腹腔镜下高位腹主动脉旁淋巴结切除术治疗子宫内膜癌的疗效

目的 探讨腹腔镜下低位、高位腹主动脉旁淋巴结切除术治疗子宫内膜癌的临床效果.方法 选取54例行手术治疗的子宫内膜癌患者,根据手术位置不同分为高位组与低位组,每组27例.高位组实施腹腔镜下高位腹主动脉旁淋巴结切除术,低位组实施腹腔镜下低位腹主动脉旁淋巴结切除术.比较两组患者手术指标、术后复发率、生存率、治疗前后肿瘤标志物...     

腹主动脉旁淋巴结切除在子宫内膜癌手术治疗中的意义

目的:探讨腹主动脉旁淋巴结切除对子宫内膜癌手术病理分期及预后的影响。方法:回顾性分析我院行系统性盆腔及腹主动脉旁淋巴结切除的68例子宫内膜癌患者的临床病理资料。结果:15例(22.1%)发生淋巴结转移的患者中,12例(17.6%)发生盆腔淋巴结转移,7例(10.3%)发生腹主动脉旁淋巴结转移,其中4例(5.9%)患者同时出现盆腔及腹主动脉旁淋巴结转移,3例(4.4%)为单纯腹主动脉旁淋巴结转移。临床分期与手术病理分期不符合率为22.1%。术后随访6～57个月,平均26个月,获访率100%,1例复发,1例复发并死亡。结论:系统性盆腔及腹主动脉旁淋巴结切除术不仅对进行准确的手术病理分期,指导术后辅助治疗有重要意义,而且能提供预后相关信息。     

子宫内膜癌患者腹主动脉旁淋巴结转移的临床病理因素分析

目的:研究子宫内膜癌(EC)患者腹主动脉旁淋巴结(PALN)转移的相关临床病理因素。方法:回顾分析159例EC患者的临床病理资料,探讨PALN转移的危险因素。结果:肌层浸润(OR=2.094,95%CI为1.173~4.095,P=0.046)、分化程度(OR=6.662,95%CI为3.864~10.164,P0.001)及髂外淋巴结转移(OR=5.428,95%CI为2.759~8.854,P0.001)是子宫内膜癌PALN转移的独立危险因素。结论:临床上对于子宫内膜癌患者,应重视肌层浸润、分化程度及髂外淋巴结转移等因素,以对PALN转移进行合理评估。     

腹主动脉旁淋巴结切除术

卵巢癌有很高的淋巴结转移率 ,腹主动脉旁和盆腔淋巴结几乎有同等的机会。在恶性生殖细胞肿瘤 ,更趋向有腹主动脉旁淋巴结转移 ,甚至在盆腹腔外观完全正常的情况 ,亦会有 30 %左右的腹主动脉旁淋巴结阳性率 ,即所谓“悄悄地转移”(ｓｉｌｅｎｔｍｅｔａｓｔａｓｉｓ)。通常在卵巢癌的肿瘤细胞减灭术时 ,腹主动脉淋巴结切除做到腹主动脉分叉 (分为左右髂总动脉 )处上 3～ 4ｃｍ ,相当于肠系膜下动脉 ,如图 1之ａ水平。图 1　腹主动脉淋巴结切除范围如果淋巴结转移瘤在此以上水平 ,则清除手术可达图1之ｂ高度 ,手术难度也便明显增加了。若达到…     

腹腔镜下腹主动脉旁淋巴结切除在子宫内膜癌诊治中的临床研究

目的:探讨腹腔镜下腹主动脉旁淋巴结切除在子宫内膜癌诊治中的应用价值及安全性、可行性。方法:选择2010年3月至2014年3月子宫内膜癌患者89例,其中,行腹腔镜下腹主动脉旁淋巴结切除手术50例(腹腔镜组),传统开腹腹主动脉旁淋巴结切除手术39例(开腹组),比较两组围手术期情况、术中及术后并发症、预后,统计分析淋巴结转移患者临床病理特征。结果:腹腔镜组和开腹组患者在切除的淋巴结数目上差异无统计学意义(P0.05),腹腔镜组较开腹组腹主动脉旁淋巴结切除出血量少、术后病率低、术后肛门排气时间早、术后住院时间短,但切除腹主动脉旁淋巴结时间长于开腹组,两组比较差异均有统计学意义(P0.01,P0.05)。腹腔镜组与开腹组在术中腔静脉损伤、术后尿潴留、淋巴囊肿、深静脉血栓、肺动脉栓塞发生率比较,差异无统计学意义(P0.05),而开腹组切口裂开4例,腹腔镜组无切口裂开,两组比较差异有统计学意义(P0.05)。术后发现盆腔和(或)腹主动脉旁淋巴结转移共8例,除术前1例患者发现脐部癌转移诊断为ⅣB期和1例患者磁共振成像提示盆腔淋巴结肿大癌转移诊断ⅢC1期与术后病理诊断相同外,其余6例分期均较术前升高。两组术后随访:开腹组复发2例,其中1例死亡;腹腔镜组复发1例后死亡,均为晚期子宫内膜癌患者。结论:腹主动脉旁淋巴结切除是子宫内膜癌规范化诊治的重要组成部分,在对子宫内膜癌患者准确分期、制定精确术后诊治方案,改善预后方面作用是肯定的,腹腔镜下腹主动脉旁淋巴结切除手术安全可行,优于传统开腹手术。     

