1、宫颈癌诊治宫颈癌诊治n全世界每年有全世界每年有47万新患病万新患病人人，死亡死亡23万；占女性恶万；占女性恶性肿瘤的性肿瘤的10%（2002)n年轻化：平均年龄年轻化：平均年龄52.2岁岁,年龄分布成双峰年龄分布成双峰35-39,60-64n区域性：在世界宫颈癌高区域性：在世界宫颈癌高发区哥伦比亚发区哥伦比亚,在中国高发在中国高发区区:山西山西 内蒙内蒙 陕西陕西 湖北湖北 湖湖南南 江西等江西等020406080100120breastcervixcolon/rectumlungstomachnew casesmatalityX105(人）人）Risk FactorsnInfection w
2、ith HPV(human papillomavirus-types 16 and 18)HSV-II,CMVnSexually-transmitted agentsnHigh-risk male partner OthersTransformation zone 鳞柱交接部 (SCJ)移行带（Transformation zone）鳞状上皮化生（Squamous metaplasia）Cervical dysplasiaCIS(cervical cancer in situ)宫颈鳞状上皮宫颈鳞状上皮 正常正常 CIN-I CIN-II CIN-III,CISCervix cancer is
3、suitable for screeningnIts a common disease.nIt has serious consequences.nIt has a detectable,asymptomatic phase.nEarly detection and treatment decrease morbidity and mortality.nThe screening test is acceptable to patients,safe,and affordable.Screening3 steps for ScreeningPap SmearTCTNormal PapASCUS
4、LSILHSILn巴氏巴氏5级级nThe Bethesda SystemnAtypical squamous cellnLSILnHSILnAtypical glandular cellColposcopy(阴道镜）阴道镜）CINSchiller test5%acetic acidNormal cervixHSILcancerLSILBiopsy and pathologybiopsyECCIN-ICIN-IICIN-IIICIScancerPathology 宫颈鳞状细胞癌(cervical squamouscarcinoma)宫颈腺癌（cervical adenocarcinoma):mu
5、cous adenocarcinoma，endometrioid adenocarcinoma,clear cell adenocarcinoma，serous adenocarcinoma，mesonephric adenocarcinoma腺鳞癌(adenosquamous carcinoma)宫颈癌宫颈癌-Cervical Cancern临床分期临床分期n临床表现临床表现n诊断诊断n鉴别诊断鉴别诊断n治疗治疗临床分期临床分期Clinical StagingIIIIAIIBIIIAIIIB100%85%66%39%11%0%0%20%20%40%40%60%60%80%80%100%100
6、%Stage 0Stage 0Stage IStage IStage IIStage IIStage IIIStage IIIStage IVStage IVFive Year Survival of Cervix Cancer by Stage of DiseaseRoutes of SpreadDirect invasion into surrounding structures including the parametria,corpus,and vaginaLymphatic metastasis fairly orderly and predictable,with involve
7、ment in the parametrial,pelvic,common iliac,and para-aortic nodesBlood-borne metastasesIntraperitoneal implantation(much less common)Asymptoms in early stageVaginal bleeding(postcoital,intermenstrual)Vaginal dischargeIn advanced cases:foul odor,pelvic pain,urinary frequency,and urinary or rectal pai
8、n,sciatica,unilateral leg edema,and ureteral obstructionAnemia,weight lossSymptomsInspect cervix for suspicious area(Stage I)Measure size and evaluate consistency of cervix(Stage I)Inspect vagina for extension of disease(Stage II and III)Perform bimanual examination to determine parametrial or pelvi
9、c extension(Stage II and III)Examine legs for swelling/pain(Stage III)Inspect supraclavicular and inguinal nodal area(Stage IV)Physical Examination晚期晚期 症状症状+体征体征+活检病理活检病理早期早期 症状及体征不明显，确诊需依赖辅助检查症状及体征不明显，确诊需依赖辅助检查workupThe Pap smear is the best screening tool:CCT TCT Schiller Test colposcopy conformat
10、ion of diagnosis requires a cervical tissue biopsy cervical conizationDiagnosis宫颈原位癌宫颈原位癌 Differential diagnosisnCervical Erosion nCervical polyps nCervical Tuberculosis nCervical Papilloma nCervical Endometriosis CIN CIN I 消炎消炎 随访随访 CIN II 物理疗法或锥切物理疗法或锥切 CIN III 子宫全切或锥切子宫全切或锥切 Leep Microinvasive di
11、sease Ia1 筋膜外全子宫切除筋膜外全子宫切除 Ia2 次广泛子宫切除次广泛子宫切除 Treatement阴道镜检阴道镜检组织活检组织活检颈管诊刮颈管诊刮宫颈病变（宫颈病变（CIN）病理诊断病理诊断阴性阴性CIN ICIN IICIN III重度非典型增生重度非典型增生原位癌原位癌锥切或锥切或全子宫切除全子宫切除LEEP物理治疗物理治疗（冷冻、电凝、激光）（冷冻、电凝、激光）定期复查诊断结果诊断结果处理处理ConizationnLEEPLEEP(Loop electro-excision procedure)Invisive cervical cancer手术 适用于IbIIa期 子宫根
12、治术和盆腔淋巴结清扫术 放疗 适用于各期 手术+放疗 术前放射：适用于癌灶大 术后放射：适用于术后有癌残留者 化学治疗 术前 术后 铂类，泰素，博莱霉素，环磷酰胺 异环磷酰胺 BIP 方案 VPB方案 TP .IV 动脉插管 宫颈癌的光动力学疗法（photodynamic therapy,PDT)原理：将光敏剂注入人体后被肿瘤组织选择性摄取或在较长时间贮留，经适当波长光作用后产生特征性荧光或高毒性的中间产物，即经过氧分子参与的一系列光化学反应和光生物学反应，释放出一种局部毒性物质单态氧，它能破坏癌组织中的微血管，造成局部缺血和细胞死亡，致病变组织坏死脱落。适应症：病理诊断为微浸癌及原位癌，年轻
13、要求保留生育功能，或老年患者不能耐受手术，放疗或拒绝手术的患者，及宫颈癌术后或放疗后复发者。QuestionsnHow to perform a cervical cancer screening?nWhat would you do after a result of TCT for CIN-III in a 35-year-old lady who has no babyn推广普查，推广普查，n合理有效治疗炎症，合理有效治疗炎症，n扼杀在癌前病变的摇篮中，扼杀在癌前病变的摇篮中，n降低宫颈癌的发生，最终消灭降低宫颈癌的发生，最终消灭宫颈癌宫颈癌通过医学和社会的共同努力，通过医学和社会的共同努力，
