早期子宫内膜癌的治疗

子宫内膜癌是女性生殖道最常见的恶性肿瘤之一,严重威胁着妇女的生命健康.但子宫内膜癌亦是预后较好的女性肿瘤之一,早期病变占内膜癌的绝大部分,美国统计75%～80%的内膜癌为临床Ⅰ期,5年存活率可达80%～90%.对早期疾病的发现和治疗对于患者的生存和预后有着非常重要的意义.对于临床Ⅰ期内膜癌,现在标准治疗是先分期手术（全子宫、双附件切除,盆腔腹主动脉淋巴结清扫,腹水或腹腔冲洗液细胞学检查）,根据手术病理分期和高危因素确定治疗方案.据统计,临床Ⅰ期内膜癌约10%盆腔淋巴结转移,6%腹主动脉淋巴结转移,5%附件转移.对这些患者应按Ⅲ期方案处理.本文主要综述手术病理分期Ⅰ期内膜癌的处理.     

腹腔镜下广泛全子宫及淋巴结清扫术24例临床分析

目的探讨腹腔镜下广泛全子宫加盆腔淋巴结清除术治疗子宫内膜癌的可行性及疗效。方法对24例子宫内膜癌患者行腹腔镜下广泛全子宫及盆腔淋巴清扫术,其中1例同时行腹主动脉旁淋巴结切除术。结果所有病例均在腹腔镜下完成手术。手术时间为(164.35±43.02)min,术中出血(181.36±92.29)mL,淋巴结切除数(18.23±6.82)个,术中无脏器损伤发生(0/24),术中、术后并发症发生率16.67%(4/24)。结论腹腔镜手术治疗子宫内膜癌短期疗效好,创伤小,术后恢复快,远期疗效有待观察。     

不同入路腹主动脉旁淋巴结切除术治疗子宫内膜癌的临床效果及安全性研究

目的：探究不同入路腹主动脉旁淋巴结切除术治疗子宫内膜癌的临床效果及安全性。方法：回顾性分析2017年6月至2020年6月就诊的82例子宫内膜癌患者的临床资料，依据手术入路方法不同分为A组（经腹膜入路腹主动脉旁淋巴结切除术）和B组（经腹膜外入路腹主动脉旁淋巴结切除术）各41例。对比两组围术期指标、术后并发症发生率、预后情况。结果：A组术中出血量多于B组，手术时间、引流管拔除时间、住院时间均长于B组，腹主动脉旁淋巴结清扫数少于B组，差异有统计学意义（P＜0.05）。A组术后并发症发生率为21.95%，高于B组的4.88%，差异有统计学意义（P＜0.05）。A组盆腔淋巴结转移率为9.76%、无瘤生存率为85.37%、总生存率为90.24%，B组盆腔淋巴结转移率为4.88%、无瘤生存率为87.80%、总生存率为92.68%，但两组间对比，差异无统计学意义（P＞0.05）。结论：经腹膜入路与经腹膜外入路腹主动脉旁淋巴结切除术均可有效治疗子宫内膜癌，但后者在子宫内膜癌患者治疗中创伤较小，术中出血量少，引流管拔除时间及住院时间均较短，且淋巴结清扫数量多，可大大降低术后复发风险，并发症少，安全性更高。     

子宫内膜癌术中前哨淋巴结识别及病理检查的临床意义

目的 探讨子宫内膜癌术中前哨淋巴结(SLN)冰冻病理检查的临床意义.方法 选择行手术治疗的子宫内膜癌患者33例,均行全身静脉麻醉.开腹后,采用5 mL注射器将1％亚甲蓝多点注射于子宫体部浆膜层下,打开腹膜,暴露淋巴引流区域,寻找出最先蓝染的淋巴结即SLN,切取后送冰冻病理检查.此后行子宫、双侧附件、盆腔淋巴结及腹主动脉旁淋巴结清扫术.对20例术中病理检查未见转移的SLN患者,行免疫组化,观察SLN中细胞角蛋白(CK)的表达.结果 33例患者中成功识别摘除SLN 25例(75.8％),其中SLN位于单侧盆腔7例(28.0％),双侧盆腔均有SLN 16例(64.0％),腹主动脉旁2例(8.0％).共识别SLN 67枚,其中闭孔26枚(38.8％),髂内15枚(22.4％),髂外13枚(19.4％),髂总10枚(14.9％),腹主动脉旁3枚(4.5％).有5例(15.2％)患者术中冰冻病理检查证实盆腔内的SLN可见癌组织转移,术后盆腔内其他淋巴结亦可见癌组织转移.术中病理检查未见SLN转移的20例患者中,有1例低分化腺癌并临床Ⅱ期患者经免疫组化染色,1枚SLN内均可见CK阳性表达细胞团,判定为SLN微转移,但在淋巴结清扫中未见癌组织转移.结论 子宫内膜癌患者术中SLN的识别及病理检查对淋巴结清扫范围有指导意义.术后对SLN进行免疫组化染色可以避免假阴性结果.     

