盆腔淋巴结清扫术在Ⅰ期子宫内膜癌治疗中的价值

「目的」探讨了临床Ⅰ期子宫内膜癌盆腔淋巴结转移率及盆腔淋巴结清扫术的意义。「方法」对１０２例经盆腔淋巴结清扫术的临床Ⅰ期子宫内膜癌进行临床分期与手术－病理分期对照，分析病理类型、肿瘤细胞分级、肌层浸润深度与淋巴结转移的关系。「结果」临床Ⅰ期子宫内膜癌盆腔淋巴结转移率为１０．８％，其中Ⅰｂ期（２０．０％）高于Ⅰａ期（４．８％），内膜样腺癌、浆液性腺癌、腺鳞癌及透明细胞癌的淋巴结转移情况分别为８／８８     

系统淋巴结清扫术治疗子宫内膜癌的疗效分析

目的探讨系统淋巴结清扫术在子宫内膜癌治疗中的临床应用。方法回顾性分析2011年12月至2013年12月禹城市人民医院收治的80例子宫内膜癌患者的临床资料,根据手术范围的差异分为对照组和观察组,每组40例。对照组患者给予次广泛全子宫切除术、双附件切除术和盆腔淋巴结结清扫术,观察组患者手术类型在对照组基础上给予系统性盆腔、腹主动脉旁淋巴结清扫术。比较两组患者淋巴结清扫枚数、手术时间、术中出血量、并发症发生率、随访2年的生存率和复发率。结果观察组患者与对照组比较,淋巴结清扫数目明显增多,手术时间延长,差异有统计学意义(P<0.05)。观察组患者与对照组比较,术中出血量差异无统计学意义(P>0.05)。观察组与对照组比较,下肢水肿、淋巴囊肿、深静脉血栓、不全性肠梗阻和输尿管瘘发生率差异无统计学意义(P>0.05)。观察组与对照组比较,随访2年复发率较低、生存率较高,差异有统计学意义(P<0.05)。结论在次广泛全子宫切除术、双附件切除术基础上,加用系统性盆腔、腹主动脉旁淋巴结清扫术,可提高2年生存率,降低复发率。     

系统性淋巴结清扫在Ⅰ期子宫内膜癌治疗中的价值

目的:探讨系统性淋巴结清扫在Ⅰ期子宫内膜癌治疗中的价值.方法:对2006年1月-2013年1月在我院行系统的腹膜后淋巴结清扫术的286例Ⅰ期子宫内膜癌患者进行回顾性分析.结果:286例患者中31例出现淋巴结转移,转移率为10.8％,盆腔淋巴结转移率为8.7％,腹主动脉旁淋巴结转移率为4.9％,其中所有淋巴结转移的患者中19.4％的患者未经盆腔淋巴结而直接转移至腹主动脉旁淋巴结.组织学分化程度、病理类型、肌层浸润深度、淋巴血管间隙浸润与淋巴结转移情况相关(P＜0.05).21例患者因淋巴结转移而分期升级,术后需要辅助化疗和/或放疗.结论:全面的分期手术可以明确淋巴结转移情况,准确提供预后相关信息,指导术后辅助治疗.     

盆腔淋巴结清扫术在Ⅰ期子宫内膜癌治疗中的价值

:[目的]探讨临床Ⅰ期子宫内膜癌盆腔淋巴结转移率及盆腔淋巴结清扫术的意义。[方法]对102例经盆腔淋巴结清扫术的临床Ⅰ期子宫内膜癌进行临床分期与手术 病理分期对照 ,分析病理类型、肿瘤细胞分级、肌层浸润深度与淋巴结转移的关系。[结果]临床Ⅰ期子宫内膜癌盆腔淋巴结转移率为10 8% ,其中Ⅰb 期(20 0%)高于Ⅰa 期(4 8%) ,内膜样腺癌、浆液性腺癌、腺鳞癌及透明细胞癌的淋巴结转移情况分别为8/88、1/4、1/5、1/5,盆腔淋巴结转移还与肿瘤细胞分级及子宫肌层浸润深度相关(P<0 05)。[结论]Ⅰ期子宫内膜癌的临床分期与手术 病理分期有较大差异。盆腔淋巴结清扫术可明确分期 ,尤其对Ⅰa(G2、3)期、Ⅰb(G1、2、3)期及特殊病理类型(如浆液性腺癌、腺鳞癌、透明细胞癌)意义重大     

