绝经后卵巢肿物诊治的中国专家共识(2021年版)
本文刊登于《中国实用妇科与产科杂志》2021,37(10):1021-1026
DOI:10.19538/j.fk2021100110
作者:中国医师协会微无创医学专业委员会妇科肿瘤学组 中国优生科学协会生殖道疾病诊治分会
基金项目:国家自然科学基金(81972437)
通讯作者:张师前,山东大学齐鲁医院,山东 济南 250012,电子信箱:r370112@126.com;薛凤霞,天津医科大学总医院妇产科 天津市女性生殖健康与优生重点实验室,天津 300052,电子信箱:xuefengxia@tmu.edu.cn
执笔作者(排名不分先后):王稳(徐州医科大学附属滕州市中心人民医院);王颖梅(天津医科大学总医院);王玉东(上海交通大学附属国际和平妇幼保健院);王建六(北京大学人民医院);王建东(首都医科大学附属北京妇产医院);马晓欣(中国医科大学附属盛);向阳(中国医学科学院北京协和医院);程文俊(江苏省人民医院);张燕(武汉大学人民医院);张国楠(四川省肿瘤医院);张师前(山东大学齐鲁医院);薛凤霞(天津医科大学总医院);刘招舰(山东大学高等医学研究院)
参与讨论专家(按姓氏笔画排序):马晓欣(中国医科大学附属盛);王小元(山东省千佛山医院);王丹波(辽宁省肿瘤医院);王平(四川大学华西第二医院);王玉东(上海国际和平妇幼保健院);王建六(北京大学人民医院);王悦(河南省人民医院);王颖梅(天津医科大学总医院);王稳(徐州医科大学附属滕州市中心人民医院);孙力(中国医学科学院肿瘤医院);刘开江(上海交通大学附属仁济医院);吕卫国(浙江大学医学院附属妇产科医院);许天敏(吉林大学第二医院);刘木彪(广东省人民医院);刘军秀(中山大学附属第一医院);向阳(中国医学科学院北京协和医院);任彤(中国医学科学院北京协和医院);朱琳(山东大学第二医院);朱颖军(天津市中心妇产科医院);孙蓬明(福建省妇幼保健院);李卫平(中国人民解放军总医院);李长忠(山东省立医院);李宁(中国医学科学院肿瘤医院);张玉泉(南通大学附属医院);杨红();张师前(山东大学齐鲁医院);张岩(北京大学第一医院);张英丽(浙江省肿瘤医院);张国楠(四川省肿瘤医院);汪洪波(华中科技大学同济医学院附属协和医院);张瑜(中南大学湘雅医院);张颐(中国医科大学附属第一医院);张燕(武汉大学人民医院);邹冬玲(重庆市肿瘤医院);陈刚(华中科技大学同济医学院附属同济医院);范江涛(广西医科大学第一附属医院);陈亮(山东省肿瘤医院);罗喜平(广东省妇幼保健院);陈琼华(厦门大学附属第一医院);林蓓(中国医科大学附属盛);赵卫东(安徽省立医院);胡丽娜(重庆医科大学第二附属医院);胡元晶(天津市中心妇产科医院);赵淑萍(青岛大学妇女儿童医院);郝敏(山西医科大学第二附属医院);贾雪梅(南京市妇幼保健院);郭瑞霞(郑州大学第一附属医院);黄向华(河北医科大学第二附属医院);郭红燕(北京大学第三医院);程文俊(江苏省妇幼保健院);熊光武(重庆医科大学附属第三医院);薛凤霞(天津医科大学总医院)
1 背景
2 绝经后卵巢肿物的诊断
2.1 病史采集和体格检查 推荐及共识:详细询问病史,注意有无卵巢恶性肿瘤的高危因素以及卵巢癌、乳腺癌或结直肠癌家族史,过去1年内是否出现肠道易激症状。全面的体格检查包括腹部检查以及妇科检查。若家族存有明确致病性或可能致病的肿瘤易感基因突变,推荐遗传风险评估(2A类推荐)。
2.2 临床表现及初步检查 推荐及共识:绝经后卵巢肿物的临床表现不尽相同,出现急腹症时,要考虑卵巢肿物扭转、破裂或出血可能。首选检查手段包括经阴道超声检查和血清CA125测定。肿瘤体积较大、超出经阴道超声检查范围时,需联合经腹超声检查(1类推荐)。
2.3 血清学标志物检测 推荐及共识:CA125可作为绝经后卵巢肿物的初选血清肿瘤标志物,若与人附睾蛋白4(human epididymis protein 4,HE4)联合检测,特异度升高;其他肿瘤标志物如CA19-9、甲胎蛋白(AFP)、癌胚抗原(CEA)、CA724、乳酸脱氢酶(LDH)、β-hCG等可以协助诊断卵巢恶性肿瘤,但不推荐多种肿瘤标志物串联检测用于最初评估(2A类推荐)。
2.4 影像学检查 推荐及共识:不推荐CT、MRI和PET-CT作为绝经后卵巢肿物的初始检查手段。当高度可疑卵巢恶性肿瘤或存在广泛腹腔转移时,推荐CT、MRI等影像学检查。既往有恶性肿瘤病史者,PET-CT可评估附件区肿物是否为转移性肿瘤(2A类推荐)。
2.5 恶性肿瘤风险的评估
2.5.1 恶性肿瘤风险指数(RMI)和卵巢恶性肿瘤风险模型(ROMA) 推荐及共识:RMI评分系统可以协助判断卵巢恶性肿瘤的风险,绝经后RMI≥200者需进一步行腹盆腔CT评估。ROMA风险分层有利于卵巢肿物分层管理(2A类推荐)。
2.5.2 国际卵巢肿瘤分析组织(IOTA)、妇科影像报告和数据系统(GI-RADS)、卵巢附件报告与数据系统(O-RADS) 推荐及共识:(1)超声诊断模型可以鉴别卵巢肿物的性质(2A类推荐)。(2)超声诊断模型(IOTA简易标准或ADNEX模型)优于CA125、HE4水平以及ROMA,在鉴别良恶性肿瘤方面具有优势(2B类推荐)。(3)推荐使用IOTA简易标准和ADNEX模型,两者优于包括RMI在内的其他评分系统(2A类推荐)。
3 绝经后卵巢肿物处理
3.1 保守观察 推荐及共识:CA125正常、最大直径<5cm的无症状单侧单房卵巢肿物,患者具有随访意向和随访条件时,可以CA125及超声联合随访,推荐间隔时间4~6个月。随访期间注意症状、卵巢肿物体积变化和(或)内部回声改变以及CA125水平变化(2A类推荐)。
3.2 手术治疗
3.2.1 腹腔镜手术 推荐及共识:无手术禁忌证、体能状态可耐受手术、RMI<200的患者可以选择腹腔镜手术,术者应具有丰富的腹腔镜手术经验,具备初步判定大体标本良恶性的能力,并严格遵循无瘤原则(2B类推荐)。
3.2.2 子宫是否需要切除 推荐及共识:绝经后卵巢良性肿物的基本术式是双侧输卵管卵巢切除术,但临床决策需高度个体化,若患者有切除子宫的指征及需求,也可行全子宫加双侧输卵管卵巢切除术(2B类推荐)。
3.2.3 开腹手术 推荐及共识:绝经后卵巢肿物RMI≥200,CT检查、临床评估可疑恶性,或腹腔镜术中明确为恶性,推荐开腹全面分期手术(2A类推荐)。
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