婦癌手術新境界 曾志仁醫師中山醫學大學附設醫院婦產科台灣女性癌症協會 Gynecologic oncologist Vice President of the Chung-Shan Medical University Hospital President of the Taiwan Women Cancer Association tsengcj@gmail.com
曾志仁醫師 Chun Shan University Hospital, 中山醫學大學附設醫院 Specialty: 中山醫學大學附設醫院副院長 婦產科癌症腫瘤 中山醫學大學附設醫院婦科主任 電子病歷 台灣女性癌症協會理事長 實證醫學與醫療品質 1 1997 年 1998 年台灣婦產科醫學會最佳論文獎全國第一名 2 2000 年台灣徐千田醫學論文獎全國第一名 3 1998 1999 2000 2001 年國科會學術研究獎 4 2005 年行政院醫療品質獎全國第一名 7 2006 年醫策會醫療品質獎全國第一名 8 2007 年國健局子宮頸癌預防篩檢品質獎全國第一名 9 2008 年醫策會實證醫學獎全國第一名
Chung-Shan Medical University Hospital 婦癌治療新趨勢 根除治療保守治療預防醫學 Advanced Operation Preserved uterus Pap smear Chemotherapy Fertility HPV test Radiation Preserved function HPV vaccine
中山醫學大學附設醫院 Chung-Shan Medical University Hospital 婦癌的治療演進 Disease treatment Functional preserved Organic preserved Fertility preserved Disease prevention
子宮頸癌 (Cervical cancer) 的治療 1 Consensus: Radical hysterectomy 1. 全子宮根除手術 2. 雙側卵巢切除手術 3. 骨盆腔淋巴腺切除手術 4. 雙側輸卵管切除手術 5. 陰道部分切除手術
手術 的醫療品質 Chun Shan University Hospital, 中山醫學大學附設醫院 Find a problem 婦癌手術常見的併發症
Chun Shan University Hospital, 中山醫學大學附設醫院 手術 的醫療品質 併發症發生的原因 1. 神經破壞 2. 組織纖維化 3. 器官切除 4. 骨盆腔底結構破壞 漏尿 尿失禁 下肢水腫 便秘 性功能障礙
子宮頸癌是女性健康重大的威脅 威脅生命 生育 性生活 排尿解便 性意象傷害
中山醫學大學附設醫院 Chung-Shan Medical University Hospital 婦癌的治療演進 Disease treatment Functional preserved Organic preserved Fertility preserved Disease prevention
疾病與文化的變遷
Treatment for invasive cervical cancer 43% of invasive cervical cancer diagnoses are in women aged 45 years or younger many of whom still wish to have children. - Taiwan, 2008,DOH Stage Ia1 Stage Ia2 Stage Ib
Treatment for invasive cervical cancer
OBGYN, CHUNG SH AN MEDICAL UNIVERSITY HOSPIT AL 創新手術 子宮頸癌的保守治療 子宮頸癌的保守治療
保留子宮的子宮頸癌手術
子宮頸侵襲癌周邊結構 Stage Ia2 Stage Ib
Radical Trachelectomy - Technique 1. Abdominal approach 2. Vaginal approach \ 3. Extraperitoneal approach
Pelvic Lymphadenectomy - Technique Lymphadenectomy 1. Laparoscopic 2. Intraperitoneal 3. Extraperitoneal
Chun Shan University Hospital, 中山醫學大學附設醫院 From October 1991 to October 2003, we have planned 82 VRT in patients with early-stage cervical cancer (stages IA, IB, and IIA). Tumor size >2 cm was statistically significantly associated with a higher risk of recurrence (P =0.03).
Chun Shan University Hospital, 中山醫學大學附設醫院 Between March 1995 and November 2005, we intend to treat 108 patients with cervical cancer (TNM stage 1A1, L1 n = 18, 1A2, n = 21, 1B1 n = 69) by RVT. The median follow-up time was 29 (1 128) months. Three (3%) recurrences occurred in 100 patients treated with RVT. The projected 5-year recurrence-free and overall survival rates were 97% and 98%.
Chun Shan University Hospital, 中山醫學大學附設醫院 When is Surgery Appropriate?? Young woman / Fertility sparing Small lesion <2 cm FIGO stage :Ia2~IB1 No uncorrectable Infertility disease Retroperitoneal LN : negative No adjuvant RT Early cervical cancer - Radical Trachelectomy
Chun Shan University Hospital, 中山醫學大學附設醫院 Between 12/2001 and 7/2007, 43 adult patients with FIGO stage IB1 cervical cancer underwent surgery with the intent to perform a fertility-sparing radical trachelectomy. VRT was attempted in 28 patients (65%) and ART in 15 patients (35%). Parametrial nodes were detected in 8 (57.3%) of the ART specimens (P=0.0002).
