How to diagnose and treat cervical cancer more accurately?Answers given from clinical guidelines to real world research2022-01-14 18:06:52 17 ℃
Source of this article
Zhang Jun.The Status and Problem of Cervical Cancer Treatment: From Clinical Guide to Real World [J]. China Academic Medicine, 2022, 25 (3): 259-263. DOI: 10.12114 / J.issn.1007-9572.2021. 02.105 (click on article topic to view full text)
Author: Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University
Submission website: www.chinagp.net
Cervical cancer is one of the psychoma of reproductive system that seriously threatens women's health. At present, there is a good guiding role in clinical renewal of cervical cancer diagnosis and treatment at home and abroad. However, in the practice of clinical work, clinical diagnosis is still not accurate enough, and minimally invasive treatment has many controversies, and there are many problems to be improved, and major doctors need to pay attention.
This paper combed the progress of the staging and surgical treatment of cervical cancer in recent years and some issues of real world research, in order to provide a basis for the diagnosis and treatment of clinical cervical cancer.
Cervical cancer diagnosis
1 Domestic and foreign guides on cervical cancer staging
(1) International Obstetrics and Gynecology Union (FIGO) 2009 cervical cancer staging mainly rely on clinical examination results, 2 high-year-old doctors conduct physical examination, according to cervical vagina, parade (including main sacral ligament and bladder rectum The case of violations) and distant metastasis were staging. But many years of clinical practice results show that the Figo 2009 cervical cancer stage has a large subjective, and its accuracy cannot meet clinical needs and judgments on prognosis.
(2) 2018 FIGO has made great modifications to cervical cancer, and in 2019, the stage II and II stage infiltration depth or tumor size "=" critical value, which is more The high-altitude correction is a lower stage.
(3) FIGO cervical cancer in 2018 (revised in 2019) Introducing imaging and pathological results into staged systems, after surgery, according to pathological results, the diagnosis of patients is more accurate, better Guide the treatment, prognosis and follow-up of such patients.
2 installment diagnosis before the premiere of cervical cancer
(1) Preoperative assessment is currently recommended for comprehensive judgment based on physical examination and imaging. The measurement of tumor infiltration depth is required for the cervical tissue specimens obtained by the IA biopsy or cone, and requires measurement of the patient's tumor size of the IB ~ IIA to further install.
(2) Domestic and foreign guides recommend surgery for the preferred treatment regimens of IB1, IB2 and IIA1 patients, and for IB3 and IIA2 patients, the preferred treatment is synchronous to chemotherapy.
(3) In real clinical practice, the physical examination is mainly based on the estimation of the naked eye and techniques. It is clear that accurate measurement, many clinical studies have shown that MRI's assessment is more accurate in existing means, such as using three-dimensional MRI assessment Tumor size can further improve the accuracy of the stage.
(4) For the staged diagnosis of cervical cancer, in addition to the size of local tumors, whether the palace is violated, the transfer of lymph nodes and distants is an important basis for the staging.
(5) For IIB phase and above, the assessment of metastasis lesions is the basis for developing synchronous radiotherapy regimens.
(6) Preoperative evaluation of the interior image of the image, including ultrasound, CT, positron emission computer tomography (PET-CT) and magnetic resonance examination, in addition to the inspection means itself is not accurate to cervical lesions, clinical practice The phenomenon of discovering the tumor size, infiltration range, and lymph nodes with a large number of judgment stages, and the hospital diagnosis accuracy of different levels and regions has also been very gap. It is routine CT, MRI inspection, or jointly dispected weighted imaging (DWI), and has not solved the problem of routine examination to diagnose lymphadenominity.
Histological diagnosis of 3 cervical cancer
Guidelines for China and NCCN, ESMO recommendation Types, according to WHO-2014 female genital organ tumor classification, histological grade is not included in the installment diagnosis system of cervical cancer.
Cervical cancer treatment
1 Recommendations for cervical cancer surgery and treatment
(1) 2021 Edition NCCN Guide Recommendation IA1 No lymphoid Veslement (LVSI) and IA1 Part Trops, IA2, IA2, IA16, at least 3 mm distance, IA1 period LVSI Or the preferred radical subtrode cutting + pelvic lymph nuts from the IA2 period, the secondary cone cut + pelvic lymph nodes are divided.