腹腔镜下子宫内膜癌手术的护理配合

[目的]总结腹腔镜下子宫内膜癌手术的护理配合措施。[方法]对72例早期子宫内膜癌病人采用腹腔镜技术行全子宫+双附件切除+盆腔淋巴结清扫+腹主动脉旁淋巴结清扫术,同时加强手术护理配合。[结果]72例病人手术顺利,未出现相关护理并发症。[结论]充分的术前护理评估及准备、术中巡回护士、器械护士的娴熟配合是手术成功的保证。     

吲哚菁绿激光荧光示踪手术导航系统应用于乳腺癌前哨淋巴结活检的护理配合

[目的]探讨吲哚菁绿激光荧光示踪手术导航系统应用于乳腺癌前哨淋巴结活检术(SLNB)的效果。[方法]配制吲哚菁绿为示踪剂,结合激光荧光示踪手术导航系统,探找前哨淋巴结。激光淋巴成像仪示踪的前哨淋巴结进行术中快速冰冻病理切片,确定前哨淋巴结有无转移,决定手术方式。[结果]2015年7月—2016年12月手术室行乳腺癌前哨淋巴结活检128例,前哨淋巴结显影率99.2%(127/128),前哨淋巴结检出率99.2%(127/128),腋窝淋巴结有转移11例,行腋窝淋巴结清扫术(ALND)11例。[结论]注射用吲哚菁绿激光荧光示踪手术导航系统能实时导航,精准定位,成为乳腺癌前哨淋巴结的新应用。     

腹腔镜下腹主动脉旁淋巴结清扫在子宫内膜癌治疗中可行性

目的探讨腹腔镜下腹主动脉旁淋巴结清扫治疗子宫内膜癌的可行性。方法 89例子宫内膜癌患者分为腹腔镜组50例和开腹组39例。比较2组围术期情况,术中、术后并发症及预后。结果 2组腹主动脉旁清扫淋巴结数无显著差异(P0.05);腹腔镜组出血量显著少于开腹组(P0.001);腹腔镜组术后病率8%,无切口裂开,开腹组术后病率25.6%,切口裂开4例,差异有统计学意义(P0.05);腹腔镜组术后肛门排气时间、术后住院时间均显著短于开腹组(P0.001);腹腔镜组清扫术时间显著长于开腹组(P0.001)。结论腹腔镜腹主动脉旁淋巴结清扫治疗子宫内膜癌安全、可行,优于传统开腹手术。     

吲哚菁绿荧光造影技术在恶性黑色素瘤前哨淋巴结活检中的应用探讨

目的前哨淋巴结活检(sentinel lymph node biopsy,SLNB)在皮肤恶性黑色素瘤中的作用已被广泛认可,但示踪目前没有一种方法能够广泛应用。本研究应用吲哚菁绿荧光示踪SLN,并探讨其临床优势。方法选择足部确诊恶性黑色色素瘤患者8例,在扩大切除足部病损后,将吲哚菁绿注射于创缘四周皮下,使用荧光照相机探测淋巴回流,测量注射节点至腹股沟区SLN显影时间。并将SLN与肿瘤同时送术中冰冻检查。如SLNB(+),则接受区域淋巴结清扫(complete lymph node dissection,CLND)。结果注射节点至腹股沟区SLN显影平均时间为(9. 3±2. 4)分钟。其中2例SLNB阳性,接受CLND; 6例SLNB阴性通过植皮或者皮瓣修复足部创面。结论吲哚菁绿荧光造影技术应用于恶性黑色素瘤前哨淋巴结活检中,显影时间快,定位准确。造影剂无辐射,价格经济,展示出良好的应用前景。     

