诊断宫颈癌淋巴结转移的研究进展

宫颈癌淋巴结转移的分布具有一定的规律性,遵循由近及远的逐站式转移模式,先从盆腔淋巴结到髂总淋巴结,然后再到腹主动脉旁淋巴结,并可继续向上转移至锁骨上淋巴结,很少见跳跃转移的情况。术前诊断宫颈癌淋巴结转移的常用影像学检查方法包括计算机断层扫描(CT)、磁共振成像(MRI)、正电子发射计算机断层显像(PET/CT),各有优缺点。近年来术中前哨淋巴结检测逐渐成为热点,但是目前仍没有人明确指出识别前哨淋巴结可以替代系统的淋巴结切除术。应根据各自的特点,选择合适的检查方法,提高检测淋巴结转移的诊断符合率,选择合适的治疗方法,减少患者不必要的损伤和并发症。     

影像学检查在宫颈癌盆腹腔淋巴结转移诊断中的价值

2018年国际妇产科联盟（International Federation of Gynecology and Obstetrics,FIGO）更新宫颈癌分期,将治疗前影像学诊断盆腔淋巴结转移定义为ⅢC1r期,腹主动脉旁淋巴结转移定义为ⅢC2r期。术前影像学检查评估盆腹腔淋巴结是否转移与诊疗方案的制定相关,影像学准确地判断盆腹腔淋巴结状态可以明确分期,让患者接受规范的诊疗。目前临床上影像学检查方法众多,常用检查有B超、盆腔磁共振成像（magnetic resonance imaging,MRI）、计算机体层摄影术（computed tomography,CT）、正电子发射体层摄影术（positron emission tomography,PET）/CT及PET/MRI。B超经济方便,但对淋巴结检出率过低;CT在国内使用广泛、检查速度快,扫描范围大,临床应用易于推广,但CT诊断缺乏统一的诊断标准,诊断价值不突出;MRI具有良好的组织分辨率、能同时实现功能成像,但存在检查敏感度不高的情况;PET检查准确性较其他影像学检查较高,但其敏感度较MRI及CT检查并无统计学上的差异。     

磁共振成像检查对早期宫颈癌分期价值研究

目的探讨磁共振成像(MRI)在评估早期宫颈癌患者宫旁浸润、阴道受侵、淋巴结转移方面的价值。方法选取2010-10-01至2013-01-31辽宁省肿瘤医院收治的48例因宫颈癌为病因首次就诊患者,以术后病理结果为金标准比较MRI、术前妇科三合诊、术中探查和剖视标本3种诊断方法在宫旁浸润、阴道受侵、淋巴结转移3个方面的价值,并以手术-病理分期为金标准对MRI分期及术前临床分期的准确度进行对比。结果 MRI在早期宫颈癌术前淋巴结转移诊断方面的敏感度、特异度、阳性预测值、阴性预测值、准确度分别为65%、94%、85%、83%、83%,在宫旁浸润方面分别为50%、91%、33%、95%、88%,在阴道受侵方面分别为50%、78%、43%、82%、71%。妇科三合诊在早期宫颈癌宫旁浸润方面的敏感度、特异度、阳性预测值、阴性预测值、准确度分别为0、100%、0、92%、92%、阴道受侵方面分别为75%、100%、100%、92%、94%。临床分期的整体准确度为81%,MRI分期的整体准确度为67%,临床-MRI分期的整体准确度为92%。结论 MRI在早期宫颈癌术前淋巴结转移诊断方面有良好的价值;在宫旁浸润、阴道受侵方面有较好的阴性预测值和特异度;将临床-MRI结合所得分期较单独运用两种诊断方法分期准确度有所提高。     

前哨淋巴结活检对早期宫颈癌盆腔淋巴结转移诊断的Meta分析

目的:系统评价前哨淋巴结活组织检查术(SLNB)用于宫颈癌早期盆腔淋巴结转移诊断的临床价值。方法:计算机全面检索Pub Med、Embase、Medline数据库及中国知网、万方、维普数据库,检索2001~2013年国内外关于SLNB确定早期宫颈癌盆腔淋巴结的研究,用Meta分析的相关软件Meta Disc1.4进行统计学处理。结果:筛选出文献11篇,患者共581例。最后合并的早期宫颈癌SLNB的敏感度为0.86(95%CI 0.78~0.91),特异度为0.98(95%CI 0.97~0.99)。结论:合并后早期宫颈癌SLNB的敏感度、特异度较高,其对诊断宫颈癌淋巴结转移是可靠的。     

