宫颈癌淋巴结切除适应证和争议

NCCN和FIGO指南对淋巴结切除适应证做出推荐,但就宫颈癌淋巴结切除仍存在争议点。对于局部晚期宫颈癌行手术分期是安全可行的。前哨淋巴结切除术目前尚不能替代系统性淋巴结切除术。对于ⅠA2~ⅡA2期宫颈癌,建议行腹主动脉旁淋巴结取样术,上界达肠系膜下动脉水平足够。有转移肿大的淋巴结建议手术切除。     

腹膜后淋巴结切除在子宫恶性肿瘤初始治疗中的临床意义

1895年,法国的EmilRies阐述了系统淋巴清扫的理论基础,2年后又详细描述了淋巴清扫的手术方式,被认为是当代淋巴清扫术之父[1]。自1988年国际妇产科联盟(FI-GO)手术病理分期在子宫内膜癌中的全面应用后,腹膜后淋巴结切除术逐渐在世界范围内广泛应用,20世纪50年代我国开展宫颈癌根治术。近年来对腹膜后淋巴结切除术的实施及其临床病历资料的积累,腹膜后淋巴结切除已经     

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。     

子宫内膜癌腹膜后淋巴结切除的现状与争议

子宫内膜癌以手术治疗为主,腹膜后淋巴结切除是其全面分期手术不可或缺的内容之一。淋巴结转移与否不仅是子宫内膜癌手术病理分期的重要依据,也是指导术后辅助治疗和判断患者预后的重要参考。目前关于腹膜后淋巴结,尤其是腹主动脉旁淋巴结的切除是否作为子宫内膜癌手术治疗的常规内容,国内外各规范指南及临床实践中都有较大争议。本文就子宫内膜癌腹膜后淋巴结切除的现状与争议进行文献综述,以期为临床实践提供参考和指引。     

扩大性宫旁切除术在宫颈癌治疗中的应用

宫颈癌是最常见的妇科恶性肿瘤之一,根治性子宫切除术与常规淋巴结清扫是手术治疗宫颈癌的标准术式,但宫颈癌患者生存率在近数十年中仍未得到显著提高,局部复发是目前影响宫颈癌伴淋巴结转移患者生存率的原因,有证据表明提高患者的局部控制情况就能改善生存率,扩大性子宫旁组织切除术(laterally extended parametrectomy,LEP)可更大范围切除盆腔侧壁淋巴组织,是临床上扩大性子宫切除治疗宫颈癌的一种有效术式。现综述LEP在宫颈癌治疗应用中的理论、疗效、争议、展望,以期为宫颈癌治疗提供另一种手术方式。     

同位素标记白蛋白和异硫蓝染料联合注射用于术中识别早期宫颈癌前哨淋巴结[英]／Mallinez-Palones JM…／／Gynecol Oncol

广泛性子宫切除及盆腔淋巴结清扫术是治疗早期宫颈癌的标准术式，但发生盆腔淋巴结转移的患者约10％～15％，说明盆腔淋巴结清扫不仅对大部分患者无益，反而有并发淋巴囊肿、淋巴水肿等风险。前哨淋巴结是指最早接受肿瘤淋巴引流的淋巴结，也是最早发生转移的淋巴结，前哨淋巴结组织学检查阴性预示其他淋巴结无转移。因此检测前哨淋巴结的转移状况可避免对患者实施过度治疗。     

宫颈癌腹主动脉旁淋巴结清扫争议问题

腹主动脉旁淋巴结(PALN)转移是影响宫颈癌患者预后的重要因素。美国国立综合癌症网络(NCCN)2015年宫颈癌治疗指南中提及部分早期宫颈癌可行腹主动脉旁淋巴结取样术,部分中晚期宫颈癌可行腹主动脉旁淋巴结清扫术(PAL)。然而,腹主动脉旁淋巴结清扫范围及其临床价值的评判等相关问题,国内外专家尚无统一意见,仍存较多争议。现对腹主动脉旁淋巴结清扫应用于宫颈癌治疗中的争议问题做一简要综述。     

