女中HPV16阳性占5Up to 50% of smears c
17、ontaining CIN 在涂片异常含CIN 中HPV16阳性占50Over 90% of invasive cervical cancer 浸润性宫颈癌中90以上患者HPV16阳性,Possible aetiological pathway for CIN and carcinoma CIN和宫颈癌可能的病原学途径,Pathology 病理学,Malignant tumors of the cervix maybe squamous (8590%) or glandular (10%) in type 宫颈癌中约8590为鳞癌，10为腺癌,exophytic,外生型,growing out
18、wards in a papillary or polypoidal excrescence,endophytic,内生型,Ulceration,溃疡型,infiltrating the surrounding structures,excavation frequently occur,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,infiltrating cervix and isthmus uteri,Route of metastasis转移途径,Direct metastasis 直接蔓延L
19、ymphatic metastasis 淋巴转移 Hematogenous metastasis 血行转移,Presentation 临床表现,Symptoms 症状,Signs 体征,Confined to cervix 局限于宫颈,At routine examination,Postcoital bleeding 性交后出血,Cervix looks suspicious at time of smear 宫颈刮片时可疑,Postmenopausal bleeding,Abnormal cells, indicative of invasive carcinoma on cytology
20、 异常细胞，细胞学提示浸润癌,Intermenstrual bleeding 月经间期出血,绝经后出血,常规检查,Offensive, blood-stained vaginal discharge 血性白带,At colposcopy 阴道镜检查,Spread to adjacent structures 侵犯临近组织,Heavy, contact bleeding 接触性出血,Fistulae - passage of urine, faeces or flatus vaginally (if bowel/ bladder involved) （尿瘘、粪瘘形成）如果直肠膀胱受累,irreg
21、ular surface contour 表面轮廓不规则,Renal failure - bilateral ureteric obstruction 肾衰竭双侧输尿管梗阻,Atypical vessels - capillaries of irregular calibre and branching pattern 不典型血管毛细血管口径、 分支不规则,Deep visceral or nerve root pain (if sacral nerve root involved) 内脏或神经根疼痛（如果骶神经根受累）,Lower limb oedema - extensive pelvic
22、 side wall infiltration 骨盆侧壁广泛浸润下肢水肿,Staging 分期,Clinic stage block diagram of cervical cancer 宫颈癌临床分期示意图,Clinic stage block diagram of cervical cancer 宫颈癌临床分期示意图,Treatment options 治疗方法选择,Microinvasive disease 微观浸润性病变,not yet completed her family,conservative approach,cone biopsy 锥切,completed her fam
23、ily,Hysterectomy 子宫全切,Invasive disease 浸润癌,stages I b, a and some cases of 2b,Radical treatment 根治术,when surgical expertise is not available, in women with a tumor greater than 4 cm in diameter,in women who are not medically fit for surgery,Radiotherapy放疗,Advanced disease (stage 4),Combinations of c
24、hemo- and radiotherapy 联合放化疗,保守治疗,Radical treatment is indicated for stages I b, a and some cases of b,子宫根治术适合于Ib, a 和某些b患者,Wertheims radical hysterectomy,Wertheim子宫根治术,pelvic lymphadenectomy,盆腔淋巴结清扫术,3 cm vaginal cuff,切除阴道上端3厘米,Squamous carcinoma,conserved the ovaries,鳞状细胞癌,保留卵巢,Adenocarcinoma,腺癌,O
25、ophorectomy,卵巢切除术,Squamous carcinoma does not spread directly to the ovaries,宫颈鳞癌不会直接蔓延至卵巢,腺癌卵巢转移发生率约510,there is a 5-10% incidence of ovarian metastases,Advanced disease (stage 4),晚期患者期,Combinations of chemo- and radiotherapy,联合放化疗,survival rate is very poor,存活率很低,Endometrial carcinoma 子宫内膜癌,Carcin
26、oma of the endometrium forms the most common type of uterine cancer. These are mainly adenocarcinomas derived from endometrial glandular cells,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,Risk factors 危险因素,Pathology病理学,the commonest is the endometrioid adenocarcinoma,最常见的为子宫内膜样腺癌,(a) View of cut surface of
27、 the uterus (b) High-power view of Grade 1 cancer,大体观子宫切面,高倍镜下看期子宫内膜癌,Route of metastasis 转移途径,Direct metastasis 直接蔓延Lymphatic metastasis 淋巴转移Hematogenous metastasis 血行转移,Symptoms and Signs 症状和体征,postmenopausal bleeding 绝经后出血,Discharge 阴道排液,pyometra 子宫积脓,Metastatic disease 转移,Pain 疼痛,Ultrasonography
28、 and color Doppler blood-flow imaging provide useful screening tools 超声和彩色多普勒血流显像图是有效的检查工具,irregular and/or heavy regular bleeding in the premenopausal group,绝经前患者中不规则的和/或量较多的规则的出血,Renal and hepatic function tests, tumor markers, chest X-ray and possibly an intravenous urogram will need to be undert
29、aken,Before the operation,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,The operation of choice is a total abdominal hysterectomy and bilateral salpingo-oophorectomy 手术选择腹式子宫全切加双侧输卵管卵巢切除,The pelvic and the para-aortic nodes should be removed if the cervix or adnexa are involved, or i
30、f the myometrium is obviously deeply infiltrated 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,histology shows a poorly differentiated,high-grade tumor,Radiotherapy 放疗,晚期,组织学显示低分化,if the nodes are involved,如果淋巴结受累,staging at the time of surgery scores more than a I b,手术时分期在 I b 期以上,The stage 3 patient 3期病人,de
31、termine whether thedisease is confined to the pelvis,确定病灶是否局限于盆腔,radical surgery,根治性手术,radiotherapy,放疗,Stage 4 disease 4期病人,Radiotherapy,放疗,most commonly spreads to the lungs 常有肺转移,spreads to peripheral lymph nodes 外周淋巴结转移,spreads to the bladder 转移至膀胱,great value for palliation,放疗对减轻症状很有价值,Prognosis
32、 预后,The stage and grade of the disease are of paramount importance 分期是影响预后的首要因素,Lymph node involvement and evidence of vascular spread reduce the survival rate 淋巴结和血管受累明显降低生存率,？,Questions,1.What are the risk factors for CIN and cervical cacinoma?,2. Can cervical cancer be prevented? How to prevent i
33、t?,3.Which diseases can induce the postmenopausal uterine bleeding?,4. How to treat the disease endometrial carcinoma?,Main Reference,1.Joan P,Alison B.P,Brian A.M,et al,Obstetrics and GynaecologyM.Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto,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,