淋巴造影术在妇科肿瘤淋巴转移诊断方面的应用进展

淋巴转移是妇科恶性肿瘤转移的重要途径,本文主要介绍淋巴造影术的方法及其在妇科恶性肿瘤淋巴转移的影像学表现和结果判定方面的应用。同时简单介绍CT、MR淋巴造影术、淋巴闪烁成像术、PET和PET-CT等方法及其临床应用。     

PET-CT在宫颈癌诊治中的应用

妇科肿瘤常用的影像学检查方法包括超声检查、计算机断层扫描（computed tomography,CT）和核磁共振成像（magnetic resonance imaging, MRI）,均属于形态学诊断方法。正电子发射体层成像-计算机断层扫描（positron emission tomography- computed tomography , PET-CT）因其实现了功能与结构成像的有机融合,近年在临床应用日益广泛。正电子发射体层成像（positron emission tomography,PET）采用正电子标记的模拟生理代谢物的放射性药物,在生理条件下追踪人体活细胞内的生物化学反应,形成功能代谢影像,在肿瘤复发、转移的诊断中具有显著优势。PET-CT结合具有高组织分辨率的CT,集中了全身显像和断层显像的优点,同时弥补了CT定性困难和PET定位不精确及由于生理性摄取造成假阳性的缺陷,提高了诊断效能和准确性,具有极高的临床应用价值。PET-CT在妇科恶性肿瘤领域应用最多、研究最深入的是宫颈癌的诊治。     

MRI评估宫颈癌病变范围的临床分析

目的评价磁共振成像对宫颈癌分期的价值。方法对33例宫颈癌患者在手术前进行磁共振成像(MRI)检查,依临床分期制定治疗计划。以术后病理诊断为金标准,将临床、磁共振成像分期结果中癌浸润的部位和范围、淋巴结转移,尤其对宫旁浸润采用患者自身对照法与手术病理所见进行对比,评价宫颈癌分期。结果MRI对宫旁浸润判断的准确度为94%,特异度为96%,敏感度为90%。MRI对宫颈癌总的分期预测的准确性为75.7%。在局限性和宫旁浸润的区分中MRI有着94%的准确性。结论MRI在宫颈癌中对区分局限性和浸润性病灶有着较高的准确性。引入MRI技术于临床,有利于治疗计划的制定,应成为宫颈癌术前常规的影像检查方法。     

磁共振成像与术中病灶探查诊断子宫内膜癌肌层浸润及盆腹腔淋巴结转移临床价值研究

目的探讨磁共振成像(MRI)和术中病灶探查在子宫内膜癌肌层浸润及盆腹腔淋巴结转移诊断中的临床应用价值。方法回顾性分析上海交通大学附属第九人民医院2010年1月至2014年3月收治的33例行全子宫+双侧附件切除术+盆腔及腹主动脉旁淋巴清扫术的子宫内膜癌患者临床资料,以手术病理诊断为标准,比较术前MRI检查、术中病灶探查在诊断肿瘤侵犯子宫肌层深度和淋巴结转移的符合率。结果 MRI检查发现有肌层浸润33例,其中浅肌层浸润8例,深肌层浸润25例;术中剖视子宫标本发现有肌层浸润33例,其中浅肌层浸润6例,深肌层浸润27例。术后病理结果浅肌层浸润6例,深肌层浸润27例。提示MRI诊断浅肌层浸润敏感度100.00%,特异度92.59%。诊断深肌层浸润敏感度92.59%,特异度100.00%;术中病灶剖视诊断深浅肌层浸润敏感度和特异度均为100.00%。33例患者中经病理组织学确诊,8例患者出现淋巴转移,其中仅有盆腔淋巴结转移4例,盆腔及腹主动脉旁淋巴结转移2例,仅有腹主动脉旁淋巴结转移2例;33例患者术前MRI检查提示2例淋巴结转移,漏诊6例,MRI诊断淋巴结转移的敏感度25%;病灶探查发现4例盆腔淋巴结肿大(病理证实2例阳性,2例阴性),2例腹主动脉旁淋巴结肿大(1例阳性,1例阴性)。3例患者因淋巴结转移分期升级,术后需要辅以化疗和(或)放疗。结论子宫内膜癌患者术前MRI检查对判断肌层浸润深度准确率较高,手术中子宫标本的剖视与病理组织学检查相同,具有重要价值;而MRI检查和术中淋巴结探查对判断子宫内膜癌患者淋巴结转移的意义不大。盆腔及腹主动脉旁(至肾静脉水平)淋巴清扫可以使手术病理分期更准确,为患者术后提供更合理的治疗指导。     