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     

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。     

卵巢癌腹主动脉旁淋巴结清除术与生存率的关系

目的:探讨上皮性卵巢癌患者行腹主动脉旁淋巴结清除术与其生存预后的关系。方法:回顾分析卵巢癌肿瘤细胞减灭术的80例患者,将其中行腹主动脉旁淋巴结(PAN)+盆腔淋巴结(PLN)清除术分为A组(30例),仅行PLN清除术者分为B组(50例),分析PAN清除与患者生存预后的相关性。结果:行卵巢肿瘤细胞减灭术的80例患者中,32例(40.0%)发生淋巴结转移。A组中19例发生淋巴结转移,其中仅PAN阳性7例,仅PLN阳性3例,PAN和PLN均阳性9例;B组中13例发生PLN转移。A与B组患者的淋巴结转移与临床分期、肿瘤细胞分化程度和组织学类型显著相关(P0.05)。A组中淋巴结转移部位以PAN最多16例,其余依次为髂内、闭孔、髂总、腹股沟及髂外淋巴结。A组患者的3年、5年生存率分别为77.9%和46.7%,均高于B组(69.0%和39.2%),但无显著差异(P0.05)。A与B组患者中转移至PLN者的3年生存率分别是68.5%和41.4%,5年生存率是49.7%和26.4%,两组比较差异显著(P=0.044)。A组患者中淋巴结阳性与阴性患者3年生存率分别为43.5%和72.7%,5年生存率是27.2%和58.5%,差异显著(P=0.048)。Cox模型单因素分析提示,淋巴结状态对患者的生存率有影响(P0.01),而且是死亡风险因素。结论:腹主动脉旁淋巴结的清除对改善卵巢癌患者预后起着重要作用。     

腹腔镜腹膜外入路腹主动脉旁淋巴结切除治疗妇科恶性肿瘤的效果分析

目的:探讨腹腔镜经腹膜入路与腹膜外入路腹主动脉旁淋巴结(PALN)切除治疗妇科恶性肿瘤的有效性和安全性。方法:回顾分析2016年5月至2018年7月因妇科恶性肿瘤(包括宫颈癌、子宫内膜癌、卵巢癌)于武汉大学中南医院妇产科行腹腔镜下肿瘤根治术的69例患者,其中经腹膜入路腹腔镜手术者22例(对照组),腹膜外入路腹腔镜手术者47例(实验组)。分析患者的手术时间、术中出血量、淋巴结切除数、术后住院天数、术后引流管拔除天数、术前与术后血红蛋白差值及其他术后并发症(如淋巴囊肿、乳糜漏、输尿管损伤、泌尿系统感染、血栓形成、肠粘连、尿潴留、膀胱阴道瘘)发生率及患者的预后情况。结果:腹腔镜经腹膜入路与腹膜外入路的总体手术时间、术中出血量、术前与术后血红蛋白差值比较,差异均无统计学意义(P0.05)。两组的PALN手术时间、PALN切除数、术后住院时间、术后引流管拔除时间、术后肠粘连发生率比较,差异有统计学意义(P0.05);淋巴囊肿、乳糜漏、输尿管损伤等发生率,以及术后随访盆腔淋巴结转移率、PALN转移率、患者生存率相比,差异均无统计学意义(P0.05)。结论:腹腔镜腹膜外入路在妇科肿瘤患者的治疗中有较好的有效性和安全性,可在临床上应用推广。     

