卵巢癌手术治疗—腹腔镜与开腹谁更合适.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,卵巢癌手术治疗,腹腔镜与开腹谁更合适,1990s,2000s,2010s,Second-look operation for evaluations,with,laparoscopy,H,and-assisted laparoscopy,Staging,Laparoscop,y,Laparoscopic Cytoreduction,CONTENTS,01,03,02,腹腔镜在早期卵巢癌分期手术中的价值,腹腔镜在晚期卵巢癌细胞减灭手术中的应用,腹腔镜下复发性卵巢癌减瘤术的应用及价值,01,全面手术分期,+,减瘤术,02,低级别浆液性癌/G1子宫内膜样癌,观察随访,以铂为基础的静脉化疗36疗程,内分泌治疗,03,A或B期/G2子宫内膜样癌,观察,以铂为基础的静脉化疗36疗程,04,A或B期高级别浆液性癌或G3子宫内膜样癌和C期,以铂为基础的静脉化疗36疗程,05,证据,支持期患者的初次化疗,需要6疗程以上的化疗,初治浸润性上皮性卵巢癌治疗原则,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,早期,少见病理组织学类型的卵巢肿瘤,的治疗原则,冰冻切片提示为恶性生殖细胞肿瘤、恶性线索-间质肿瘤，可行保留生育功能的手术,无生育要求者或间质肿瘤患者或癌肉瘤患者，进行全面手术分期。,根据病理术后可选择观察或相应化疗,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,腹腔镜可被用于评估是否能达到满意的减瘤术,腹腔镜可被用于有经验的妇瘤医生完成手术分期及满意的减瘤术,若腹腔镜减瘤术不理想，必须中转开腹,手术,基本原则,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,手术步骤,Step Four,全子宫,+,双侧附件切除；,需要保留生育功能的患者，在符合适应证的前提下可考虑行单侧附件切除术或双侧附件切除术,手术过程必须尽力完整切除肿瘤并避免肿瘤破裂,可根据需要切除肠管、阑尾、脾脏、胆囊、部分肝脏、部分胃、部分膀胱、胰尾、输尿管及剥除膈肌和其他腹膜；,力求使残余肿瘤病灶直径1cm，最好切除所有肉眼可见病灶,腹腔冲洗液行细胞学检查；,对腹膜表面进行全面诊视，腹膜活检,切除能够切除的肿大或者可疑淋巴结；盆腔外肿瘤病灶,2cm,者（即,B,期）必须行双侧盆腔和主动脉旁淋巴结切除术,Step Three,Step Two,Step One,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,腹腔镜手术争议,术中,肿瘤破裂,气腹致,肿瘤扩散,手术分期,不全面,穿刺孔,肿瘤种植,A,B,C,腹腔镜术中出血更少,(466.8 95%CI,340.1,-,593.4 vs 233.8;95%CI,195.7,-,272.0 mL;P .001),组间术后分期提高无明显差异(I,2,=,43.8%),腹腔镜术中肿瘤破裂率为可接受范围内,(I,2,=,35.6%,总体 25.4%,),Staging laparoscopy for the management of,early-stag,e,ovarian cancer:a meta,-,analysis,Hyun Jong Park et al./,American Journal of Obstetrics&Gynecology,/,JULY,201,3,开腹手术出血更多,PFS,无显著差异,OS,无显著差异,PPT,模板下载：,PPT,素材下载：,PPT,图表下载：,PPT,教程：,Excel,教程：,PPT,课件下载：,Minig et al./European Journal of Obstetrics&Gynecology and Reproductive Biology 201(20,16,）,腹腔镜与开腹,手术分期范围相似,Laparoscopic surgical staging in women,with early stage epithelial ovarian cancer,81 of 665(,12.2%,),laparoscopy,group,VS,126 of 656(,19.2%,),laparotomy,group,U,pstaged on the final pathological evaluation,(P,0,.001),腹腔镜手术的肿瘤负荷较开腹手术小,组间,PFS,及,OS,无显著性差异,Laparoscopic staging for,apparent stage I epithelial ovarian cancer,Alexander Melamed et al./,American Journal of Obstetrics&Gynecolog,y/,JANUARY 2017,LAC,手术在早期,EOC,L,onger operative tim,e-,not statistically significant,L,ower estimated blood loss,(WMD=156.5 mL;95%CI,216.4 to 96.5),S,horter length of hospital stay,(WMD=3.7 days;95%CI,5.2 to 2.1),L,ower postoperative complication rate,(odds ratio OR=0.48;95%CI,0.290.81),U,pstaging,(OR=0.81;95%CI,0.551.20),C,yst rupture,(,OR=1.32;95%CI,0.523.38),R,ates were similar between groups.,A,shorter time to chemotherapy,(WMD=5.16 days;95%CI,8.68 