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1、,I期子宫内膜癌淋巴结切除有必要吗 北京大学人民医院妇产科 王建六,妇科常见肿瘤诊治指南 中华医学会妇科肿瘤分会 p49 I期子宫内膜癌应行手术分期 术式为筋膜外子宫切除术及双附件切除术 盆腔及腹主动脉旁淋巴结切除和（或）取样术 术中如无明显淋巴结肿大，应系统切除淋巴结 术中有可疑淋巴结肿大，取样明确有无转移即可 腹主动脉旁淋巴结切除/取样指征： 可疑淋巴结转移 特殊组织类型 CA125显著升高 宫颈受累 深肌层受累 低分化,全国高等院校教材 妇产科学 乐杰主编 林仲秋编写 p275 I期子宫内膜癌应行筋膜外子宫切除术及双附件切除术 盆腔及腹主动脉旁淋巴结切除和（或）取样术 下列情况之一，应行
2、盆腔及腹主动脉旁淋巴结切除 和（或）取样术 可疑淋巴结增大 宫颈受累 CA125显著升高 特殊组织类型 癌灶累及宫腔面积超过50% 低分化 深肌层受累,Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007585. Lymphadenectomy for the management of endometrial cancer. May K, Bryant A, Dickinson HO, Kehoe S, Morrison J University of Oxford, Womens Centre,No evidence that lymphade
3、nectomy decreases the risk of death or disease recurrence compared with no lymphadenectomy in women with presumed stage I disease. The evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgically related systemic morbidity or lymphoedema
4、/lymphocyst formation.,J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16. Epub 2008 Nov 25 Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. Rome, Italy,CONCLUSION: Although systematic pelvic lymphadenectomy statistically significa
5、ntly improved surgical staging, it did not improve disease-free or overall survival.,Lancet. 2009 Jan 10;373(9658):125-36. Epub 2008 Dec 16. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.,Collaborators (180) Amos C, Blake P, Branson A, Buck
6、ley CH, Redman CW, Shepherd J, Dunn G, Heintz P, Yarnold J, Johnson P, Mason M, Rudd R, Badman P, Begum S, Chadwick N, Collins S, Goodall K, Jenkins J, Law K, Mook P, Sandercock J, Goldstein C, Uscinska B, Cruickshank M, Parkin DE, Crawford RA, Latimer J, Michel M, Clarke J, Dobbs S, McClelland RJ,
7、Price JH, Chan KK, Mann C, Rand R, Fish A, Lamb M, Goodfellow C, Tahir S, Smith JR, Gornall R, Kerr-Wilson R, Swingler GR, Lavery BA, Chan KK, Kehoe S, Flavin A, Eddy J, Davies-Humphries J, Hocking M, Sant-Cassia LJ, Pearson S, Chapman RL, Hodgkins J, Scott I, Guthrie D, Persic M, Daniel FN, Yiannak
8、is D, Alloub MI, Gilbert L, Heslip MR, Nordin A, Smart G, Cowie V, Katesmark M, Murray P, Eddy J, Gornall R, Swingler GR, Finn CB, Moloney M, Farthing A, Hanoch J, Mason PW, McIndoe A, Soutter WP, Tebbutt H, Morgan JS, Vasey D, Cruickshank DJ, Nevin J, Kehoe S, McKenzie IZ, Gie C, Davies Q, Ireland
9、D, Kirwan P, Davies Q, Lamb M, Kingston R, Kirwan J, Herod J, Fiander A, Lim K, Head AC, Lynch CB, Browning AJ, Cox C, Murphy D, Duncan ID, Mckenzie C, Crocker S, Nieto J, Paterson ME, Tidy J, Duncan A, Chan S, Williamson KM, Weekes A, Adeyemi OA, Henry R, Laurence V, Dean S, Poole D, Lind MJ, Deale
10、y R, Godfrey K, Hatem MM, Lopes A, Monaghan JM, Naik R, Evans J, Gillespie A, Paterson ME, Tidy J, Ind T, Lane J, Oates S, Redford D, Ford M, Fish A, Larsen-Disney P, Johnson N, Bolger A, Keating P, Martin-Hirsch P, Richardson L, Murdoch JB, Jeyarajah A, Lamb M, McWhinney N, Farthing A, Mason PW, Ki
