妇科恶性肿瘤保留生育功能生育结局

子宫颈癌、子宫内膜癌和卵巢癌是妇科常见的三大恶性肿瘤,近年来随着发病的年轻化及女性育龄的推迟,保留生育功能的治疗在妇科恶性肿瘤患者中的应用越来越广泛。在妇科恶性肿瘤保留生育功能的临床诊治中,需联合多学科协作诊疗,在不增加肿瘤复发的情况下,保留患者生育功能,制定个体化治疗方案,提供最佳的生育指导,改善生育结局。     

保留生育功能的妇科恶性肿瘤患者生育后再处理

妇科恶性肿瘤保留生育功能患者产后再处理问题争议较多。早期宫颈癌产后不增加复发风险,可随访。子宫内膜癌产后多存在癌复发高危因素,主张补充手术。卵巢上皮性癌预后差,多建议产后补充手术,而交界性上皮肿瘤及生殖细胞肿瘤产后可密切随访。     

妇科恶性肿瘤保留生育功能治疗应注意的几个问题

随着医学技术日新月异的发展和医学治疗模式的转变,妇科恶性肿瘤患者保留生育功能的治疗越来越受到重视.在治疗年轻妇科恶性肿瘤患者的同时,要考虑到患者的生育情况,若有可能,应采取保留生育功能的治疗方法,这是当前妇科肿瘤治疗中必须面对的问题.但是,我们应该看到保留生育功能治疗是个新的治疗理念,在很多方面并没有达成共识,甚至还存有争论.很多治疗方法也并不十分完善,还处在临床研究阶段,期待着更多的循证医学证据来指导和支持.因此,正确理解妇科恶性肿瘤保留生育功能治疗的内涵,掌握治疗方法和技术,严格治疗的适应证,及时处理治疗过程中出现的各种问题,是保证妇科恶性肿瘤保留生育功能的治疗能循序渐进、健康发展的关键.另外,在治疗前一定要向患者和家属交代保留生育功能治疗的利弊,争取得到他们的理解、支持和配合,避免发生更多的医疗纠纷.     

妇科恶性肿瘤保留生育功能的治疗进展

随着医学技术发展的日新月异,妇科恶性肿瘤保留生育功能治疗的指征亦随之拓宽,治疗的方法也不断更新.本文就妇科恶性肿瘤保留生育功能治疗的适应证、治疗方法、注意事项以及治疗过程中出现的各种问题与处理进展进行了综述.     

妇科恶性肿瘤保留生育功能的手术

传统观念认为肿瘤治疗最根本的任务是延长患者的生存,以此为目的,为尽可能切除已存在或潜在的肿瘤病灶,因而不断扩大手术范围.但大量临床实践表明,无限扩大手术范围不一定延长患者生存,并以牺牲生存质量为代价.     

妇科恶性肿瘤保留生育功能的治疗进展

随着医学技术发展的日新月异，妇科恶性肿瘤保留生育功能治疗的指征随之拓宽，治疗的方法也不断更新。本文就妇科恶性肿瘤保留生育功能治疗的适应证、治疗方法、注意事项以及治疗过程中出现的各种问题与处理进展进行了综述。     

卵巢恶性肿瘤保留生育功能治疗52例临床分析

目的:评价卵巢恶性肿瘤保留生育功能手术和化疗对生育和卵巢功能的影响.方法:回顾性分析我院1996年6月至2010年6月卵巢恶性肿瘤行保留生育功能治疗并有完整随访资料的52例患者的临床资料,对其手术、术后化疗及术后月经和妊娠情况进行分析,并对是否行全面分期手术和不同病理类型行保留生育功能治疗后的生存率和复发率相比较,以及是否化疗的妊娠率进行比较.结果:52例患者中生殖细胞恶性肿瘤25例,上皮性恶性肿瘤12例,交界性肿瘤15例.复发3例,其中1例死亡.计划妊娠41例中妊娠成功16例,2例流产.术后化疗的38例患者中,2例化疗期间月经正常,36例在化疗1～2次后停经,但停止化疗后月经恢复.52例患者中行全面分期手术(15例)的生存率和复发率与行附件切除术或卵巢肿瘤剥除术(37例)比较,差异均无统计学意义(P均＞0.05).3种病理类型肿瘤患者保留生育功能治疗后的生存率和死亡率比较,差异均无统计学意义(P＞0.05).化疗患者中的妊娠率与未化疗患者的妊娠率比较,差异也无统计学意义(X2 =0.1186,P＞0.05).结论:卵巢恶性肿瘤保留生育功能治疗是有效和可行的,化疗对卵巢功能可能有影响,但可以逆转.保留生育功能手术以附件切除术或病灶切除术为宜,但结论尚有待大样本量研究及长期随访.     

