2023年版膀胱癌治疗指南（教学课件）.ppt

膀胱癌诊断治疗指南膀胱癌诊断治疗指南 Together it is possible 意意 义义 对膀胱癌的四个“有利于对膀胱癌的四个“有利于 诊疗方式的选择与统一诊疗方式的选择与统一 治疗方式的结果判定治疗方式的结果判定 不同地区诊疗结果的比较不同地区诊疗结果的比较 提高诊疗水平，维护患者的利益提高诊疗水平，维护患者的利益 内内 容容 1.前言前言 2.流行病学和病因学流行病学和病因学 3.组织病理学组织病理学 4.诊断诊断 5.非肌层浸润性膀胱癌治疗非肌层浸润性膀胱癌治疗 6.肌层浸润性膀胱癌治疗肌层浸润性膀胱癌治疗 7.尿流改道尿流改道 8.放疗与化疗放疗与化疗 9.生活质量、预后与随访生活质量、预后与随访 10.膀胱非尿路上皮癌膀胱非尿路上皮癌 一、前一、前 言言 2022年，年，Evidence-Based-Medicine?吴阶平泌尿外科学吴阶平泌尿外科学?Campbells Urology 国外的指南：国外的指南：EUA；AUA；NCCN 前前 言言 版本更新版本更新 2022年版年版 2022年版年版 2022年版年版 引用文献：总引用文献：总393条，我国学者论文条，我国学者论文38条，条，占占9.67%。二、流行病学和病因学二、流行病学和病因学 流行病学流行病学 发病率和死亡率发病率和死亡率 自然病程自然病程 致病的危险因素与病致病的危险因素与病因学因学 Jemal A,et al.Global cancer statistics 2022.CA Cancer J Clin,2022,61:69-90 发病率 死亡率 自然病程自然病程 10%进展为肌层浸润性进展为肌层浸润性/转移性膀胱癌转移性膀胱癌 分期分期T 分级分级G 大小大小 数目数目 欧洲肿瘤协作组欧洲肿瘤协作组EORTC权重评分表权重评分表 致病的危险因素致病的危险因素 吸烟吸烟 职业暴露职业暴露 慢性感染慢性感染 Schistosoma hematobium Jemal A,et al.Global cancer statistics.CA Cancer J Clin,2022,61:69-90 癌基因癌基因 HER-2、Bcl-2、H-Ras p53、Rb、p21 SYK、CAGE-1 EGFR 上尿路尿路上皮肿瘤病史上尿路尿路上皮肿瘤病史 病因学病因学 三、组织病理学三、组织病理学 分级：分级：WHO 1973，1998，2004分级标准分级标准 浸润深度：浸润深度：UICC TNM分期法分期法 尿路上皮细胞癌尿路上皮细胞癌 Urothelium/transitional epithelium 鳞状细胞癌鳞状细胞癌 腺细胞癌腺细胞癌 其他：小细胞癌、混合细胞癌、癌肉瘤以及转其他：小细胞癌、混合细胞癌、癌肉瘤以及转移性癌移性癌 组织学类型组织学类型 Fleshner NE,et al.Cancer,1996,78:1505-1513 组织学分级组织学分级Grade Grade-EUA Papillary hyperplasia is characterized by slight“tenting,undulating,or an elevated configuration of the urothelium of varying thickness,lacking nuclear atypia.The lesion often has one or a few small,dilated capillaries at its base but it lacks a well-developed fibrovascular core.Papillary Hyperplasia Urothelial papilloma is defined as discrete papillary growth with a central fibrovascular cores lined by urothelium of normal thickness and cytology.There is no need for counting the number of cell layers.Urothelial Papilloma Papillary urothelial neoplasm of low malignant potential is a papillary urothelial lesion with an orderly arrangement of cells within papillae with minimal architectural abnormalities and minimal nuclear atypia irrespective of the number of cell layers.The urothelium in papillary urothelial neoplasms of low malignant potential is much thicker than in papillomas and/or the nuclei are significantly enlarged and somewhat hyperchromatic.Mitotic figures are infrequent in papillary urothelial neoplasms of low malignant potential,and usually confined to the basal layer.Papillary Urothelial Neoplasm of Low Malignant Potential Low-grade papillary urothelial carcinomas are characterized by an overall