腹腔镜下腹主动脉旁淋巴结清扫术治疗子宫内膜癌的可行性分析

目的：探讨腹腔镜下行腹主动脉旁淋巴结清扫术应用于子宫内膜癌治疗的临床疗效,并分析其安全性。方法选取子宫内膜癌患者90例为研究对象,应用随机数字表法分为观察组与对照组,各45例,其中观察组患者行腹腔镜下腹主动脉旁淋巴结清扫术,对照组患者行传统开腹腹主动脉旁淋巴结清扫术,对比两组患者手术情况、术后恢复情况、术中或术后并发症发生情况,并进行随访。结果与对照组比较,观察组的腹主动脉旁淋巴结切除淋巴结数增多,出血量降低及术后并发症发生率降低,术后肛门排气时间及术后住院时间均缩短,腹主动脉旁淋巴结切除时间延长,差异有统计学意义（P﹤0.05）;与对照组比较,观察组患者术后淋巴囊肿、尿潴留、切口裂开、肺动脉栓塞、深静脉血栓及腔静脉损伤的发生率降低,差异有统计学意义（P﹤0.05）。结论腹腔镜下行腹主动脉旁淋巴结清扫术应用于子宫内膜癌的治疗疗效显著,值得临床推广应用。     

系统性淋巴结清扫术治疗子宫内膜癌的临床疗效及对性激素水平的影响

目的探讨系统性淋巴结清扫术治疗子宫内膜癌的临床疗效及对性激素水平的影响。方法选取2013年10月至2015年3月间收治的120例子宫内膜癌患者,依据手术范围的不同分为实验组和对照组,每组60例。实验组患者接受次广泛子宫全切+双附件切除+盆腔淋巴结清扫术+腹主动脉旁淋巴结清扫术,对照组患者接受次广泛子宫全切+双附件切除+盆腔淋巴结清扫术。比较两组患者下肢水肿、深静脉血栓、不全性肠梗阻发生率以及雌激素和孕激素水平。结果与对照组比较,实验组患者3年、5年生存率升高,复发率降低,差异有统计学意义(P<0.05)。与对照组患者相比较,实验组患者下肢水肿、深静脉血栓、不全性肠梗阻发生率均明显降低,差异有统计学意义(P<0.05)。与对照组比较,实验组患者术前雌激素和孕激素水平间差异无统计学意义(t=1.24,P>0.05;t=1.36,P>0.05);实验组患者术后3个月雌激素水平降低,孕激素水平升高,差异有统计学意义(t=3.56,P<0.05;t=3.11,P<0.05)。与术前相比,术后3个月对照组患者雌激素水平降低,孕激素水平升高,差异有统计学意义(t=3.03,P<0.05;t=2.58,P<0.05)。两组术后雌激素和孕激素水平间差异有统计学意义(t=3.25,P<0.05;t=3.15,P<0.05)。与对照组比较,实验组患者淋巴结清扫数增多、出血量减少、手术时间延长,组间差异有统计学意义(P<0.05)。结论采用系统性淋巴结清扫术治疗子宫内膜癌的临床疗效突出,可改善患者雌激素水平,较传统局部淋巴结清扫手术具有诸多优势,可作为一种理想方法应用于临床工作中。     

早期子宫内膜癌盆腔及腹主动脉旁淋巴结清扫术的作用

关于子宫内膜癌的手术范围和模式至今尚无统一的意见,尤其是对系统性盆腔及腹主动脉旁淋巴结清扫的必要性和清扫范围仍然存在较大争议。早期低危子宫内膜癌可以通过前哨淋巴结检测进行局部淋巴结选择性切除,从而降低手术风险。但在中-高危子宫内膜癌患者中,腹膜后淋巴结活检不能代替系统性盆腔及腹主动脉旁淋巴结清扫。腹主动脉旁淋巴结清扫术不会增加重大脏器损伤、二次手术及重度肠梗阻的风险。系统性盆腔及腹主动脉旁淋巴结清扫可以提高子宫内膜癌患者的生存率并改善预后。     

