子宮頸癌篩檢及治療共識 National Health Research Institutes (NHRI) Division of Cancer Research Taiwan Cooperative Oncology Group (TCOG) 115 128 No. 128, Yen-Chiu-Yuan Road, Sec. 2, NanKang, Taipei 115, Taiwan, R.O.C. TEL886-2-26534401 FAX886-2-27823755 http://www.nhri.org.tw ISBN GPN:016304890226
子宮頸癌篩檢及治療共識 出版機關 : 國家衛生研究院 (NHRI) 癌症研究組 臺灣癌症臨床研究合作組織 (TCOG) 著者 :TCOG 婦癌研究委員會地址 :115 臺北市南港區研究院路二段 128 號電話 :886-2-26534401 傳真 :886-2-27823755 國家衛生研究院網址 : 出版年月 :1998 年 1 月初版 2000 年 10 月再版工本費 : 新臺幣 10 元 GPN:016304890226 ISBN:9570268840
癌症治療共識建立之源由 目錄 1982 20 (http://www.nhri.org.tw) 一 簡介 二 子宮頸癌的篩檢與預防 三 子宮頸上皮內腫瘤的適當處置模式 四 初期子宮頸癌的適當處理模式 五 較晚期與復發之子宮頸癌的處理模式 六 結論 表ㄧ 抹片判讀結果 表二 婦癌研究委員會名單 20 參與討論之專家學者名單
子宮頸癌篩檢及治療共識 一 簡介 2000 950 471,000 (HPVHuman Papilloma Virus) (Preinvasive Lesion) (Palliative therapy) 二 子宮頸癌的篩檢與預防 (Screening and Prevention) 1. 篩檢 (Screening) 1991 Bethesda System ()Bethesda System (Adequacy) (Transformation zone) 1940 NHRI/TCOG 1 NHRI/TCOG
20% (False Negative Rate) (spatulaendocervical brushbroom cotton swab) 1995 (FDA) 198818 31995 American Collage of Obstetricians and Gynecologists ( HIVHPV Low Grade Squamous Intraepithelial Lesion )65 (HPV) (1) (2) (3) (4) E6 E7 (Transformation) (5) (6) (1) (Sensitivity) (Specificity) (2) 2. 預防 (Prevention) NHRI/TCOG 3 NHRI/TCOG
三 子宮頸上皮內腫瘤的適當處置模式 (CINCervical Intraepithelial Neoplasia) 1. 異常抹片的處置 (LGSIL HGSIL ASCUS AGCUS): LGSIL (Low Grade Squamous Intraepithelial Lesion) HGSIL (High Grade Squamous Intraepithelial Lesion) ASCUS(Atypical Squamous Cell of Undetermined Significance) AGCUS (Atypical Glandular Cell of Undetermined Significance) (Satisfactory) (Unsatisfactory) (Knife, LEEPLoop Electrical Excisional Procedure, Laser) LGSILASCUS AGCUS (Fractional D&C) (Laser Ablation) (LEEP) (Conization) 4. 重度子宮頸上皮內腫瘤的處置方案 (CIN 3): (Knife, Laser, LEEP) (Microinvasion Stage Ia1) ( ) Adenocarcinoma in situ 2. 輕度子宮頸上皮內腫瘤的處置方案 (CIN 1): 3. 中度子宮頸上皮內腫瘤的處置方案 (CIN 2): NHRI/TCOG 5 NHRI/TCOG
四 初期子宮頸癌的適當處理模式 (Low stage cervical cancer, FIGO stage I-IIa) 1994 FIGO (International Federation of Gynecologists and Obstetricians) () Stage Ia1 (punch biopsy) () (LVSILymphatic Vascular Space Invasion)Stage Ia1 ( ) 100% (LVSI) Stage Ia1 Stage Ia1 (Radical Hysterectomy) (Modified Radical Hysterectomy) (Total Hysterectomy) Stage Ia2 Stage Ia2 (Teletherapy) (Brachytherapy) Stage IbIIa Stage IbIIa Stage Ib2 ( > 4cm) (LVSI) (parametrectomy) Stage IbIIa NHRI/TCOG 7 NHRI/TCOG
Stage IaIb1 Stage Ib2 (Tumor Marker) 五 較晚期與復發之子宮頸癌的處理模式 (Advanced Stage Cervical Cancer, Recurrent Cervical Cancer) (FIGO Stage IIbIIb) (Megavoltage Radiation Energies) (Teletherapy) (Brachytherapy) (Multiple Field Arrangement) (LDRLow Dose Rate Brachytherapy) (HDRHigh Dose Rate Brachytherapy) (Fractionation Schemes) (Interstitial Therapy) Cisplatin (Response Rate) 18 ~ 31% ( Bleomycin Ifosphamide MethotrexateVincristine5FU) (the National Cancer InstitueNCI) 1999 (Concurrent NHRI/TCOG 9 NHRI/TCOG
Chemoradiation) cisplatin Hydroxyurea 1. 手術後復發性子宮頸癌的處置 : 16 ~ 47% (Central Recurrence) 2. 放射線治療後復發性子宮頸癌的處置 : (Full Dose) (Central Recurrence) (Pelvic Exenteration) (Pelvic Exenteration) 10% (Continent Urinary Reservoirs) (Vaginal Reconstruction) (Low Rectal Anastomosis) 30 ~ 60%2 (Radical Hysterectomy) (Pelvic Exenteration) (Pelvic Sidewall) (Intraoperation Electron Beam or Brachytherapy) 3. 緩解性治療 (Palliative Therapy): () (Short Course Radiation) NHRI/TCOG 11 NHRI/TCOG