11、tchener H, Beynon JL, Hogston P, Low EM, Woolas R, Anderson R, Murdoch JB, Niven PA, Kerr-Wilson R, Chin K, Flynn P, Freites O, Newman GH, McNally O, Cullimore J, Olaitan A, Mould T, Menon V, Redman CW, George M, Hatem MH, Evans A, Fiander A, Howells R, Lim K, Cawdell G, Warwick AP, Eustace D, Giles
12、 J, Leeson S, Nevin J, van Wijk AL, Karolewski K, Klimek M, Blecharz P, McConnell D.,Hysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease and
13、as a therapeutic procedure,median follow-up of 37 months (IQR 24-58) 191 women had died: 88/704 standard surgery group 103/704 lymphadenectomy group 251Recurrent disease 107/704 standard surgery group 144/704 lymphadenectomy group),INTERPRETATION no evidence of benefit in terms of overall or recurre
14、nce-free survival for pelvic lymphadenectomy in women with early endometrial cancer. Pelvic lymphadenectomy cannot be recommended as routine procedure for therapeutic purposes outside of clinical trials.,子宫内膜癌淋巴结切除利与弊 争论“由来已久”！,早期：淋巴结转移率较低,国内 中山肿瘤：临床7.9%,8.6%, 38.4% 浙江肿瘤：临床4.4%,14%，34.8% 国外 Stageb（a
15、）G1-2 或 IaG3：转移率 0-2% Stageb（a）G3或 Ic（b）G1：转移率16%-20%,早期：LND并未降低复发 改善生存,1996年10月到2006年3月 意大利多个中心的514例术前FIGO分期为期子宫内膜癌患者 随机分配接受盆腔淋巴结切除术（n=264）或者不进行此手术（n=250）,“冲锋在前”的意大利研究,生存上没有差异,5年DFS 5年OS 未接受淋巴结切除术 81.7% 90.0% 接受淋巴结切除术 81% 85.9%,复发时间和复发率相似,复发时间 复发率 （mth） （49mth） 未进行淋巴结切除 13mth 33例（13.2%） 淋巴结切除术者为 14
16、mth 34例（12.9%）,复发部位相似,LND手术并发症明显增加,在手术时间和住院时间上，两组有显著的统计学差异 接受盆腔淋巴结切除术的患者有较高的早期和晚期术后并发症率，两组出现并发症的患者分别为81例和34例。,改变观念 无容置疑,子宫内膜癌治疗正朝个性化治疗发展 已有充足证据证明期子宫内膜癌患者，淋巴结切除术不能带来任何生存获益。,特殊患者手术难度增加，风险增加 肥胖 高龄 心血管疾病 糖尿病,淋巴结真的可以不切除吗？,Lesion sites and region Depth of myometrial invasion Cervical invasion Extrauterine
17、 invasion or not, single or multiple Pathological grade and classification Lymph vascular invasion(LVI),淋巴转移相关因素,病灶大小与淋巴结转移,Tumor Size LN mets: 2cm 4% 2cm 15% entire uterine cavity 35% 5-y survival: 2cm - 98% 2cm - 84% entire uterine cavity - 64%,建议有指征的行腹膜后淋巴结切除术,腹膜后淋巴结切除指征,术前B超、MRI等估计深肌层受侵 术前病理分级为G
18、3 术前临床分期II期以上 术中探查腹膜后淋巴结可疑转移 术中发现侵肌1/2 术中发现宫腔50%以上有病灶累及 子宫内膜浆乳癌、透明细胞癌等,淋巴结切除范围,一定要切除腹主动脉旁淋巴结吗？,Eur J Gynaecol Oncol. 2007;28(2):98-102. Prince of Wales Hospital, Shatin, Hong Kong Is aortic lymphadenectomy necessary in the management of endometrial carcinoma? 75 (46.0%) pelvic lymphadenectomy alone
19、88 (54.0%) had both pelvic and aortic lymphadenectomy 35 (21.5%) nodal metastases positive pelvic 26 (16.0%) positive aortic 24 (27.3%) Isolated aortic metastases 17 cases (19.3%),35 patients with nodal metastases recurrence developed in 15 (42.9%) and all except one died within five to 50 months Th
20、e recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases all those who recurred died of disease within seven to 28 months.,CONCLUSIONS,aortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metasta
21、tic risk.,Todo Y et al.Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet. 2010 Apr 3;375(9721):1165-72,671 patients with endometrial carcinoma systematic pelvic lymphadenectomy (n=325) pelvic and para-aortic lymphadenectomy (n=346) INTERPRETATION: Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence.,正确在哪里？ 标准在哪里？ 真理在哪里？ 应该在自己头脑里！ 应该在自己的心中！ 用心，用脑去诊治疾病，而非仅仅是用手！ 用心，用脑去思考问题，而非仅是听别人！,