系统的淋巴结清扫术在子宫内膜癌治疗决策中的价值及可行性分析

背景与目的：淋巴结清扫术在子宫内膜癌治疗中的价值一直有争议,国内多数医院仅对部分高危型子宫内膜癌患者行淋巴结活检或选择性盆腔淋巴结切除术,罕有妇科医生对子宫内膜癌行系统的盆腔淋巴结清扫＋腹主动脉旁淋巴结清扫。本文探讨系统的淋巴结清扫术在子宫内膜痛治疗决策中的价值以及手术的可行性。方法：回顾2005年1月-2008年7月在我院行系统的腹膜后淋巴结清扫术的128例子宫内膜癌,对其临床病理特点、淋巴结转移情况、术后治疗决策改变情况以及手术并发症进行分析。结果：128例患者中19例（14．8％）出现淋巴结转移,其中盆腔淋巴结转移15例（11．7％）,腹主动脉旁淋巴结转移11例（8．6％）,7例患者同时出现盆腔及腹主动脉旁淋巴结转移,4例患者仅有腹主动脉旁淋巴结转移。病理类型、组织学分化程度、肌层浸润深度以及淋巴血管间隙浸润与淋巴结转移相关（P〈0．05）。15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;另50例中危、中高危早期患者因手术排除了子宫外转移免去术后辅助治疗。8例（6．3％）患者术后出现并发症,其中盆腔感染3例,阴道残端出血2例,不全性低位肠梗阻、深静脉血栓伴淋巴囊肿和腔隙性脑梗塞各1例。中位手术时间为150min．中位出血量为300mL,其中27例（21．1％）患者接受输血治疗。结论：在子宫内膜癌患者中行系统的淋巴结清扫足安全可行的,通过全面的手术分期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。     

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。     

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.     

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。     

腹腔镜下子宫全切术联合盆腔淋巴结清扫术治疗早期子宫恶性肿瘤的疗效分析

目的 探讨在早期子宫恶性肿瘤患者中应用腹腔镜下子宫全切术联合盆腔淋巴结清扫术治疗的临床效果.方法 入组90例早期子宫恶性肿瘤患者作为研究对象,根据治疗方案进行分组,对照组42例患者应用传统开腹手术进行子宫全切术联合盆腔淋巴结清扫术治疗,观察组48例患者应用腹腔镜下子宫全切术联合盆腔淋巴结清扫术治疗,比较2组患者术中情况和术后治疗效果.结果 观察组患者术中出血量低于对照组,手术时间、术后肛门排气时间和住院时间均较对照组短,差异均有统计学意义(P均<0.05);观察组切除的淋巴结个数明显多于对照组,差异有统计学意义(P<0.05);观察组并发症总发生率明显低于对照组,差异有统计学意义(P<0.05).结论 在早期子宫恶性肿瘤患者中应用腹腔镜下子宫全切术联合盆腔淋巴结清扫术治疗,手术效果良好,术后恢复快、安全性高,值得临床推广.     

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。     

子宫广泛性切除术及盆腔淋巴结清扫术的改进

作者介绍一种在子宫广泛切除术中改进的分离输尿管的方法：即在分离膀胱阴道间隙，暴露膀胱宫颈浅层韧带后，将该韧带内半束先行切断，再沿阔韧带后叶自上而下分离输尿管直至入膀胱。２２例患者术中采用该法，左、右侧输尿管完全分离的平均时间分别为１９．７分、２０．２分。同时，作者还总结了其所在医院各级医生采用“撕剥式盆清术”治疗１０９例宫颈癌的结果。盆腔清扫的平均时间：在侧１１．２分，右侧１２．１分。术后并发症：     

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.     

Postchemotherapy retroperitoneal lymph node dissection for testis cancer

The treatment of patients with metastatic testicular cancer is multimodal. Postchemotherapy retroperitoneal lymph node dissection is a technically demanding procedure that can benefit appropriately selected patients. In this article, we review postchemotherapy retroperitoneal lymph node dissection, including indications, technical updates, and the management and outcomes of patients who undergo surgery. Many aspects continue to evolve, and we review the evidence regarding current controversies in the field.     

Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer: A systematic review and meta-analysis

BackgroundThe Z0011-study, a landmark randomised controlled trial (RCT) challenged the benefits of complete axillary lymph node dissection (ALND) compared with sentinel lymph node dissection only (SLND) in breast cancer patients with positive sentinel nodes. The study, however, has been criticised for lack of power and low applicability. The aim of this review was to systematically assess the evidence on the comparative benefits and harms of ALND versus SLND for sentinel node positive breast cancer patients.MethodsWe systematically searched PubMed, Embase, the Cochrane Library, and reference lists of pertinent review articles from January 2006 to August 2011. We dually reviewed the literature and rated the risk of bias of each study. For effectiveness, we included RCTs and observational studies of at least 1 year follow-up. In addition, we considered studies conducted in sentinel node-negative women to assess the risk of harms. If data were sufficient, we conducted random effects meta-analysis of outcomes of interest.ResultsMeta-analysis of three studies with 50,120 patients indicated similar 5-year survival and regional recurrence rates between patients treated with ALND or SLND, although prognostic tumour characteristics varied among the 3 study-populations. Results from 6 studies on more than 11,500 patients reported a higher risk for harms for ALND than SLND. Long-term evidence on pertinent health outcomes is missing.ConclusionThe available evidence indicates that for some women with early invasive breast cancer SLND appears to be a justifiable alternative to ALND. Surgeons need to discuss advantages and disadvantages of both approaches with their patients.     

保留乳房手术联合腔镜腋窝淋巴结清扫术治疗早期乳腺癌的疗效分析

目的探讨保留乳房手术联合腔镜腋窝淋巴结清扫术(简称腔镜保乳术)治疗早期乳腺癌的疗效。 方法纳入2009年7月至2011年7月在新疆克拉玛依市中心医院普通外科就诊的60例早期乳腺癌患者进行前瞻性分析。根据患者意愿分配入腔镜保乳术组(16例),传统保留乳房手术组(20例),改良根治术组(24例)。采用χ²检验和Fisher确切概率法比较术后1年、3年、5年时3组患者在患肢活动功能障碍、患肢淋巴水肿、切口瘢痕、患肢疼痛、患肢感觉异常、局部复发、远处转移、病死率及乳房美容效果等方面的差异。 结果腔镜保乳术组5年局部复发率和病死率均为1/16,传统保留乳房手术组(简称保乳术组)5年局部复发率和病死率均为5.0%(1/20),改良根治术组5年局部复发率和病死率均为4.2%(1/24),3组的5年局部复发率及病死率差异无统计学意义(P＝1.000)。术后1年3组患者切口瘢痕形成率分别为0、60.0%(12/20)、100%(24/24)( χ²＝40.000,P<0.001),患肢感觉异常发生率分别为1/16、30.0%(6/20)、50.0%(12/24) (χ²＝8.530,P＝0.014),组间差异均有统计学意义。术后3年时3组患者患肢活动功能障碍的发生率分别为0、0、29.2%(7/24)(P＝0.002),切口瘢痕的发生率分别为0、50.0%(10/20)、91.7%(22/24)(χ²＝32.545,P<0.001),患肢感觉异常的发生率分别为0、10.0%(2/20)、33.3%(8/24) (P＝0.011),差异均有统计学意义。术后5年时3组患者患肢活动功能障碍发生率分别为0、0、25.0%(6/24) (P＝0.007),切口瘢痕的发生率分别为0、45.0%(9/20)、83.3%(20/24)(χ²＝27.609,P<0.001),患肢感觉异常的发生率分别为0、10.0%(2/20)、33.3%(8/24) (P＝0.011),差异均有统计学意义。在术后1年、3年和5年时,腔镜保乳术组的切口瘢痕形成少于保乳术组(P<0.001、0.001、0.002)和改良根治术组(P均<0.001),其余并发症发生率与保乳术组差异无统计学意义,但是在患肢感觉异常方面明显优于改良根治术组(P＝0.005、0.013、0.013)。3组患者在术后1年、3年和5年的并发症发生率差异均有统计学意义(χ²＝32.237、31.917、16.481,P均<0.001),腔镜保乳术组在术后1年和3年时明显少于保乳术组(Bonferroni校正P＝0.001、0.009)。术后5年腔镜保乳术组与保乳术组在乳房美容效果方面差异无统计学意义(P ＝0.715)。 结论保留乳房手术联合腔镜腋窝淋巴结清扫术不增加乳腺癌患者的复发、转移率,同时具有手术创伤小、并发症少和瘢痕不明显等优势。     