六 結論 (Microinvasive Squamous Carcinoma, FIGO stage Ia) FIGO Stage IbIIa70 ~ 85% 40 ~ 60% (Concurrent Chemoradiation) NHRI/TCOG 13 NHRI/TCOG
表ㄧ. 抹片判讀結果 一 抹片品質 : (1) (2) (3) 二 抹片尚可或難以判讀之原因 : (1) (2) (3) (4) (5) (6) () (7) (8) 三 可能的感染 : (1) Candida (2) Trichomonas (3) Herpes (4) Human papilloma virus (5) Chlamydiae (6) Others NHRI/TCOG 15 NHRI/TCOG
四 細胞病理診斷 : NORMAL (WITHIN NORMAL LIMIT) Normal Reactive changeinflammation, repair, radiation, and others Atrophy with inflammation ATYPICAL CELLS OF UNDETERMINED SIGNIFICANCE Atypical squamous cells Atypical glandular cells LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION (LSIL) Mild dysplasia (CIN 1) HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL) Moderate dysplasia (CIN 2) Severe dysplasia (CIN 3) Carcinoma In situ (CIN 3) SQUAMOUS CELL CARCINOMA ADENOCARCINOMA OTHER MALIGNANT NEOPLASM OTHERS Atypical glandular cells favor neoplasm Atypical squamous cells favor HSIL Dysplasia, favor HSIL 表二. The FIGO Staging System for Cervix Cancer (1994) Stage 0 Carcinoma in situ, intraepithelial carcinoma. Cases of Stage 0 should not be included in any therapeutic statistics for invasive carcinoma. I The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded). IA Invasive cancer identified only microscopically. All gross lesions, even with superficial invasion, are stage IB cancers. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm. (The depth of invasion should not be more than 5 mm taken from the base of the epithelium, either surface or glandular, from which it originates. Vascular space involvement, either venous or lymphatic, should not alter the staging.) IA1 Measured invasion of stroma no greater than 3 mm in depth and no wider than 7 mm. IA2 Measured invasion of stroma greater than 3 mm and no greater than 5 mm in depth and no wider than 7 mm. IB Clinical lesions confined to the cervix or preclinical lesions greater than IA. IB1 Clinical lesions no greater than 4 cm in size. IB2 Clinical lesions greater than 4 cm in size. NHRI/TCOG 17 NHRI/TCOG
II The carcinoma extends beyond the cervix, but has not extended on to the pelvic wall; the carcinoma involves the vagina, but not as far as the lower third. IIa No obvious parametrial involvement. IIb Obvious parametrial involvement. III The carcinoma has extended on to the pelvic wall; on rectal examination there is no cancer-free space between the tumor and the pelvic wall; the tumor involves the lower third of the vagina; all cases with a hydronephrosis or nonfunctioning kidney should be included, unless they are known to be due to other cause. IIIa No extension on to the pelvic wall, but involvement of the lower third of the vagina. IIIb Extension on to the pelvic wall or hydronephrosis or nonfunctioning kidney. IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. IVa Spread of the growth to adjacent organs. IVb Spread to distant organs. 婦癌研究委員會名單 醫院 科別 姓名 () () NHRI/TCOG 19 NHRI/TCOG
醫院 科別 姓名 TCOG TCOG 參與討論之專家學者名單 醫院 科別 姓名 NHRI/TCOG 21 NHRI/TCOG
醫院 科別 姓名 NHRI/TCOG 23