卵巢恶性肿瘤患者保留生育功能治疗后的妊娠问题

近年来,保留卵巢恶性肿瘤患者的生育功能已经成为了一个重要的焦点问题,原因有以下几个方面:生育年龄患者的卵巢恶性肿瘤并非罕见;随着卵巢恶性肿瘤治疗上的进步,癌症患者的存活率有了明显提高;全球妇女准备受孕的时间越来越晚,越来越多的妇女将她们的第一次生育拖延至35~45岁;卵巢恶性肿瘤的主要治疗方法是切除子宫和卵巢以及化疗,而这些治疗方法会导致患者丧失生育能力,或即使患者保留子宫和卵巢,若接受化疗或放疗,也有可能会增加随后妊娠并发症的风险,如早期流产、早产或低出生体重儿等。为此,本文对卵巢恶性肿瘤患者保留生育功能的可行…     

卵巢恶性肿瘤年轻患者保留生育功能手术的效果评价

目的总结评价卵巢恶性肿瘤年轻患者保留生育功能手术和术后辅助化疗的效果及对生育功能及卵巢功能的影响.方法回顾性分析四川大学华西第二医院1989-2004年收治的64例接受保留生育功能手术治疗的卵巢恶性肿瘤年轻患者的临床资料.结果初诊时患者中位年龄为20（7～30）岁.64例患者中,卵巢上皮性癌患者22例,恶性生殖细胞肿瘤38例,性索间质肿瘤4例.首次手术方式如下：单侧附件切除术23例;单侧附件切除＋大网膜切除＋阑尾切除术10例,单侧附件切除＋大网膜切除＋阑尾切除＋盆腔淋巴结切除或取样术10例;单侧附件切除＋肿瘤细胞减灭术4例;单侧附件切除＋对侧卵巢楔形切除活检术11例;6例仅行患侧肿瘤剥除术.64例患者平均随访76（5～192）个月,5例（8%）死亡,59例（92%）存活至今,其中卵巢恶性生殖细胞肿瘤患者存活率为89%（34/38）,上皮性癌患者为95%（21/22）,性索间质肿瘤患者全部健在（4/4）.15例患者行二次手术,其中发现癌灶者6例.生存病例中53例患者有月经,除2例周期缩短外,其余患者月经均正常.20例有生育计划的患者中,13例（65%）患者有15次妊娠,9次足月分娩.结论对卵巢恶性生殖细胞肿瘤患者,无论期别如何,行保留生育功能手术是可行的;对于卵巢上皮性癌患者行保留生育功能手术需慎重,仅限于年轻、有强烈生育要求、肿瘤为Ⅰ期、高分化且术后有条件密切随访的患者;坚持规范化疗对卵巢恶性肿瘤的治疗十分必要;化疗对卵巢及生育功能无明显影响.     

恶性滋养细胞肿瘤保留生育功能的手术治疗

恶性滋养细胞肿瘤多发于育龄妇女。自５０年代首先证实大剂量氨甲喋呤能有效治疗恶性滋养细胞肿瘤及随后发现一系列有效化疗药物后,恶性滋养细胞肿瘤的治愈率已达８０％～９０％。许多年轻妇女可通过化疗治愈而保留生育机能。宋鸿钊等报道通过单纯化疗治愈有生育要求的２...     