(2) Small cell neuroendocrine cancer, gastric adenocarcinoma retains fertility.
(3) Do not retain maternity function surgery with querleu-morrow (QM) typography. Surgical manner is recommended for open surgery. For the treatment of recurrence, especially the potential recurrence of pelvic cavity can be selected.
(4) About the treatment of pelvic lymph nodes, can be selected from the pelvic lymph node or sentinel lymph nodes.
(5) Patients, NCCN and ESMO, were recommended for patients in Ia2 to Ib2 and part IB3 ~ IIA1, and the radical uterus extension and double-sided pelvic lymphobiosis extension (or except lymph nuts), if necessary, remove abdominal aortic pulse lymph nodes, The standard formula of the root-cured subterior pendant exterior is open. (6) advanced cases of IIB period and above are usually suggested, chemotherapy. In some countries and regions, some cases of IIB period may choose radical uterus and re-surgery.
(7) For local advanced or non-tolerant surgeons, radiotherapy is the best treatment, and there is high risk factors after radical uterus, and high risk factors can be selected as auxiliary treatment.
(8) An international, multi-center, retrospective queue study (ENGOT-CX3 / CEEGOGCX2), published in the ESMO conference, which is recommended to give up further radical surgery if the lymph nodes are discovered during the operation. Patients are placed, chemotherapy. This also suggests clinicians, should pay more attention to the installment and assessment of cervical cancer treatment.
2 Controversy about cervical cancer root surgery
(1) In the NCCN Guide issued in 2015-2018, the wide uterus to recommend cervical cancer can be implemented via laparoscopic or open abdomen.
(2) Chinese scholars have compared the diagnostic date in 2009-01-01 to 2016-12-31, the ending of laparoscopic and open surgical patients in patients with laparoscopic and open surgical patients, 5 of patients with minimally invasive surgery group The annual survival rate and tumor survival are lower than that of the open surgery group, minimally invasive surgery is the independent risk factor for recurrence or death.
(3) 2018, a forward-looking randomized control study involving 33 centers around the world (LACC research) showed 93.8% and 99.0%, cervical cancer, 99.0%, minimally invasive group and open group. The mortality rate was 4.4% and 0.6%, respectively, and the recurrent survival rate without local region was 94.3% and 98.3%, respectively, showing that the laparoscopic group has higher mortality and recurrence rate than the open group.
(4) In 2019, "China Expert Consensus" emphasizes the choice of surgery to fully tailor and informed the patient, and requires strengthening training for gynecological tumors and choices for cases, especially mentioned The principle of "tumorless operation" of surgery. It is recommended to improve the hometry method. It is recommended to "lift the homology method". The vagina below the tumor before the vaginal is separated, or the vaginal is discharged from the vaginal; the lymph nodes are immediately placed in the specimen bag; the uterus specimens are removed after removing the basin , Abdominal cavity and other measures.
(5) In 2020-2021, the relevant guidelines released by NCCN clearly recommend that there is a standard model of root-cured uterine-pendant pendant.
(6) There is currently no significant data of China minimally invasive surgery, but there is a postoperative transfer recurrence case that is different from the previous characteristics of the past, combined with the recommendation of the NCCN guide, and safely implement cervical cancer roots. Minimally invasive surgery has been widely valued.
(7) Cervical cancer minimally invasive surgery for more than 30 years, in recent years, the improvement of the principle of surgery and the improvement of surgery methods have been the hot problem of clinical attention, and China's multi-center cervical cancer begins in 2019. The real world research of minimally invasive and open surgery is currently in progress, and the results of new research have brought more reference to the clinical.
In summary, there are still many disputes and explorations in the installment and treatment of invasive cervical cancer, including the judgment of prognosis, the choice of cervical cancer treatment plan, local advanced cervical cancer surgery or formation of chemical chemotherapy regimen, cervical cancer The operation of the operation, the clinical work needs to be accurately staging under the existing medical conditions, balance the treatment plan for fertility requirements and special pathological types, and pay attention to the principle of tumor surgery. In the clinical study, it emphasizes the recommendation of the guidelines, randomized controlled trials combined with real-world research, will provide more based on improved updates to cervical cancer treatment programs.
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