放射影像学检查在子宫内膜癌诊断中的价值

子宫内膜癌（endometrial cancer,EC）的发病率和病死率在我国居女性生殖系统恶性肿瘤第2位，在美国居首位。近年由于高脂饮食和低运动量生活方式的影响，我国EC的发病率有所上升，发病人群逐渐年轻化。约90%的子宫内膜癌患者表现为不规则阴道流血流液，治疗以手术为主，辅以放化疗及激素治疗。虽然子宫内膜病理学检查是确诊子宫内膜癌的“金标准“，但是影像学检查可以术前了解子宫肌层浸润、子宫颈间质侵犯、淋巴结及远处转移等高危情况，从而帮助诊疗方案的制定，也可以进行放化疗疗效评估、术后监测和随访，从而提高患者预后。文章对CT、磁共振（MRI）、正电子发射计算机断层显像/磁共振显像（PET-CT/MRI）不同影像学检查在子宫内膜癌诊治中的应用及新进展进行阐述。     

彩色多普勒超声检查对卵巢癌腹膜及淋巴结转移的诊断价值

目的:探讨彩色多普勒超声检查对卵巢癌腹膜及淋巴结转移的诊断价值.方法:对46例可疑为卵巢癌的患者术前行超声和彩色多普勒血流显像(CDFI),观察其腹膜及腹主动脉、左右髂总动脉、髂外动脉、髂内动脉和闭孔动脉旁淋巴结声像图情况.结果:手术病理检查46确诊为卵巢癌,有腹膜转移40例,超声检查诊断正确率87.5%(35/40);有淋巴结转移25例,超声诊断正确率76.0%(19/25).卵巢癌肿瘤的CDFI、RI值、伴腹水情况与腹膜及淋巴结转移有关(P<0.05).结论:彩色多普勒超声可做为诊断卵巢癌腹膜及淋巴结是否发生转移的首选方法,给卵巢癌的临床分期及治疗策略的选择提供依据.     

应用MRI评价宫颈癌分期的临床研究

目的探讨应用磁共振成像(MRI)指导宫颈癌分期的价值。方法对64例宫颈癌患者在手术前行MRI,均依临床分期结果制定治疗计划。以术后病理诊断为金标准,采用病例自身对照法将临床、MRI分期中癌浸润的部位和范围、淋巴结转移,尤其是宫旁浸润情况与手术病理所见对比,评价宫颈癌分期。结果MRI对浸润性宫颈癌判断的准确率为93.7%,特异性为95.7%,敏感性为88.9%。MRI预测宫颈癌总的分期的准确率为75.1%。在区分局限性和宫旁浸润中MRI的准确率为93.7%。MRI对宫颈癌侵犯部位和范围判断的准确率达88.5%。MRI对淋巴结转移预测的准确性为90.6%。结论MRI可多方位成像清楚显示宫颈肿瘤病变范围,MRI对区分局限性和浸润性病灶、淋巴结转移有着较高的准确性。临床引入MRI技术,有利于合理制定治疗计划,应成为宫颈癌术前常规的影像检查方法。     