Extended lymph node dissection in gastrointestinal cancer

We reviewed the literature concerning the effect of extended lymph node dissection on survival in patients with gastrointestinal cancer. Most retrospective and/or prospective nonrandomized comparative studies have claimed that extended lymph node dissection significantly improves survival rate in patients with esophageal cancer, gastric cancer, and colorectal cancer. However, it is difficult to interpret these results since specialized care provided in trials may itself improve survival. In gastric cancer, several prospective randomized trials have failed to demonstrate a survival advantage of extended dissection, while there are few well-done prospective randomized trials in esophageal or colorectal cancer. Therefore, the therapeutic value of extended lymph node dissection remains to be determined in gastrointestinal cancer. Randomized prospective studies within the bounds of the ethical treatment of patients can and should be done. J. Surg. Oncol. 1997;65:57-65. © 1997 Wiley-Liss, Inc.     

Retroperitoneal lymph node dissection in testicular cancer

With long-term survival in excess of 90% across all stages, testicular cancer has come to represent the model for successful multidisciplinary cancer care. Retroperitoneal lymph node dissection (RPLND) remains an integral component of testis cancer management strategies for both early- and advanced-stage disease. Commensurate with improvements made in clinical staging and in our understanding of the natural history of testis cancer, lymphatic spread, and neuroanatomy, considerable modifications in the technique and template of RPLND have taken place. The morbidity of primary RPLND and postchemotherapy RPLND is low when performed by experienced surgeons. This article reviews the evolution, role, and technique of RPLND in contemporary practice.     

Sentinel lymph node identification in endometrial cancer

OBJECTIVE To evaluate the feasibility of intra-operative detection of sentinel lymph nodes （SLN） in the patient with endometrial cancer （EC）.
METHODS Thirty-one patients with Stage Ⅰ and Ⅱ endometrial cancer, who underwent a hysterectomy and a lymphadenectomy, were enrolled in the study. At laparotomy, methylene blue dye tracer was injected into the subserosal myometrium of corpus uteri at multiple sites, and dye uptake into the lymphatic channels was observed. The blue nodes which were identified as SLNs were traced and excised. The other nodes were then removed. All of the excised nodes were submitted for pathological hematoxylin and eosin （H＆E） staining examination.
RESULTS Failure of dye uptake occurred in 4 of the 31 cases （12.9%） because of spillage, and no lymphatic coloration was observed there. Lymphatic staining was clearly observable as blue dye diffused to the lymphatic channels of the uterine surface and the infundibulopelvic ligaments in 27 （87.1%） cases. Concurrent coloration in the pelvic lymphatic vessels was also observed in 22 of the 27 patients. The SLNs were identified in 23 of the 27 （85.2%） cases with a lymphatic staining, with a total number of 90 SLNs, and a mean of 3.9 in each case （range, 1-10）. Besides one SLN （1.1%） in the para-aortic area, the other 89 （98.9%） were in the nodes of the pelvis. The most dense locations of SLNs included obturator in 38 （42.2%） and interiliac in 19 （21.1%） cases. In our group, pelvic lymphadenectomy was conducted in 27 （87.1%） patients and pelvic nodal sampling in 4 （12.9%）. Of the 31 cases, a concurrent abdominal para-aortic lymph node sampling was conducted in 7. A total of 926 nodes were harvested, with an average of 39.8 in each case （range, 14-55）. Nodal metastases occurred in 3 patients （9.7%）, 2 of them with SLN involvement and the other without SLN involvement. Adverse reactions or injury related to the study was not found.
CONCLUSION Application of methylene blue dye is feasible in an intra-operative SLN identification of endometrial cancer. The technology is convenient, safe, and worth further investigation.     

Sequelae following axillary lymph node dissection for breast cancer

Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.     

Sequelae following axillary lymph node dissection for breast cancer

Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.