子宫内膜癌患者临床病理资料特点与淋巴结转移的相关性分析

目的回顾性分析子宫内膜癌患者的临床病理资料,探讨临床病理资料特点与淋巴结转移的相关性。方法纳入2011年1月至2012年12月诊断为子宫内膜癌患者210例,回顾性分析患者临床病理资料,并针对患者的复查等情况进行后续随访,随访病例截止时间为2015年12月,了解患者的淋巴结转移情况。采用Logistic回归分析患者出现淋巴结转移的高危因素。结果 210例宫颈癌患者共22例出现淋巴结转移阳性,转移率10.48%。其中17例(77.27%)为盆腔淋巴结转移;2例(9.09%)为腹主动脉旁淋巴结转移;3例(13.64%)盆腔及腹主动脉旁淋巴结转移。根据患者临床病理资料进行单因素分析结果显示:病灶大小、分化程度、组织学分期、肌层浸润、CA125和脉管转移与淋巴结转移相关(P0.05),比较具有统计学意义;多因素Logisic回归分析:病灶大小、组织学分期、肌层浸润和CA125为患者出现淋巴结转移的高危因素。结论子宫内膜癌发生淋巴结转移部位主要为盆腔淋巴结。子宫内膜癌病灶≥2、组织学分期为G3、CA125升高是淋巴结转移的高危因素,临床上应予以重视。     

子宫内膜癌患者临床病理资料特点与淋巴结转移的相关性分析

目的 探讨子宫内膜癌患者临床病理资料特点与淋巴结转移的相关性。方法 选择2011年1月至2012年12月诊断为子宫内膜癌的患者210例,回顾性分析其临床病理资料,并针对患者的复查等情况进行后续随访,随访病例截止时间为2014年12月,了解患者的淋巴结转移情况,采用χ2检验及Logistic回归分析患者出现淋巴结转移的高危因素。结果 1210例宫颈癌患者共22例出现淋巴结转移阳性,转移率为10.48%,其中盆腔淋巴结转移17例(77.27%),腹主动脉旁淋巴结转移2例(9.09%),盆腔及腹主动脉旁淋巴结转移3例(13.64%);2根据患者临床病理资料进行单因素分析结果显示:病灶大小、分化程度、组织学分期、肌层浸润、CA125和脉管转移与淋巴结转移相关,差异有统计学意义(P0.05);3多因素Logistic回归分析显示:病灶大小、组织学分期、肌层浸润和CA125为患者出现淋巴结转移的高危因素。结论 子宫内膜癌发生淋巴结转移部位主要为盆腔淋巴结。子宫内膜癌病灶≥2 cm、组织学分期为G3、CA125升高是淋巴结转移的高危因素,临床上应予以重视。     

腹腔镜与开腹手术治疗早期子宫内膜癌临床疗效分析

目的比较腹腔镜与开腹手术治疗早期子宫内膜癌的临床价值。方法回顾性分析我院2011年6月～2012年8月74例早期子宫内膜癌病例,其中腹腔镜组24例,开腹手术组50例,对比分析两组临床效果。结果两组中年龄、绝经情况、体重指数、FIGO分期、清扫淋巴结数、术后体温、术后排气时间、留置尿管时间、术后并发症方面无统计学差异;手术时间、术中出血、抗生素使用时间、术后住院时间方面有统计学差异。结论腹腔镜治疗早期子宫内膜癌疗效肯定,安全可行,优势在于出血量少、住院时间短、使用抗生素时间短。随着患者对生活质量要求的提高、经济发展对医疗卫生投入的增多、器械设备的改进,腹腔镜手术有望替代开腹手术,成为所有早期子宫内膜癌患者的手术方式。     

Local treatment of gynaecological cancer featuring surgical staging,lymphadenectomy and LAVH (Laparoscopic Assisted Vaginal Hysterectomy) in stage I endometrial cancer

The role of surgery in the treatment of patients with invasive cervical cancer is undisputed, but how radical the surgery should be is discussed. Every case requires detailed knowledge of the development and spread of cervical cancer. Tumour volume is the most important diagnostic factor in cervical cancer and also correlates with vascular invasion and lymph node involvement. In cervical cancer radical hysterectomy also requires an easily performable lymphadenectomy together with resection of parametria and skeletonization of ureters. In order to do this we have started to treat endometrial cancer in a combined laparoscopic and vaginal approach. In patients with the suspicion of stage I endometrial cancer prior to the laparoscopic staging, the prerequisites histological grading with ploidy and measurement of monoclonal antibodies were performed. All patients underwent a general check with radiography, computer tomography, liver scan, bone scan and lymphography. The performance of lymphadenectomy in cases of stage I endometrial cancer remains a controversial subject [1, 2]. We believe that laparoscopic assisted surgical staging of stage I endometrial cancer is an attractive alternative to the traditional laparotomy-surgical approach. The change from laparotomy to the laparoscopic assisted vaginal approach results in a similar success rate with the less invasive approach. No complications occurred in this series and the results of our pilot study were satisfactory.     