妇科恶性肿瘤筛查中基因检测技术的应用

近年来的研究认为癌症是一种基因疾病,遗传性或获得性基因缺陷可导致癌症的发生和发展。因而,基因检测技术在妇科肿瘤的筛查中显得尤为重要。目前,人乳头瘤病毒（HPV）检测已在宫颈癌筛查中广泛应用,对于遗传性卵巢癌和子宫内膜癌高危群体,也可通过检测BRCA1/2和MLH1/MSH2突变进行高危人群风险分层。     

Diagnostic value of telomerase activity in gynecologic malignancies

Nagai N, Murakami J, Oshita T, Ohama K, Tahara H. Diagnostic value of telomerase activity in gynecologic malignancies. Int J Gynecol Cancer 1998; 8 : 481–488.
We investigated the diagnostic significance of telomerase activity in gynecological malignancies. Tissue samples were obtained from 24 cervical cancers, 27 uterine cancers (22 endometrial cancers and five sarcomas), 33 ovarian cancers (31 epithelial tumors and 2 germ cell tumors), and 11 benign ovarian tumors. In addition, cervical cytology specimens were obtained from 30 squamous intraepithelial lesions (13 low grade and 17 high grade), and from 22 normal females. Telomerase activity was detected using the TRAP assay, and the relative telomerase activity was obtained using the BioMax DNA image analysis system. Telomerase activity was detected in 22/24 (91.7 %) cervical cancers, 23/27 (85.2%) uterine tumors and 30/33 (90.9%) ovarian cancers. Weak telomerase activity was detected in two mature cystic teratomas and also found in 9/17 (52.9%) high grade SIL and 2/13 (15.4%) low grade lesions. Telomerase activity showed no relationship with tumor histology or clinical stage, and there was no statistically significant difference between patients with uterine cancer and ovarian cancer. Relative telomerase activity showed a correlation with the dilution assay, and significantly higher telomerase activity was found in uterine cervical cancer compared with precancerous lesions and in ovarian cancer compared with benign ovarian tumors. After establishment of an assay for telomerase, it may be useful for cancer diagnosis and identification of high-risk groups.     

Complications of pelvic radiation therapy for gynecologic malignancies in elderly women

The purpose of this study was to determine the frequency and severity of complications following pelvic irradiation in elderly women with gynecologic malignancies. A retrospective analysis was conducted of the 60 women over 65 years of age treated with pelvic radiation therapy for cervical (26), endometrial (31) or proximal vaginal (3) cancer at the UCLA Medical Center between 1978 and 1991. Acute grade 3 to 4 gastrointestinal (GI) complications, using Gynecologic Oncology Group (GOG) criteria occured in three of 60 patients (5%). Chronic complications occured in 28 of 49 patients (57%) followed for longer than 3 months after radiation therapy. The 3-year actuarial rate of chronic GI and/or genitourinary (GU) complications was 63% for any grade and 24% for grades 2,3 or 4. Twelve of the 14 grade 2–4 chronic complications were GI. The 3-year actuarial chronic complication rate was 45% for GI compared to 17% for GU ( P = 0.01). The median time to occurrence for GI and GU chronic complications was 8 and 19 months, respectively. In multivariate analysis, two or more pre-existing medical problems ( P = 0.03) and dose of external beam radiation therapy 45 Gy ( P = 0.07) were associated with the development of a chronic complication. We conclude that moderate to severe intestinal complications are common after pelvic irradiation of elderly women, particularly those with two or more pre-existing medical problems. Pelvic radiation therapy should be used judiciously in elderly women.     

Oncological and pregnancy outcomes after high-dose density neoadjuvant chemotherapy and fertility-sparing surgery in cervical cancer

Objective

28 women under 35 years with early-stage cervical cancer and strong desire for fertility preservation that do not fulfil standard criteria for fertility-sparing surgery (tumour larger than 2 cm or with deep of infiltration more than half of stroma) were included in prospective study.

Methods

Dose-dense neoadjuvant chemotherapy (NAC) was performed on all 28 patients in 10-day intervals: cisplatin plus ifosfamide in squamous cell cancer (15 women—53.6%) or cisplatin plus doxorubicin in adenocarcinoma (13 women—46.3%). Patients underwent laparoscopic lymphadenectomy and vaginal simple trachelectomy after NAC. Patients with positive lymph nodes or inadequate free surgical margins underwent radical hysterectomy.

Results

No residual disease was found in 6 women (21.4%), microscopic disease was observed in 11 women (39.3%) and macroscopic tumour in was observed in 11 women (39.3%). Ten women (35.7%) lost fertility. Four women (20%) after fertility-sparing surgery recurred, two died of the disease (10%). Fertility was spared in 20 (71.4%) women and 10 of them became pregnant (50%). Eight women delivered ten babies (6 term and four preterm deliveries). There were two miscarriages in second trimester (in one woman) and one in first trimester. One woman underwent four unsuccessful cycles of IVF, one failed to become pregnant and one recurred too early. Two women underwent chemoradiotherapy for recurrence and lost chance for pregnancy.