盆腔淋巴结清扫术对Ⅰ期子宫内膜癌的疗效研究

目的评价盆腔淋巴结清扫术对Ⅰ期子宫内膜癌的有效性及安全性。方法应用计算机检索PUBMED(1966～2009.11)、EMbase(1980～2009.11)、Cochrane图书馆(2009年第4期)、中国生物医学文献数据库(1978～2009.11)、维普中文科技期刊数据库(1989～2009.11)、中文期刊全文数据库(1994～2009.11)。对纳入文献进行质量评价后提取有效数据,采用RevMan5.0软件进行Meta分析。结果最终纳入2个随机对照试验,共1922例患者。Meta分析结果显示:标准手术组与淋巴结清扫组比较,5年总生存率[RR=88%,95%CI(0.70,1.11),P=0.27]和复发率[RR=81%,95%CI(0.62,1.06),P=0.13]差异均无统计学意义;标准手术组术后并发症发生率、输血率较淋巴结清扫组低,手术时间和住院时间较淋巴结清扫组短。结论Ⅰ期子宫内膜癌患者初次手术时,不推荐行系统性盆腔淋巴结清扫术。虽然纳入研究质量较高,但纳入文献数量较少,对Ⅰ期子宫内膜癌高危组尚需要进一步验证,从而为临床提供更为科学的依据。     

腹主动脉旁淋巴结清扫治疗早期子宫内膜癌的疗效评价

目的 探讨腹主动脉旁淋巴结清扫治疗早期子宫内膜癌的疗效及安全性.方法 选取早期子宫内膜癌患者62例作为研究对象进行回顾性分析.根据淋巴结清扫范围的不同将其分为A组(盆腔淋巴结清扫)及B组(盆腔淋巴结清扫+腹主动脉旁淋巴结清扫).比较2组患者手术情况、性激素水平、复发转移率及1年生存率、并发症发生情况.结果 B组患者手术时间长于A组,淋巴结清扫数量多于A组(P<0.05),但2组术中出血量及住院时间无统计学差异(P>0.05).2组手术前孕激素及雌激素水平均无统计学差异(P>0.05);手术后2组孕激素水平明显上升,雌激素水平明显下降,以B组变化幅度更为显著(P<0.05).A组患者复发转移率明显高于B组(P<0.05);B组患者1年生存率略高于A组,但组间差异不明显(P>0.05).A组患者并发症发生率低于B组,但差异不明显(P>0.05).结论腹主动脉旁淋巴结清扫有利于淋巴结全面清扫,可刺激性激素水平改善,能有效降低早期子宫内膜癌患者复发转移率,安全性尚可.     

前哨淋巴结定位在高级别子宫内膜癌手术中的价值

近年来,前哨淋巴结（sentinel lymph node, SLN）定位在妇科恶性肿瘤尤其是子宫内膜癌手术中广泛开展,与系统性的淋巴切除术相比,其能缩短手术时间、减少创伤及降低手术并发症发生率。然而,目前SLN主要应用于低级别子宫内膜癌,在高级别子宫内膜癌中的应用尚具争议。本文综述了SLN在高级别子宫内膜癌中的研究进展,以期对临床工作有参考和指导意义。     

Therapeutic role of systematic retroperitoneal lymphadenectomy in endometrial cancer

ObjectiveThe purpose of this study was to evaluate the therapeutic role of systematic retroperitoneal lymphadenectomy in patients with endometrial cancer.MethodsFrom December 2003 to December 2008, 349 eligible patients who underwent surgical staging procedures at primary treatment were retrospectively analyzed: systematic lymphadenectomy group (n = 246) and no-lymphadenectomy group (n = 103). Survival was analyzed using Kaplan-Meier method and Cox proportional hazards model.ResultsOverall, patients who underwent lymphadenectomy improved 5-year disease-free survival (89.0% versus 80.7%, P = 0.019) and overall survival (92.8% versus 81.5%, P = 0.001) compared to those who did not undergo lymphadenectomy. Overall survival was not related to lymphadenectomy in 212 low-risk patients (93.1% versus 84.6%, P = 0.176). However, this association was found in 137 patients with intermediate and high-risk (86.2% versus 73.3%, P = 0.021). Multivariate Cox regression analysis showed that FIGO stage (P = 0.037) and lymphadenectomy (P = 0.023) were independent prognostic factors for overall survival.ConclusionsSystematic retroperitoneal lymphadenectomy has a potentially therapeutic role on survival in surgically staged patients with endometrial cancer.     

Current treatment strategies for endometrial cancer

Treatment paradigms for endometrial cancer are rapidly evolving. New minimally invasive surgical techniques have helped to reduce the morbidity of women with early-stage tumors undergoing hysterectomy. A growing body of evidence has helped to stratify women with intermediate-risk endometrial cancer to optimize adjuvant therapy in this subset of patients. For women with high-risk and metastatic endometrial cancer there has been a renewed interest in incorporating chemotherapy into treatment paradigms. This review summarizes the latest advances in the treatment of endometrial cancer with a special focus on adjuvant therapy.     