妇科恶性肿瘤腹腔镜下腹膜外腹主动脉旁淋巴结切除术的意义探讨

腹膜后淋巴结转移是影响妇科恶性肿瘤预后的重要因素之一。在妇科恶性肿瘤的治疗中,腹主动脉旁淋巴结的评估尤为重要。腹主动脉旁淋巴结切除术是判断腹主动脉旁淋巴结转移的金标准。近年来腹腔镜下腹膜外腹主动脉旁淋巴结切除(PAL)已成为妇科恶性肿瘤的研究热点。从腹膜后间隙解剖及妇科肿瘤腹主动脉旁淋巴结转移特点入手,综合分析国内外腹主动脉旁淋巴结切除和经腹膜外腹主动脉旁淋巴结切除的相关研究及其意义,不同学者对经腹膜外腹主动脉旁淋巴结切除的观点不尽相同,其临床价值有待进一步研究。     

Analysis of clinicopathologic factors predicting para-aortic lymph node metastasis in endometrial cancer

The purposes of this study were to compare the relationships between para-aortic lymph node metastasis and various clinicopathologic factors to evaluate whether para-aortic lymph node dissection is necessary when treating endometrial cancer. A retrospective study was performed on 841 patients with endometrial cancer, who underwent the initial surgery at the Keio University Hospital. Clinicopathologic factors related to para-aortic lymph node metastasis significant on a univariate analysis were analyzed in a multivariate fashion using a logistic model. According to the multivariate analysis, the clinicopathologic factor most strongly related to the existence of para-aortic lymph node metastasis was positive pelvic lymph node metastasis (P < 0.01). Among the 155 patients who underwent pelvic and para-aortic lymph node dissection, the difference of 5-year overall survival by the presence of retroperitoneal lymph node metastasis was examined by Kaplan-Meier method. The prognosis was poor even if para-aortic lymph node dissection was performed in cases of positive para-aortic lymph node metastasis. In conclusion, when deciding whether to perform para-aortic lymph node dissection in patients with endometrial cancer, it is necessary to consider the pelvic lymph nodal status. If there is no pelvic lymph node metastasis, it could not be necessary to perform para-aortic lymph node dissection.     

宫颈癌手术盆腹腔淋巴结切除相关问题

盆腹腔淋巴结切除是宫颈癌手术治疗的重要组成部分。如何评判盆腔淋巴结切除是否彻底？哪些患者需要腹主动脉旁淋巴结切除？前哨淋巴结在宫颈癌治疗中的作用？这些是当今宫颈癌淋巴结切除面临的问题,文章就以上问题进行讨论。     

Chylous ascites following operation for para-aortic lymph node dissection in a patient with cervical cancer

Abstract.   Takeuchi S, Kinoshita H, Terasawa K, Minami S. Chylous ascites following operation for para-aortic lymph node dissection in patient with cervical cancer. Int J Gynecol Cancer 2006; 16(Suppl. 1): 418–422.
This is a case report of chylous ascites caused by performing para-aortic lymph node dissection for a patient with cervical cancer. Postoperative chylous ascites is a rare condition that usually develops as a result of operative trauma to the thoracic duct, cisterna chyli, or their major tributaries. It has mainly occurred in thoracic operations, and chylous ascites has rarely been reported in gynecologic surgery. It is associated with serious nutritional and immunologic consequences due to the constant loss of protein and lymphocytes. Treatment that comprises conservative and surgical procedures is selected based on disease severity. We experienced massive chylous ascites after para-aortic surgery and successfully managed it conservatively with dietary intervention and parenteral nutrition.     

The curative role of radiotherapy in patients with isolated para-aortic node recurrence from cervical cancer and value of squamous cell carcinoma antigen for early detection

The objective of this study was to examine the clinical benefits of routine squamous cell carcinoma antigen (SCC-ag) monitoring of patients with locally advanced cervical cancer. Recurrent disease occurred in 99 uterine cervical cancer patients with elevated pretreatment SCC-ag before primary radiotherapy. Elevated SCC-ag levels persisted in 23 patients after primary radiotherapy (group 1), and SCC-ag was normalized in 76 patients after primary radiotherapy (group 2). The overall survival (OS) rate was higher for patients with SCC-ag elevation as the first sign than for patients with recurrence predicted by other modalities for group 2 patients (P = 0.033). The prediction of isolated para-aortic node recurrence significantly correlated with SCC-ag elevation as an initial sign (P = 0.001). The SCC-ag level before primary radiotherapy (> or = 10.8 ng/mL) significantly affected recurrence predicted by SCC-ag elevation as an initial sign (P = 0.002). For multivariate analysis, the presence of para-aortic node recurrence was statistically significant in OS (P < 0.0001). Routine SCC-ag monitoring of patients with carcinoma of the uterine cervix can lead to the early diagnosis of isolated para-aortic lymph node recurrence, and prolonged survival can be achieved by applying radiation therapy to the para-aortic region. To reduce the number of patients monitored for SCC-ag, we recommend monitoring group 2 patients with pretreatment SCC-ag level before primary radiotherapy > or = 10.8 ng/mL.     

