卵巢癌淋巴结切除适应证和争议

手术是治疗卵巢癌的主要手段及重要基石。初次手术的彻底性与预后密切相关。淋巴结转移是卵巢癌常见的转移方式,也是评价早晚期的重要指标。尽管淋巴结切除在卵巢癌手术中具有重要地位,但仍具有一些争议。文章就卵巢癌淋巴结切除的适应证及争议予以总结。     

Pelvic lymphadenectomy in operative treatment of ovarian cancer

From the end of 1979 to September, 1985, radical pelvic lymphadenectomy was performed at the Graz Clinic in 123 cases of Stages IA to IV ovarian cancer following maximum debulking procedure. In 97 patients lymphadenectomy was done primarily. In 26 it was performed during a follow-up operation to chemotherapy. The frequency of pelvic node involvement was 61.8% in the total material and 78.0% in 82 cases of Stage III disease only; 75.0% positive nodes were found in Stage III after chemotherapy. Aortic nodes were positive in 41.4%, but only when pelvic nodes were also positive. The 5-year actuarial survival rate for Stage III disease was 53.0% after pelvic lymphadenectomy compared with 13.0% without. In cases with negative nodes the survival rate was 74.7%; with positive nodes the survival rate was 45.9%.     

Role of lymphadenectomy in endometrioid endometrial cancer

OBJECTIVE: To assess the risk factors associated with node involvement. Study design: In the period 1990-2008 a total of 265 endometrial cancers were treated in the Institut Universitari Dexeus. We analysed the rate of myometrial invasion, tumour grade, histological type and node involvement. RESULTS: Overall, 86% of tumours were endometrioid, 5.3% papillary serous, 4.9% mixed and 2.6% endometrial stroma sarcoma. Among those with endometrioid histology, lymphadenectomy was not performed (NL) in 85 cases (37.2%), whereas pelvic lymphadenectomy (PL) or pelvic and aortic lymphadenectomy (PAL) was carried out in 84 (36.84%) and 59 patients (25.87%), respectively. In NL patients the overall disease-free survival (DFS) rate at five years was 92.8%. In the PL group, node involvement was observed in 2.4% of cases and the five-year DFS rate was 92.3%. Among PAL patients, 18.6% showed node involvement (72.7% positive pelvic nodes and 63.6% aortic). Aortic involvement was present in 5.9% of cases when there was no pelvic disease, whereas in the presence of positive pelvic nodes the rate of aortic involvement was 50%. The DFS rate at five years was 93.6%. Referring to the risk factors, when infiltration was > 50% of the myometrium, lymph node involvement occurred in 37% of cases and G3 tumors in 45.5%. Conclusions: Node involvement is more commonly observed in cases with > 50% myometrial invasion and G3, accounting for 25% of cases that can be considered as at-risk patients. When node involvement is present it is equally distributed between the pelvic and aortic levels. As node involvement is a predictive factor for distant metastasis, the 25% of patients considered to be at risk should undergo pelvic and aortic lymphadenectomy     

Association of lymphadenectomy and survival in stage I ovarian cancer patients

OBJECTIVE: To estimate the survival impact of lymphadenectomy in women diagnosed with clinical stage I ovarian cancer. METHODS: Demographic and clinicopathologic information were obtained from the Surveillance, Epidemiology and End Results Program between 1988 and 2001. Data were analyzed using Kaplan-Meier methods and Cox proportional hazards regression. RESULTS: A total of 6,686 women had clinical stage I ovarian cancer (median age 54 years, range 1-99). Of this total, 75.9% of patients were Caucasian, 8.3% were Hispanic, 5.8% were African American, and 7.3% were Asian. Epithelial tumors were present in 85.8% of the women, and 2,862 (42.8%) patients underwent lymphadenectomy. Patients aged 50 years or more were less likely to undergo lymphadenectomy compared with their younger cohorts (39.8% compared with 60.2%, P<.001). Only 32.7% of African-American women had lymphadenectomy compared with 42.7% of Caucasian women, 47.2% of Hispanics, and 48.8% of Asians (P<.001). Lymphadenectomy was associated with improved 5-year disease-specific survival of all patients from 87.0% to 92.6% (P<.001). More specifically, lymphadenectomy improved the survival in those with non-clear cell epithelial ovarian cancer (85.9% to 93.3%, P<.001) but not in those with clear cell carcinoma, germ cell tumors, sex cord stromal tumors, and sarcomas. Moreover, the extent of lymphadenectomy (0 nodes, less than 10 nodes, and 10 or more nodes) increased the survival rates from 87.0% to 91.9% to 93.8%, respectively (P<.001). On multivariable analysis, the extent of lymphadenectomy was a significant prognostic factor for improved survival, independently of other factors such as age, stage, histology, and grade of disease. CONCLUSION: Our data suggest that women with stage I non-clear cell ovarian cancers who underwent lymphadenectomy had a significant improvement in survival. LEVEL OF EVIDENCE: II.     

Role of hysterectomy and lymphadenectomy in the management of early-stage borderline ovarian tumors

Objective

To examine survival of women with stage T1 borderline ovarian tumors (BOTs) stratified by hysterectomy and lymphadenectomy status at surgery.