The clinical experience of robot-assisted surgery in gynecologic cancer

The comparison of robotic and conventional laparoscopic hysterectomy and pelvic lymphadenectomy in gynecologic cancer still needs to be studied. In all, 98 consecutive cases of patients with gynecologic cancer undergoing robot-assisted hysterectomy and pelvic lymphadenectomy, and another 98 consecutive cases of conventional laparoscopic hysterectomy and pelvic lymphadenectomy during the same period in the Obstetrics and Gynecology Hospital of Fudan University were included. The duration of the operation, blood loss, drainage during the first 24?h after the operation, total hospital stay, hospital stay after the operation, lymph nodes collected, perioperative complications, and the cost of each operation for both procedures were recorded. The duration of the operation was longer, and the cost of each operation was almost seven times higher in the robot group than that in the conventional laparoscopy group. But the differences with regard to blood loss, drainage during the first 24?h after the operation, total hospital stay, hospital stay after operation, the lymph nodes collected, and the rate of perioperative complications were not statistically significant. Robot-assisted surgery (RAS) in gynecologic cancer is as feasible as conventional laparoscopic surgery. We recommend further studies about the cost and effect of RAS in gynecologic cancer.     

Precision laparoscopic sentinel node navigation surgery for femoral skin cancer

Navigation surgery using indocyanine green (ICG) fluorescence imaging has been used in thoracoabdominal surgery, and its usefulness has been reported in many cases. In this study, laparoscopic lateral lymph node dissection was performed using ICG fluorescence imaging in a patient with left femoral spinous cell carcinoma with inguinal and external iliac lymph node metastases. Spinous cell carcinoma is classified as a rare cancer in Japan, and there is a scarcity of evidence for pelvic lymph node dissection, as well as a lack of studies that mention the dissection area. We hypothesized that visualization of lymph nodes and lymph flow using intraoperative ICG fluorescence imaging would indicate the area of dissection and lead to more efficient dissection. In conclusion, intraoperative ICG fluorescence imaging may be useful in this area where there is limited evidence, although there are some limitations.     

Ⅲ期子宫内膜癌预后的多因素分析

目的探讨Ⅲ期子宫内膜癌的治疗方法等多种因素与生存时间的关系 ,为临床处理提供更合适的方案。方法采用COX模型回归分析 2 4例Ⅲ期子宫内膜癌的治疗方法、淋巴结转移、病理学特征、年龄、肌浸深度及宫腔深度 6个预后因素对生存时间的影响。结果治疗方法与淋巴结转移对生存率影响最大 ,肌浸深度与宫腔大小对生存率影响最小 ,年龄与生存率呈负相关。结论Ⅲ期子宫内膜癌的治疗方式以综合放疗加广泛子宫切除加盆腔淋巴结清扫术为优 ;年轻患者辅以化疗或激素治疗能否防止远处转移及提高生存率有待研究。     

Serum CA 125 levels and lymph node metastasis in patients with endometrial cancer

The aim of this study was to evaluate the correlation of preoperative serum CA 125 levels and lymph node metastasis in patients with endometrial cancer. Preoperative levels of serum CA 125 were determined in 64 patients with endometrial cancer treated with total abdominal hysterectomy with a lymph node dissection as initial therapy. Lymph node status, determined by histopathology, was correlated with both normal and elevated CA 125 levels, determined preoperatively. A serum CA 125 level of >30 IU/ml was considered elevated. There were five patients (7.8%) with pelvic or paraaortic lymph node metastases and 59 patients (92.2%) without nodal metastases. In all five patients with lymph node metastases, serum CA 125 was within normal limits. Preoperative serum CA 125 levels were above normal in eight lymph node-negative patients. In the remaining group of 51 node-negative patients, serum CA 125 levels were within normal limits. Among the five lymph node-positive patients, four had endometrioid and one had serous papillary cancer. One patient had histologic grade 2 tumor and four patients had histologic grade 3. Preoperative serum CA 125 levels do not offer any information for predicting lymph node metastasis in patients with endometrial cancer.     