宫颈癌根治术中加行腹主动脉旁淋巴结切除在ⅠB2及ⅡA2期宫颈癌治疗中的临床价值

目的:探讨宫颈癌根治术中加行腹主动脉旁淋巴结切除在Ⅰ B2及ⅡA2期宫颈癌治疗中的临床应用价值.方法:选择2006年5月至2011年7月在我院诊治的Ⅰ B2及ⅡA2期宫颈癌患者86例,分成两组.对照组45例,行宫颈癌根治术;观察组41例,宫颈癌根治术中加行腹主动脉旁淋巴结切除术;两组术后辅以放疗或放化疗.对两组术中、术后情况及复发率、生存率进行比较分析,并分析盆腔淋巴结转移、腹主动脉旁淋巴结转移与临床病理因素的关系.结果:观察组复发6例,复发率为15.0％;48个月总生存率和无瘤生存率均为70.0％.对照组复发17例,复发率为38.6％;48个月总生存率和无瘤生存率分别为68.0％和66.0％.两组比较,差异均有统计学意义(P＜0.05).两组并发症发生率(29.3vs 40.0％)、术中出血量(325.0±58.0ml vs 315.0±50.1 ml)及盆腔淋巴结阳性率(56.1％vs 57.8％)比较,差异均无统计学意义(P＞0.05).观察组中腹主动脉旁淋巴结阳性率为17.1％,盆腔淋巴结转移个数与腹主动脉旁淋巴结转移呈正相关(P＜0.01).单因素分析表明腹主动脉旁淋巴结转移是影响宫颈癌患者预后的因素之一(P＜0.05);多因素分析则表明盆腔淋巴结转移个数及腹主动脉旁淋巴结转移是影响宫颈癌患者预后的因素之一(P＜0.05).结论:宫颈癌盆腔淋巴结转移个数与腹主动脉旁淋巴结转移有关.在宫颈癌根治性手术中加腹主动脉旁淋巴结切除并辅以术后治疗,可以降低复发率,提高生存率,且安全可行.     

腹腔镜下Ⅲ型根治性子宫切除及腹膜后淋巴结切除术20例分析

目的:探讨腹腔镜下Ⅲ型根治性子宫切除及腹膜后淋巴结切除术的解剖、技术要点及安全可行性.方法:对20例ⅡB期宫颈癌患者先辅助化疗后行腹腔镜下Ⅲ型根治性子宫切除及腹膜后淋巴结切除术,并对手术时间、术中失血量、术后排气时间、术后膀胱功能恢复情况及术后大便、术中术后并发症情况进行统计分析.结果:所有手术均在腹腔镜下完成,手术平...     

子宫内膜癌淋巴结切除适应证和争议

早期子宫内膜癌有淋巴转移风险,但是否对所有患者均需行区域淋巴结切除仍有争议。可根据术前、术中的评估决定是否行淋巴结切除及何种范围的淋巴结切除。高危病例应该实施系统性淋巴结切除。     

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery.     

腹腔镜与开腹手术在宫颈癌腹主动脉旁淋巴结清扫术的安全性和生存结局比较

目的:探讨腹腔镜与开腹手术在宫颈癌腹主动脉旁淋巴结清扫术的安全性和生存结局比较。方法:回顾分析2015年1月至2016年12月于武汉大学人民医院行腹主动脉旁淋巴结清扫的86例宫颈癌患者的临床资料。其中50例行腹腔镜术(腹腔镜组),36例行开腹术(开腹组)。比较两组患者的手术时间、术中出血量、腹主动脉旁淋巴结清扫数、术中及术后并发症、术后肛门排气时间、总住院时间、预后情况。结果:两组患者的手术时间比较,差异无统计学意义(P0.05)。与开腹组比较,腹腔镜组的术中出血量明显减少,术后肛门排气时间早,术后总住院时间短,淋巴结清扫数多,差异均有统计学意义(P0.05)。两组的术中输尿管损伤、血管损伤、术后淋巴囊肿、尿潴留、肠梗阻、深静脉血栓、呼吸系统感染发生率比较,差异均无统计学意义(P0.05)。开腹组切口液化4例,腹腔镜组无切口液化,差异有统计学意义(P0.05)。腔镜组与开腹组患者的远期临床预后并无明显差异。结论:腹腔镜下腹主动脉旁淋巴结清扫手术用于宫颈癌治疗有较好的安全性,值得临床推广。     

盆腹腔淋巴取样术在子宫内膜癌手术中的临床意义

目的探讨盆腹腔淋巴取样术在子宫内膜癌的临床意义。方法分析2000年1月-2007年12月上海同济大学附属第一妇婴保健院手术治疗的213例子宫内膜癌患者,其中,86例行盆腹腔淋巴取样术,127例行淋巴结切除术。手术方式根据手术切除淋巴结的情况分为两组。①取样组：淋巴取样术,筋膜外全子宫双附件切除/次广泛子宫切除术＋盆腔/腹主动脉旁淋巴结取样术86例;②切除组：次广泛/广泛子宫切除术＋盆腔淋巴结切除/腹主动脉旁淋巴结切除术127例。结果取样组：切除淋巴结中位数18枚,淋巴结的转移10例。切除组：切除淋巴结中位数32枚,淋巴结转移11例。5年生存率分别为94.2%和94.5%。取样组无病发症发生,淋巴结切除组中有9例,分别是1例术中大出血（〉2000ml）,淋巴囊肿感染6例,淋巴漏2例。结论在子宫内膜癌中淋巴结取样术可准确了解淋巴结的转移情况,适宜手术分期,并不影响生存率,是避免过度手术减少并发症发生的有效方法。     

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases

Objective

To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer.