Evaluation of endometrial carcinoma on magnetic resonance imaging

Our aims were to assess diagnostic performance of T2-weighted (T2W) and dynamic gadolinium-enhanced T1-weighted (T1W) magnetic resonance imaging (MRI) in the preoperative assessment of myometrial and cervical invasion by endometrial carcinoma and to identify imaging features that predict nodal metastases. Two radiologists retrospectively reviewed MR images of 96 patients with endometrial carcinoma. Tumor size, depth of myometrial and cervical invasion, and nodal enlargement were recorded and then correlated with histology. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the identification of any myometrial invasion (superficial or deep) were 0.94, 0.50, 0.93, 0.55 on T2W and 0.92, 0.50, 0.92, 0.50 on dynamic T1W, and for deep myometrial invasion were 0.84, 0.78, 0.65, 0.91 on T2W and 0.72, 0.88, 0.72, 0.88 on dynamic T1W. The sensitivity, specificity, PPV and NPV for any cervical invasion (endocervical or stromal) were 0.65, 0.87, 0.57, 0.90 on T2W and 0.50, 0.90, 0.46, 0.92 on dynamic T1W, and for cervical stromal involvement were 0.69, 0.95, 0.69, 0.95 on T2W and 0.50, 0.96, 0.57, 0.95 on dynamic T1W. Leiomyoma or adenomyosis were seen in 73% of misdiagnosed cases. Sensitivity and specificity for the detection of nodal metastases was 66% and 73%, respectively. Fifty percent of patients with cervical invasion on MRI had nodal metastases. In conclusion, MRI has a high sensitivity for detecting myometrial invasion and a high NPV for deep invasion. MRI has a high specificity and NPV for detecting cervical invasion. Dynamic enhancement did not improve diagnostic performance. MRI may allow accurate categorization of cases into low- or high-risk groups ensuring suitable extent of surgery and adjuvant therapy.     

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。     

前哨淋巴结检测在子宫内膜癌中的临床意义

子宫内膜癌患者手术是否清扫盆腔和腹主动脉旁淋巴结尚存在争议。在缺乏前瞻性临床试验证实淋巴结清扫可以改善临床预后前提下,随着精准治疗与微创治疗理念的兴起,最新的近红外光谱技术、超分期技术的应用,近年来子宫内膜癌前哨淋巴结检测技术发展迅速,临床研究结果也显示了其良好的应用前景,但是在具体注射部位、示踪剂选择、腹主动脉周围前哨淋巴结采样等环节也面临较多问题,前哨淋巴结检测能否替代子宫内膜癌全面分期手术,仍需进一步研究。     

Sentinel lymph node in endometrial cancer

The aim of this study was to evaluate the possibility of identifying the sentinel lymph node and involvement of neoplastic cells in patients with endometrial carcinoma limited to the uterus, and also its correlation with the conditions of other pelvic and para-aortic lymph nodes. Forty patients with endometrial carcinoma, clinical staging I and II, were submitted to complete surgical staging through laparotomy, as recommended by FIGO in 1988. The sentinel node was investigated using patent blue dye in the myometrial subserosa. The sentinel node was excised and submitted to frozen section examination of specimen, stained with hematoxylin and eosin (H&E). Afterward, selective bilateral para-aortic and pelvic lymphadenectomy, total hysterectomy with bilateral salpingo-oophorectomy were performed. The lymph nodes excised were examined by means of paraffin-embedded slices stained with H&E and of imunohistochemistry with antikeratin antibody AE1/AE3. The sentinel lymph node was identified in 77.5% of patients (31/40), and 16.1% (5/31) presented neoplastic involvement in the node. In 25 cases of negative sentinel node, 96% (24/25) had no neoplastic involvement, and 4% (1/25) had other lymph node affected (false negative). In nine cases with no sentinel node identified, 55.5% (5/9) had lymph node involvement. The results of this study allow us to conclude that it is possible to identify the sentinel node using the methods described, and the pathologic examination significantly represents the same conditions of other pelvic and para-aortic lymph nodes.