卵巢恶性肿瘤二次剖腹探查术中行腹膜后淋巴结清除术的研究

目的　探讨卵巢恶性肿瘤腹膜后淋巴结清除术的最佳时机和临床价值。方法　回顾性分析了 5 0例二次剖腹探查术 (SLL)中行腹膜后淋巴结清除术的卵巢恶性肿瘤患者的临床资料。结果　患者中位数年龄 49岁 ,其 3年和 5年生存率分别为 72 %和 62 %。SLL阳性率为 40 % ( 2 0 / 5 0 ) ,其中临床分期 [国际妇产科联盟 (FIGO)标准 ]Ⅰ期SLL阳性率为 0 % ( 0 / 15 ) ,Ⅱ期和Ⅲ期分别为 40 %( 4/ 10 )、62 % ( 15 / 2 4) ,Ⅳ期为 1例中 1例。SLL阳性率与临床分期的期别呈正相关 ,其中Ⅰ～Ⅱ期( 16% ,4/ 2 5 )和Ⅲ～Ⅳ期 ( 64 % ,16/ 2 5 )患者SLL阳性率比较 ,差异有极显著性 (P <0 0 1)。腹膜后淋巴结转移率为 3 2 % ( 16/ 5 0 ) ,其中Ⅰ、Ⅱ、Ⅲ期分别为 0 % ( 0 / 15 )、2 0 % ( 2 / 10 )、5 4% ( 13 / 2 4) ,Ⅳ期为 1例中1例。SLL阳性患者中 ,4例 ( 8% )仅盆腹腔内有转移灶 ,淋巴结无转移 ;6例 ( 12 % )仅显微镜下淋巴结转移 ,而无盆腹腔转移灶。SLL中 ,行二次肿瘤细胞减灭术共 2 0例 ,其中术后 13例残留灶直径≤ 0 5cm ,7例残留灶直径 >0 5cm。中位数随访时间 44个月 ( 2 4～ 10 4个月 ) ,至随访截止日SLL阴性者 ( 3 0例 )均无肿瘤复发。结论　腹膜后淋巴结清除术在SLL术中进行比较合理 ,而且对降低SLL阴性患     

晚期卵巢上皮性癌腹膜后淋巴结清的合理选择

目的 探讨腹膜后淋巴结清除术在晚期卵巢上皮性癌治疗中的合理应用。方法 对４２例晚期卵巢上皮性癌行腹膜后淋巴结清除术,根据术后钱留灶大小成分两组。Ａ组：２６例,残留癌灶直径２〈ｃｍ;Ｂ组：１６例,残留癌灶直径≥２ｃｍ。术后两组进行的联合化疗基本相同。临床分期和病理分级基本相同。结果 Ａ组５年生存率５３．８％（１４／２６）,Ｂ组５年生存率１２．５％（２／１６）,两组比较,差异有显著意义（Ｐ〈０．００１     

Role of chemotherapy in epithelial ovarian cancer

Despite the fact the standard-of-care primary chemotherapy strategy in epithelial ovarian cancer has undergone very limited changes over the past decade there have been important advances in treatment outcomes resulting from data generated in evidence-based trials that has modified the paradigm for second-line disease management. Recently reported data suggest novel classes of agents, including anti-angiogenic drugs and PARP inhibitors may add to the established utility of standard cytotoxic chemotherapy.     

Role of palliative surgery in ovarian cancer

The most common indication for palliative surgery in recurrent ovary cancer is malignant bowel obstruction. After careful diagnosis of bowel obstruction, conservative management should be employed. If resolution of obstruction does not occur, the decision to perform surgery must be made. Several authors have reported on outcomes in patients undergoing surgery. Operative morbidity and mortality is 7–64% and 4–32%, respectively, and median survival is 5–33 weeks in these reports. Surgery should be considered in select patients after a thorough discussion with the patient regarding the likely outcome following the procedure, including the potential for morbidity and mortality. The surgery should be aimed at relieving the symptoms and improving quality of life.     

卵巢上皮性癌的腹膜后淋巴结切除对预后的影响

目的　探讨卵巢上皮性癌患者腹膜后淋巴结切除对预后的影响。方法　回顾性分析13 1例卵巢上皮性癌患者的临床资料 ,应用COX风险比例回归模型判断影响预后的因素。结果　多因素分析显示 ,年龄、临床分期、残留灶、腹膜后淋巴结切除术及术后化学药物治疗 (化疗 ) ,是影响预后的重要因素。行和未行腹膜后淋巴结切除术患者的 5年生存率分别为 66%和 41% (P <0 0 1)。对于早期和Ⅲ、Ⅳ期肿瘤残留灶直径 >2cm或黏液性癌患者 ,腹膜后淋巴结切除术并不能提高生存率。Ⅲ、Ⅳ期肿瘤残留灶直径≤ 2cm ,行与未行腹膜后淋巴结切除术患者的 5年生存率分别为 65 %、3 0 %(P <0 0 1)。卵巢浆液性癌 ,行与未行腹膜后淋巴结切除术患者的 5年生存率分别为 61%、3 1% (P<0 0 1)。结论　年龄、临床分期、残留灶大小、腹膜后淋巴结切除与否及术后化疗的疗程数 ,与卵巢上皮性癌患者的预后有关。腹膜后淋巴结切除术虽能提高患者生存率 ,但对肿瘤残留灶直径 >2cm的Ⅲ、Ⅳ期卵巢上皮性癌患者 ,可不必行腹膜后淋巴结切除术