A total of 61 women were followed up for a median of 27 months (range: one month 79 months). There were six recurrences (9.8%); None of the recurrences occurred in patients with a tumor diameter of < 20 mm L.T. Gien, A. Covens / Gynecologic Oncology 117 (2010) 350 357
Uterine blood supply after radical trachelectomy is similar as control group (health women).
Uterine blood supply after radical trachelectomy
Uterine blood supply after radical trachelectomy
What about following pregnancy? Pregnancy rate? Miscarriage? Premature labour? Caesarean Section?
Lancet, July 8, 2010, Lukas Rob. et al.
Early cervical cancer - Radical Trachelectomy
Radical Trachelectomy
Post Radical Trachelectomy Cervical Circlage is option Parametrial Tissue Cervical Cancer
Early cervical cancer - Radical Trachelectomy
倫理與性別議題 Review of the psychological impact of cancer on patients' partners and other key relatives. C. Pitceathlya European Journal of Cancer,39, 11, 1517-1524, 2003. Review of sexuality, partners, and family after Cancer. Leslie R. Schover, Hematology ;523-8,2005. Chun Shan University Hospital, 中山醫學大學附設醫院
證據搜尋與證據解讀 Search Evidence and Clinical Appraise Chun Shan University Hospital, 中山醫學大學附設醫院 文獻蒐集 等級分類 文獻評讀 Patient Intervention Comparison Outcome 文獻等級 Review Randomized Cervical Cancer Traditional operation New surgical technique Conservative surgery Complications Disease free survival Cost-effective 篇數 2 2 References [19-20] [21-22] Case control 3 [23-25] Chun Shan University Hospital, 中山醫學大學附設醫院
Early cervical cancer - Radical Trachelectomy Characteristics (2006~2009 CGMH-CY ; 2010~2011 CSH) RT (N=11) Age (years) 29 (range, 24-32) Hisrology (SCC) 8 (AdenoCA) 3 Operative time (mins) 167 (range,136 214) Blood loss (ml) 226 (range,50-720) Hospital stay (days) 6 (range,5-10) Tumor size (cm) 1.7 (range,0-2.5)
Case 8: 27 Y/O, G0P0, Unmarried, Cervical cancer Ib1, Post conservative radical trachelectomy and lymphadnenctomy NED for 2.5 years
RESULTS Operation records Characteristics RT Successful Rate 11 (100%) Dissected Nodes (Mean) 21 Positive Pelvic lymph node 0 Positive para-aortic lymph node 0 Parametrial involvement 0 Positive section margin 0 Operation-related complications 0
RESULTS Follow-up (range, 2-41 months). RT (N=11) Recurrence rate 0% Survival 100% Married 6 Pregnancy 2 Delivery 0
Early cervical cancer - Radical Trachelectomy Conclusions Radical trachelectomy can be safe for early stage cervical cancer in young and fertility sparing women.
Suggestion When is Surgery Appropriate?? Young woman Fertility When all disease can be excised. Inform consent
手術品質 的臨床運用 Evidence based surgical improving program Assessing 國際婦癌手術訓練中心 : ( 日本 美國 台灣 ) 香港 新加坡 泰國
Endometrial Cancer 子宮內膜癌 Consensus: Maximal debulking 1. 全子宮切除手術 2. 雙側卵巢切除手術 3. 骨盆腔淋巴腺切除手術 4. 腹腔網膜切除手術 5. 盲腸切除手術 6. 雙側輸卵管切除手術
子宮癌 (Uterine cancer) 的保守治療 Consensus: Conservative - Hormone therapy Leupline Megace Hysteroscopy follow up Stage Ia g1
Endometrial Cancer Review: Conclusion: High remission rates with subsequent pregnancies are seen in well selected stage Ia, grade 1 endometrial cancer of young women using hormone therapy (usually progestins) as fertility-preserving treatment, yet late recurrences and death have been reported. Current Opinion in Obstetrics and Gynecology 2006, 18:29 34. CGMH
Endometrial Cancer
卵巢癌 (Ovarian cancer) 的治療 Consensus: Maximal debulking 1. 全子宮切除手術 2. 雙側卵巢切除手術 3. 骨盆腔淋巴腺切除手術 4. 腹腔網膜切除手術 5. 盲腸切除手術 6. 雙側輸卵管切除手術 7. 腹膜切除手術
婦癌手術新境界 - 手術品質改善 Chun Shan University Hospital, 中山醫學大學附設醫院 Quality of Life 減低併發症保護功能保護器官生育能力性生活