腹腔镜手术和开腹手术治疗妇科恶性肿瘤的并发症分析

目的探讨妇科恶性肿瘤腹腔镜手术及开腹手术的并发症。方法回顾性分析妇科恶性肿瘤腹腔镜手术89例及开腹手术100例的临床资料及并发症发生情况。结果腹腔镜手术及开腹手术并发症发生率分别为16.8%和18.0%,差异无显著性;腹腔镜组并发症主要有血管损伤、膀胱损伤及术后膀胱功能障碍,开腹组并发症主要有术中出血和术后膀胱功能障碍及腹壁切口感染;开腹组术中出血及腹壁切口感染发生率明显高于腹腔镜组(P<0.05);腹腔镜组的术后发热、膀胱功能障碍、输尿管狭窄的发生率高于开腹组,但差异无显著性(P>0.05)。结论腹腔镜下妇科恶性肿瘤手术并未增加手术相关并发症的发生,具有临床应用价值。     

Status of surgery in therapy of cervix cancer

Between 1969 and 1980 296 patients with cervical cancer were treated by surgery in our department and some were given postoperative irradiation. The five-year survival rate was 96.2% in stage I a cases and 85.2% in stage Ib. The surgically obtained specimens were evaluated for tumour extension and lymph node spread. These parameters were examined for their prognostic value. The tumour size correlated with the five-year survival rate. Lymph node spread was found in 1% of stage Ib cases. Intraoperative complications were seen in 2.4% of patients. Postoperative complications appeared in 44%. Late complications were found in 19.1%. Diagnostic conisation is of predominant value for the adequate surgical management of cervical cancer stage Ia and borderline stage Ib cases. Our own results and comparable data of other authors allow the following guidelines to be laid down for the operative treatment of early invasive cervical cancer: In stage I a: When the tumour volume is less than 1 mm3 (early stromal invasion according to Lohe) simple hysterectomy (in special cases possible only conisation) is sufficient. Microcarcinoma (tumour size less than 10 X 10 X 5 mm) is best treated by the conventional Wertheim operation. When tumour invasion of blood or lymph vessels is diagnosed, additional lymphadenectomy must be performed. In stage Ib-IIa: Radical operation according to the Latzko technique is advisable.     

The role of operative laparoscopy in gynecologic oncology

The potential applications of operative laparoscopy have expanded with improvements in technology and instrumentation. With newly developed techniques to complete both pelvic and paraaortic lymph node dissection, the use of the laparoscope has increased in patients with pelvic malignancies. Gynecologic oncologists are currently incorporating the techniques of operative laparoscopy in the management of patients with cervical, endometrial, and ovarian cancer. Multicenter prospective clinical trials are necessary to further define the role of laparoscopy in gynecologic oncology.     

Renaissance of vaginal hysterectomy for cervical carcinoma. 100th anniversary of the first abdominal radical surgery of cervical carcinoma by Ernst Wertheim on November 16, 1898

In the 100 year long history of the abdominal radical operation of collum carcinoma, due to the continued clinical surgical and scientific work of several generations of physicians, abdominal radical operation with standardized pelvic lymphonodectomy has become the method of choice for surgical treatment of collum carcinoma since 1970. Vaginal radical operation in its various forms has since played only a very restricted role in surgical treatment of collum carcinoma. According to the opinion of the majority of cancer surgeons vaginal radical operation had to be abandoned in view of discontinuous spreading of carcinoma into the regional pelvic lymph nodes. Because of its simplicity vaginal radical operation would still be useful today for very old high-risk patients and very young women with early invasive collum carcinoma detected in cancer screening. In view of our knowledge of the lymph node problem in collum carcinoma, however, this can no longer be the vaginal radical operation of past generations. In order to prevent critical objections to vaginal radical operation, the early attempts of Stoeckel, Suboth Mitra, Bastiaanse, Navratil, Inguilla, and Akashi were resumed. Since 1989 attempts have been made to combine vaginal radical operation of collum carcinoma with laparoscopic pelvic or para-aortic lymphonodectomy. The development has passed the following stages: the development of laparoscopic pelvic and para-aortic lymphonodectomy based on staging criteria the combination of laparoscopic lymphonodectomy with vaginal radical operation of collum carcinoma the combination of laparoscopic lymphonodectomy with complete laparoscopic radical hysterectomy and only subsequent vaginal removal of organs.