to 1.64).,Survival outcomes were not influenced by the route of surgery.,Minimally Invasive Surgical Staging in Early-stage Ovarian,Carcinoma:A Systematic Review and Meta-analysis,GiorgioBogani,et al./,Journal of Minimally Invasive Gynecology,Vol 24,No 4,May/June 2017,小结,术中出血少,术后住院日短,有经验的手术医生,可将腹腔镜更广泛地应用于,早期卵巢癌的全面分期手术,未提高手术分期,无更高的肿瘤破裂率，且术中破裂并不明确影响预后,PFS,及,OS,相,比,开腹手术无显著性差异,CONTENTS,01,03,02,腹腔镜在早期卵巢癌分期手术中的价值,腹腔镜在晚期卵巢癌细胞减灭手术中的应用,腹腔镜下复发性卵巢癌减瘤术的应用及价值,PDS,NACT+IDS,晚期卵巢癌的初始手术策略,Phase III randomised clinical trial comparing primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load(SCORPION trial):Final analysis of peri-operative outcome A.Fagotti et al./European Journal of Cancer 59(2016)22e33,Fagotti laparoscopy-based score,N.R.Gmez-Hidalgo et al./Gynecologic Oncology 137(2015)553558,“The Fagotti laparoscopy-based score is a useful predictor of optimal cytoreduction.”,Predictive Index Value(PIV)2,Low Tumor Load,G.Vizzielli et al./Gynecologic Oncology 142(2016)1924,“,Early identification of high-risk patients could help the surgeon to adopt tailored strategies on individual basis.,”,A laparoscopic risk-adjusted model to predict major complications after,primary debulking surgery in ovarian cancer:Asingle-institution assessment,More favorable estimated blood loss and median length of stay and TTC.,No difference in PFS or OS.,Minimally invasive approach could representation advantage alternative surgical way.,Minimally invasive versus standard laparotomic interval debulking surgery in ovarian neoplasm,S.Gueli Alletti et al./Gynecologic Oncology 143(2016)516520,The high rate of complete cytoreduction,is perhaps because of the accurate selection of patients,Laparoscopy potentially,improves the detection of,microscopic peritonealimplants,Laparoscopy significantly,reduces procedure-related,morbidity and,expedites recovery.,Fanning et al,Feuer et al,suggested laparoscopy in advanced ovarian cancer,Fanning J,Yacoub E,Hojat R.Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer:success,morbidity and survival.Gynecol Oncol.2011;123:472011.,Laparoscopic Management of Ovarian Cancer Patients Journal of Minimally Invasive Gynecology,Vol 23,No 4,May/June 2016,CONTENTS,01,03,02,腹腔镜在早期卵巢癌分期手术中的价值,腹腔镜在晚期卵巢癌细胞减灭手术中的应用,腹腔镜下复发性卵巢癌减瘤术的应用及价值,影像学或临床复发,考虑再次减瘤术后参加临床试验或以铂为基础的联合化疗,或按复发治疗或支持治疗,化疗后继续参加临床试验或部分或完全缓解者,既往用过贝伐珠单抗者继续贝伐珠单抗维持治疗，,或考虑尼拉帕尼、或奥拉帕尼或雷卡帕尼维持治疗,铂耐药复发,参加临床试验或支持治疗或按复发治疗,首选非铂类单药化疗,生化复发,可以参加临床试验、或推迟至出现临床复发再治疗、,或立即开始以铂为基础的联合化疗或支持治疗。