orderly appearance but with easily recognizable variation of architectural and or cytologic features even at scanning magnification.Variation of polarity and nuclear size,shape,and chromatin texture comprise the minimal but definitive cytologic atypia.Mitotic figures are infrequent and usually seen in the lower half,but may be seen at any level of the urothelium.It is important to recognize that there may be a spectrum of cytologic and architectural abnormalities within a single lesion,such that the entire lesion should be examined,with the highest grade of abnormality noted.Low-grade Papillary Urothelial Carcinoma High-grade papillary urothelial carcinomas are characterized by a predominantly or totally disorderly appearance at low magnification.The disorder results from both architectural and cytologic abnormalities.Architecturally,cells appear irregularly clustered and the epithelium is disorganized.Cytologically,there is a spectrum of pleomorphism ranging from moderate to marked.The nuclear chromatin tends to be clumped and nucleoli may be prominent.Mitotic figures,including atypical forms,are frequently seen at all levels of the urothelium.There is an option in the diagnosis of high-grade papillary urothelial carcinoma to comment on whether there is marked nuclear anaplasia.High-grade papillary urothelial carcinomas UICC 2002年第年第6版版 UICC 2022年第年第7版推荐版推荐 非浸润性非浸润性 Tis,Ta,T1 浸润性浸润性T2以上以上 分分 期期 推荐意见推荐意见 1.膀胱癌分期系统：推荐采用膀胱癌膀胱癌分期系统：推荐采用膀胱癌2022年第年第7版版 TNM分期系统分期系统(UICC)。2.膀胱癌分级系统：在证明新的膀胱癌分级系统：在证明新的WHO分级法比分级法比WHO 1973分级法更合理之前，可以同时使分级法更合理之前，可以同时使用用WHO 1973和和WHO 2004分级法。分级法。四、诊断四、诊断 1.早期检测与病症早期检测与病症 2.体格检查体格检查 3.影像学检查影像学检查 4.尿细胞学其它标记物尿细胞学其它标记物 5.尿液膀胱癌标记物尿液膀胱癌标记物 6.膀胱镜检查和活检膀胱镜检查和活检 7.诊断性电切诊断性电切 8.荧光膀胱镜检查荧光膀胱镜检查 9.二次经尿道电切术二次经尿道电切术 10.窄带光成像窄带光成像 Stenzl A,et al.European Association of Urology,2022,14-20 1.超声检查超声检查 2.KUB+IVP 3.CT 4.胸部检查胸部检查 5.MRI检查检查 6.骨扫描骨扫描 7.PET 影像学检查影像学检查 主要目的：主要目的：1.明确病理诊断明确病理诊断 2.治疗治疗 酌情省略膀胱镜酌情省略膀胱镜 方法：肿瘤、基底部、周边区域方法：肿瘤、基底部、周边区域 诊断性电切诊断性电切 推荐意见推荐意见 1.膀胱肿瘤患者需询问病史，做体格检查、尿常规、膀胱肿瘤患者需询问病史，做体格检查、尿常规、B超、尿脱落细胞学、超、尿脱落细胞学、IVU检查及胸片。检查及胸片。2.对所有考虑膀胱癌的患者应行膀胱镜检查及病理活检对所有考虑膀胱癌的患者应行膀胱镜检查及病理活检或诊断性或诊断性TUR。3.诊断性诊断性TUR应包括肿瘤基底的膀胱肌层。应包括肿瘤基底的膀胱肌层。4.对疑心原位癌、尿脱落细胞学阳性而无明确粘膜异常对疑心原位癌、尿脱落细胞学阳性而无明确粘膜异常者应考虑随机活检。者应考虑随机活检。5.对肌层浸润性膀胱癌患者根据需要可选择盆腔对肌层浸润性膀胱癌患者根据需要可选择盆腔CT/MRI、骨扫描。、骨扫描。五、非肌层浸润性膀胱癌治疗五、非肌层浸润性膀胱癌治疗 危险因素危险因素 低危：单发、低危：单发、Ta、G1、直径、直径3cm等。等。非肌层浸润性膀胱癌治疗非肌层浸润性膀胱癌治疗 手术治疗手术治疗 TUR-BT 经尿道激光手术经尿道激光手术 光动力学治疗光动力学治疗 术后辅助治疗术后辅助治疗 膀胱灌注化疗膀胱灌注化疗 膀胱灌注免疫治疗膀胱灌注免疫治疗BCG、免疫调节剂、免疫调节剂 术后膀胱灌注化疗术后膀胱灌注化疗 即刻即刻24h 单次低危单次