子宫内膜癌的诊断和治疗

Approximately 6000 endometrial cancer death occurs annually worldwide, predominantly noticed in postmenopausal women. The current diagnostic and therapeutic research trials for endometrial carcinoma are giving new clues to select best postoperative adjuvant treatment especially in high risk disease. Transvaginal ultrasound and hysteroscopy endometrial biopsies are tending to replace the dilation and curettage in establishing a diagnosis. The standard primary treatment of endometrial carcinoma is surgery but to select best adjuvant therapy, the risk of disease recurrence is determined by certain pathological factors and also by surgical stage. The most commonly used adjuvant therapy is radiation therapy but satisfactory results have not been noticed in high-risk endometrial carcinoma. On the basis of review of current research guidelines it is indicated that hormonal or chemotherapeutic agents must be added with radiation therapy to improve prognosis and efficacy in endometrial carcinoma after surgery.     

Lymphadenectomy and adjuvant therapy in endometrial carcinoma: role of adjuvant chemotherapy

To evaluate the therapeutic benefit of lymphadenectomy and adjuvant therapy, in particular chemotherapy, we retrospectively analysed survival rates and patterns of recurrence of endometrioid adenocarcinoma in 106 patients who underwent surgery including retroperitoneal lymphadenectomy. Adjuvant chemotherapy was administered to 46 patients (42 received a platinum-based regimen) and pelvic irradiation to 12. The 5-year survival rate of 23 patients with lymph node metastasis was worse than that of patients without lymph node metastasis (60% vs 96%, P<0.0001). Recurrence was observed in 14 patients (10 patients with chemotherapy, two with irradiation, and two without adjuvant therapy); the first site of recurrence was in distant sites in 12 patients; recurrence in the pelvic sidewall or exclusively in lymph nodes was not observed. The 5-year survival rate of 18 patients with lymph node metastasis treated with chemotherapy, was 61% including all 14 with macroscopically positive nodes and all nine with paraaortic metastasis. Of seven patients with bulky positives nodes, three patients with bulky paraaortic nodes died of the disease, three of the four patients with bulky pelvic but without bulky paraaortic nodes had no recurrence. In summary, lymphadenectomy may afford a survival benefit via the debulking of macroscopically positive nodes, and the predominance of distant recurrences suggests that chemotherapy is a suitable choice as an adjuvant therapy in endometrial carcinoma after lymphadenectomy.     

淋巴结切除术对子宫内膜癌的临床意义

手术治疗是子宫内膜癌的主要治疗方式,通过手术治疗可以明确诊断、病理分级、临床分期,并为术后的辅助治疗提供充分的临床资料。对于子宫内膜癌患者是否常规进行淋巴结切除仍存在较大争议,特别是对于低危的子宫内膜癌患者而言,因为低危患者淋巴结转移发生率非常低,且不影响患者的预后,但目前没有全面的划分淋巴结转移危险因素及其危险程度的统一标准。本文就子宫内膜癌的淋巴结转移特点,影响淋巴结转移的因素,淋巴结切除的并发症,淋巴结切除术对预后的影响,淋巴结切除的临床意义及淋巴结切除的发展方向等方面加以综述,我们认为对于内膜癌患者应选择个体化的治疗方案,注重术前的全面评估,对于G3,透明细胞,浸润肌层≥1/2,病灶>2cm,宫颈受累等应进行包括腹主动脉旁淋巴结在内的系统淋巴结切除术。     

Clinical study investigating the role of lymphadenectomy, surgical castration and adjuvant hormonal treatment in endometrial stromal sarcoma