Magnetic resonance imaging in the preoperative staging of endometrial carcinoma

PURPOSE OF INVESTIGATION: Magnetic resonance imaging (MRI) has emerged as an important imaging modality in the evaluation of the extension of endometrial carcinoma which is essential in planning treatment and predicting prognosis. This study aimed to assess the value of MRI in the preoperative staging of endometrial carcinoma. METHODS: We included in this study 162 patients with a histological diagnosis of endometrial carcinoma who underwent MRI pelvic imaging and surgical staging. MRI images were compared with pathological findings to measure MRI's sensitivity, specificity, positive and negative predictive values and diagnostic accuracy in what concerns myometrial, cervical and lymph node invasion. RESULTS: MRI differentiation of deep myometrial invasion from superficial disease agreed with pathological findings in 77% of cases, with a sensitivity of 83%, a specificity of 72% and a diagnostic accuracy of 77%. Concerning cervical invasion, MRI had a sensitivity, specificity and diagnostic accuracy of 42%, 92%, 81% respectively. In assessing lymph node invasion, MRI presented a sensitivity of just 17%, a specificity of 99% and a diagnostic accuracy of 89%. CONCLUSION: Our study confirmed the high accuracy of MRI imaging in assessing myometrial and cervical invasion in endometrial carcinoma. When evaluating lymph node invasion, micrometastases are responsible for the low sensitivy of MRI.     

前哨淋巴结在妇科恶性肿瘤中的研究及应用

前哨淋巴结（sentinel lymph node,SLN）是原发恶性肿瘤淋巴转移的第一站,可以通过SLN中是否检测出肿瘤淋巴结转移,推测整个淋巴引流区域的肿瘤转移情况。目前有关SLN的研究已经应用到乳腺癌、黑色素瘤等恶性肿瘤的临床诊疗中。在妇科肿瘤方面,研究者最先在外阴癌中进行了SLN研究,之后在宫颈癌、子宫内膜癌中也相继开展了有关SLN检测及SLN活检（SLNB）的探索研究,并在临床上得到了一定的应用。本文结合相关文献,对国内外子宫内膜癌、宫颈癌、外阴癌和卵巢癌中SLN 的研究现状及目前尚待解决的问题进行简单总结。     

Validity of positron emission tomography using fluoro-2-deoxyglucose for the preoperative evaluation of endometrial cancer

To clarify the validity of positron emission tomography using fluoro-2-deoxyglucose (FDG-PET) for the preoperative evaluation of endometrial cancer, we analyzed the preoperative FDG-PET images of both primary and metastatic lesions of 30 patients with endometrial cancer, and compared them with computed tomography (CT) and/or magnetic resonance imaging (MRI) images and the results of postoperative pathologic findings. As to the primary lesions, FDG-PET could easily identify the cancer, and the sensitivity was 96.7%, which tended to be higher than that of 83.3% by CT/MRI. As to the evaluation of retroperitoneal lymph node metastasis, FDG-PET could detect none of five cases of lymph node metastatic lesions of up to 0.6 cm in diameter but had higher specificity (100%) compared with CT/MRI (85.7%). The sensitivity of FDG-PET for detection of extrauterine lesions excluding retroperitoneal lymph nodes was 83.3% and was superior to that of CT/MRI (66.7%), although there was no difference in the specificity between the modalities (100%). The diagnostic ability of FDG-PET was limited if used alone, but FDG-PET gave additional information especially with regard to the extrauterine lesions whose significance could not be determined on CT/MRI. However, we also found that FDG-PET could not identify any lymph node metastasis less than 1 cm in diameter; therefore, a negative finding of lymph node metastasis on FDG-PET should not be interpreted as a reason for omitting retroperitoneal lymph node dissection for the precise surgical staging of endometrial cancer.     

Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings

OBJECTIVE: In advanced cervical cancer, it has been reported that progression-free survival is significantly related to para-aortic lymph node metastasis. Computed tomography (CT) has been widely used for clinical staging, but its sensitivity for lymph nodal metastasis is low. Therefore, this prospective study was undertaken to evaluate (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting para-aortic lymph nodal metastasis in patients with locally advanced cervical carcinoma when CT findings were negative. METHODS: Fifty women with advanced cervical cancer confined to the pelvis with negative abdominal CT findings were included in this study. After 10 mCi of FDG was administered intravenously, the abdomens were scanned by PET. Para-aortic lymph node metastases were diagnosed as present or absent according to a standardized staging procedure. RESULTS: Retroperitoneal surgical exploration revealed 14 patients with para-aortic lymph nodal metastasis. Two patients had false-negative FDG-PET findings and the other two patients had false-positive FDG-PET findings. CONCLUSION: Overall, FDG-PET imaging had a sensitivity of 85.7%, a specificity of 94.4%, and an accuracy of 92%. When abdominal CT findings are negative, the use of FDG-PET can accurately detect para-aortic lymph nodal metastatis in patients with advanced cervical cancer.     

Diagnostic efficacy of the preoperative lymphoscintigraphy, Ga-67 scintigraphy and computed tomography for detection of lymph node metastasis in cases with ovarian or endometrial carcinoma

BACKGROUND: To investigate the diagnostic efficacy of preoperative lymphoscintigraphy (LS), Ga-67 scintigraphy (GS) and computed tomography (CT) for detection of lymph node metastasis in patients with endometrial or ovarian carcinoma. METHODS: The results of preoperative LS, GS and CT used to detect lymph node metastasis were compared to the postoperative histopathological results of lymph node dissection materials of a total of 37 patients, including 16 patients with endometrial and 21 patients with ovarian carcinomas. The diagnostic efficacy of these methods for detecting lymph node metastasis were calculated. RESULTS: When the results of all of the patients were taken into account, the preoperative LS, GS and CT were found to have sensitivities of 50%, 20% and 40% and specificities of 51.8%, 96.3%, and 92.6%, respectively, for detection of pelvic lymph node metastasis. The same methods had sensitivities of 27.3%, 27.3% and 72.7% and specificities of 88.5%, 88.5%, 84.6%, respectively, for detecting para-aortic lymph node metastasis in all patients. CONCLUSION: These data suggested that although LS, GS and CT had relatively high specificity, low sensitivity of these imaging methods precluded their routine preoperative use for diagnosis of lymph node metastasis of ovarian or endometrial carcinoma.     

Magnetic resonance imaging to identify risk of lymph node metastasis in patients with endometrial cancer

Objective

To assess the value of magnetic resonance imaging (MRI) to identify endometrial cancer patients at risk of lymph node metastasis.

Methods

Retrospective review of data from 108 patients with clinical stage I endometrial cancer who underwent preoperative MRI and were treated surgically. Patients at risk of lymph node metastasis were defined as those who had more than 50% myometrial infiltration or cervical invasion. Preoperative MRI reports were compared with final pathologic results.

Results

The mean age of the patients was 69.5 years and most patients had endometrioid cancer. On final pathologic analysis, 59 patients had deep myometrial infiltration or cervical invasion. For diagnosis of deep myometrial infiltration, cervical invasion, or both, MRI sensitivity and specificity were 56% and 85%; 47% and 83%; and 67% and 77%, respectively.

Conclusion

MRI has limited value in identifying patients with endometrial cancer who are at risk of lymph node metastasis. Minimally invasive laparoscopic lymph node staging should be undertaken when it is feasible.     

The diagnostic accuracy of magnetic resonance imaging in detecting cervical involvement in endometrial cancer

OBJECTIVES: The objective of this study was to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting cervical involvement by endometrial cancer. METHODS: A retrospective accuracy study of 135 consecutive women who underwent preoperative MRI and surgery for endometrial cancer at a single gynaecological cancer centre between 1st February 2003 and 30th November 2004. RESULTS: For the detection of any cervical involvement by MRI, the sensitivity was 72%, specificity 93.2%, positive predictive value (PPV) 89.8%, negative predictive value (NPV) 80.2%, positive likelihood ratio (+LR) 10.7 and negative likelihood ratio (-LR) 0.3. When cervical stromal invasion was considered alone, the sensitivity was 84.4%, specificity 87.4%, PPV 67.5%, NPV 94.7%, +LR 6.7 and -LR 0.18. CONCLUSION: We believe that MRI is able to accurately predict cervical involvement in endometrial cancer and allows a decision to be made on the type of hysterectomy to be offered.