Methods

The same single port was used for the transperitoneal step and the extraperitoneal approach used thereafter (in the absence of peritoneal disease) for the lymphadenectomy. Para-aortic lymphadenectomy was performed via a left-sided extraperitoneal approach.

Results

Fourteen consecutive patients with cervical cancer underwent a laparoscopic staging procedure (3 stage IB2, 10 IIB and 1 stage IVA). No patient had para-aortic FDG uptake on PET/CT. In one case lymphadenectomy was unfeasible because of vascular anomalies of the renal vessels (low insertion of 2 left renal arteries). The median operative time was 190 min (range, 135–250). The median number of lymph nodes removed was 14 [range, 2–23]. The definitive pathological analysis revealed that three patients had metastatic disease. No conversion to conventional multiport laparoscopy was necessary.

Conclusions

This series reports that para-aortic lymphadenectomy technique via the extraperitoneal approach with a multichannel single port is feasible and reproducible.     

Upper margin of para-aortic lymphadenectomy in cervical cancer

Patients with early stage cervical cancer routinely undergo pelvic lymphadenectomy. A para-aortic lymphadenectomy is only performed in the setting of grossly enlarged lymph nodes. In patients with locally advanced disease, a para-aortic lymphadenectomy is indicated particularly when pelvic nodes are suspicious for disease on preoperative imaging. There is no consensus about the extent of para-aortic lymph node dissection in these patients. We reviewed relevant literature to determine the extension of para-aortic lymphadenectomy in patients with cervical cancer in order to establish whether lymph node dissection up to the inferior mesenteric artery or higher to the level of renal vessels should be performed. We performed a systematic search (PubMed; up to June 2011) to review systematic complete para-aortic lymphadenectomy. According to our search, eight women (1.09%) had isolated para-aortic node metastases, of which two had only lymph node metastases above the inferior mesenteric artery.     

子宫内膜癌淋巴结切除意义及指征

子宫内膜癌采用手术病理分期,然而是否对所有子宫内膜癌患者都行全面分期手术(全子宫切除术+双附件切除术+双侧盆腔淋巴结及腹主动脉旁淋巴结切除)争议广泛,尤其是对于早期子宫内膜癌患者淋巴结切除的价值值得探讨。文章回顾子宫内膜癌淋巴结切除的最新研究进展,进一步讨论淋巴结切除的意义及指征。     

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.     

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma

ObjectivesAdequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection.Study designEight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy.ResultsWe isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low.ConclusionsRobot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.     

Para-aortic and Right Obturator Lymphadenectomy for Surgical Staging of Advanced Cervical Cancer through the TU-LESS Extraperitoneal Approach

ObjectiveTo present an innovative transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy in a patient with advanced cervical carcinoma.DesignDemonstration of the novel technique through video.SettingIn advanced cervical cancer, determining the status of the para-aortic lymph nodes is essential because extended-field radiologic therapy is recommended for a patient with positive para-aortic lymph nodes [1]. Nonetheless, the sensitivity and specificity of currently available imaging workup for positive lymph nodes are limited. Surgical staging enables precise evaluation. However, laparotomy has potential wound complications and leads to treatment delay. Multiport laparoscopic transperitoneal and extraperitoneal approaches limit surgeons’ ability to reach the para-aortic area or obturator fossa in the same operation [2]. Thus, we take full use of these approaches’ advantages and avoid their disadvantages to design a promising minimally invasive surgery approach [3].InterventionsPara-aortic and obturator lymphadenectomy through the TU-LESS extraperitoneal approach was successfully performed without complications. The patient recovered quickly and received subsequent concurrent chemoradiation on schedule.ConclusionTU-LESS extraperitoneal para-aortic lymphadenectomy provides satisfactory exposure and easy access to both the para-aortic area and obturator fossa. In addition, the bowels are uplifted by an extraperitoneal air cushion to achieve excellent exposure and reduce the risk of bowel injury. With quick recovery, the patient could start accurate radiation treatment promptly.