,复发性上皮性卵巢癌治疗原则,铂,敏感,复发,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,减瘤术,化疗或临床试验或支持治疗,复发性,少见病理组织学类型的卵巢肿瘤,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,初次化疗结束后612个月后复发,病灶孤立可以完整切除或病灶局限,无腹水,手术指征,2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南,Minimal access surgery can be a possible,treatment option for recurrent,ovarian cancer,.,L,aparoscopy is a feasible and safe approach,to optimal cytoreduction,Valerio Gallotta,et al/,Surgical EndoscopyJune 2014,Volume 28,Issue 6,pp 18081815,R,obotic-assisted surgery,is,safe and,feasible approach,A.Lucidi et al./Best Practice&Research Clinical Obstetrics and Gynaecology 45(2017)74e82,L,aparoscopic approach for spleen removal,is feasible,.,Journal of Minimally Invasive Gynecology,Vol 23,No 3,March/April 2016,Complete removal of the recurrent disease was achieved in all patients.,All postoperative complications were managed without long-term sequeale,.,Secondary Laparoscopic Cytoreduction in Recurrent,Ovarian Cancer:A Large,Single-Institution Experience,Valerio Gallotta,et al./,Journal of Minimally Invasive Gynecology,Vol 25,No 4,May/June 2018,难以达到满意的减瘤,理想的手术目标仍是达到无肉眼残留。即使是上腹部转移病灶也需彻底切除。,前次手术可能致盆腹腔粘连影响手术操作,腹腔镜,SCS,手术难点,您的内容打在这里，或者通过复制您的文本，在此框中选择粘贴，并选择只保留文字。,您的内容打在这里，或者通过复制您的文本后，在此框中选择粘贴，并选择只保留文字。,您的内容打在这里，或者通过复制您的文本后，在此框中选择粘贴，并选择只保留文字。,Analysis of secondary cytoreduction for recurrent,ovarian cancer by robotics,laparoscopy and laparotomy,J.F.Magrina et al./Gynecologic Oncology 129(2013)336340,For selected patients,“,E,xtensive recurrent disease and/or ascites were not considered candidates for minimally invasive cytoreduction,”,接受微创手术患者肿瘤负荷小、病灶少,(P0.01）,微创手术术中出血少、术后住院时间短,(,P0.01,）,组间完全减瘤率无差异,组间,PFS,、,OS,无差异,For selected patients“,Selection was based on surgeon preference rather than tumor and/or patient characteristics,and selection was highly dependent on the individual surgeons experience with MAS.,”,F,easible and,S,afe！,Minimal access surgery,(MAS),compared to laparotomy,for secondary surgical cytoreduction,A.G.Z.Eriksson et al./Gynecologic Oncology 146(2017)263267,Minimally invasive surgery(MIS)is practiced by,more than 90%of gynecologic oncologists.,Knowledge of anatomy,the disease process,and surgical technique is key during,these complicated surgical procedures.,Several studies have shown that,10 to 20 cases are needed to,gain proficiency with a certain procedure,.,MIS reduces blood loss,transfusions,length of,hospital stay,and wound complications without,compromising adequacy of the procedure or staging,even in(extremely)morbidly obese patients.,1,2,3,4,Role of Minimally Invasive Surgery,in Gynecologic Malignancies,掌握解剖,HIGH VOLUME,量变 质变,ClinicalTrial,注册,在进行中或已完成的,NCT,仍待相关结果,更多,NCT,探索最佳选择,