The objective of this study is to assess the therapeutic importance of surgical castration, adjuvant hormonal treatment and lymphadenectomy in endometrial stromal sarcoma (ESS). A retrospective and multicentric search was performed. Clinicopathologic data were retrieved from cases that were confirmed to be ESS after central pathology review. The protocol was approved by the Ethical Committee. ESS was confirmed histopathologically in 34 women, but follow-up data were available in only 31 women. Surgical treatment (n=31) included hysterectomy with or without bilateral salpingo-oophorectomy (BSO) in 23 out of 31 (74%) and 8 out of 31 (26%) cases, respectively. Debulking surgery was performed in 6 out of 31 cases (19%). Stage distribution was as follows: 22 stage I, 4 stage III and 5 stage IV. Women with stage I disease recurred in 4 out of 22 (18%) cases. Among stage I women undergoing hormonal treatment with or without BSO, 3 out of 15 (20%) and 1 out of 7 (14%) relapsed, respectively. Among stages III-IV women receiving adjuvant hormonal treatment or not, 1 out of 5 (20%) and 3 out of 4 (75%) relapsed, respectively (differences=55.0%, 95% CI=-6.8-81.2%). Kaplan-Meier curves show comparable recurrence rates for stage I disease without adjuvant hormonal treatment when compared to stages III-IV disease treated with surgery and adjuvant hormonal treatment. Furthermore, women taking hormones at diagnosis have a better outcome when compared to women not taking hormonal treatment. Three out of 31 (9%) patients had a systematic lymphadenectomy whereas 3 out of 31 (9%) had a lymph node sampling. In one case, obvious nodal disease was encountered at presentation. Isolated retroperitoneal recurrence occurred in 1 out of 31 (3%) of all cases and in 1 out of 8 (13%) recurrences. This single woman later also developed lung and abdominal metastases. Leaving lymph nodes in situ does not appear to alter the clinical outcome of ESS. Although numbers are low, the retrospective data suggest that the need for surgical castration (BSO) in premenopausal women with early-stage disease should be discussed with the patient on an individual basis. The data support the current practice in some centres to administer adjuvant hormonal treatment.     

Randomised study of systematic lymphadenectomy in patients with epithelial ovarian cancer macroscopically confined to the pelvis

No randomised trials have addressed the value of systematic aortic and pelvic lymphadenectomy (SL) in ovarian cancer macroscopically confined to the pelvis. This study was conducted to investigate the role of SL compared with lymph nodes sampling (CONTROL) in the management of early stage ovarian cancer. A total of 268 eligible patients with macroscopically intrapelvic ovarian carcinoma were randomised to SL (N=138) or CONTROL (N=130). The primary objective was to compare the proportion of patients with retroperitoneal nodal involvement between the two groups. Median operating time was longer and more patients required blood transfusions in the SL arm than the CONTROL arm (240 vs 150 min, P<0.001, and 36 vs 22%, P=0.012, respectively). More patients in the SL group had positive nodes at histologic examination than patients on CONTROL (9 vs 22%, P=0.007). Postoperative chemotherapy was delivered in 66% and 51% of patients with negative nodes on CONTROL and SL, respectively (P=0.03). At a median follow-up of 87.8 months, the adjusted risks for progression (hazard ratio [HR]=0.72, 95%CI=0.46-1.21, P=0.16) and death (HR=0.85, 95%CI=0.49-1.47, P=0.56) were lower, but not statistically significant, in the SL than the CONTROL arm. Five-year progression-free survival was 71.3 and 78.3% (difference=7.0%, 95% CI=-3.4-14.3%) and 5-year overall survival was 81.3 and 84.2% (difference=2.9%, 95% CI=-7.0-9.2%) respectively for CONTROL and SL. SL detects a higher proportion of patients with metastatic lymph nodes. This trial may have lacked power to exclude clinically important effects of SL on progression free and overall survival.     

Adjuvant radiotherapy for stage I endometrial cancer: systematic review and meta-analysis.

The role of adjuvant radiotherapy in stage I endometrial cancer following surgery remains unclear. The management for these patients varies widely, particularly in stage I patients with different risk factors. Using the methodology of Cochrane Collaboration, we did a systematic and meta-analysis of all know randomised controlled trials which compared adjuvant radiotherapy versus no radiotherapy following surgery for patients with stage I endometrial cancer. The meta-analysis was carried out on four trials (three published and one unpublished) and a total of 1770 patients. The addition of pelvic external beam radiotherapy to surgery reduced locoregional recurrence, a relative risk (RR) of 0.28 [95% confidence interval (CI) 0.17-0.44, P < 0.00001], which is a 72% reduction in the risk of pelvic relapse (95% CI 56% to 83%) and an absolute risk reduction of 6% (95% CI of 4% to 8%). The reduction in the risk of locoregional recurrence did not translate into a reduction in the risks of death from all causes, endometrial cancer death or distant recurrence. A subgroup analysis showed a trend towards the reduction in the risks of death from all causes and endometrial cancer in patients with multiple high risk factors (including stage 1c and grade 3). External beam pelvic radiotherapy should be considered in patients with multiple high-risk features including stage 1c and grade 3. However, it carries an inherent risk of damage and toxicity and should be avoided in stage 1 endometrial cancer patients with no high risk factors.