Conclusions

Downstaging by NAC in IB1 and IB2 cervical cancer before fertility-sparing surgery is still an experimental procedure, but shows some promise. Long-term results in relation to oncological outcome for this concept are still needed.     

Technique and feasibility of radical para-aortic and pelvic lymphadenectomy for gynecologic malignancies: a prospective study

Abstract. Of 284 patients evaluated for entry into the study between January 1986 and June 1990, systematic para-aortic and pelvic lymphadenectomy was performed in 208 cases (108 cervical cancer, 43 and 57 ovarian and endometrial cancer, respectively). The median number of nodes removed was 58, 49 and 54 for cervical, ovarian and endometrial cancer, respectively. The operating data are divided into 2 groups according to the consecutive number of the cases. The median operating time and the median estimated blood loss of lymphadenectomy was 230 minutes (range 120–270) and 390 ml (range 200–3300) in the first 95 cases. These operating data decreased to 150 minutes (range 100–240) and 250 ml (range 100–2800) in the second 113 cases. No surgery-related deaths occurred. Severe hemor-rages (blood loss exceeding 1000 ml) occurred in 6 patients. The obturator nerve was dissected in 1 patient and in 1 case the left ureter was cut. Formation of lymphoceles occurred in 20.4% of patients. Eighteen patients (8.8%) developed deep venous thrombosis. Nine of these patients experienced pulmonary microembolism. In 3 patients a retroperitoneal abscess was diagnosed. One patient developed a fistula of the most proximal part of the right ureter during the third postoperative week. The resection or coagulation of branches of the genito-femoral and obturator nerves determined mild paresthesis localized at the supero-anterior and internal side of thigh in 11 cases (5.4%). No statistically significant differences were found between the clinical (age, weight and previous chemotherapy) and pathological (type of cancer and lymph node status) parameters considered on one hand and postoperative complications on the other.     

妇科恶性肿瘤术后化疗后淋巴囊肿并发感染及治疗分析

目的:探讨妇科恶性肿瘤术后化疗后淋巴囊肿感染的易感因素、防治方法及预防措施。方法:对67例妇科恶性肿瘤患者术后化疗后淋巴囊肿发生感染及治疗情况进行回顾性分析。结果:中性粒细胞计数(ANC)降低、贫血、年龄>60岁患者淋巴囊肿感染率增高,抗生素联合粒细胞集落刺激因子(G-CSF)治疗使化疗后淋巴囊肿感染患者发热及ANC恢复天数分别缩短为(7.0±1.6)天和(6.0±1.3)天。结论:妇科恶性肿瘤术后患者化疗后ANC降低、贫血、患者年龄>60岁是淋巴囊肿感染感染主要易感因素,抗生素加用G-CSF合理应用,能减少淋巴囊肿感染发生率及严重程度。     

Multiple primary malignancies in patients with gynecologic cancer

A retrospective analysis was made of 1044 patients with gynecologic malignancies treated in our department over a 12-year period, in order to review the frequency and types of multiple primary neoplasms. Multiple primary neoplasms were detected in 45 (4.3%) cases, including 16 (2.1%) out of 733 cervical cancers, 14 (8.2%) out of 166 endometrial cancers, three (15%) out of 20 vaginal cancers and 12 (9.8%) out of 123 ovarian cancers. Fifteen cases were synchronous and the remaining 24 cases were heterochronous, with an average 4.9-year interval. The most frequent other site of neoplasm was the breast, particularly in patients with endometrial or ovarian cancer. We conclude that gynecologic malignancies are often associated with primary cancers elsewhere, especially in the breast, stomach, colon and thyroid. A patient presenting with a gynecologic malignancy should be thoroughly examined for a second cancer, as should patients being followed-up after treatment for genital tract cancer.     

Intraoperative radiation therapy in the treatment of pelvic gynecologic malignancies: a review of fifteen cases

OBJECTIVE: The aim of this study was to review the experience with intraoperative radiation therapy (IORT) in the treatment of gynecologic pelvic malignancies at the Massachusetts General Hospital. METHODS: From July 3, 1996, through July 28, 1999, 15 patients were treated with IORT for gynecologic malignancies in a dedicated IORT operating room suite at the Massachusetts General Hospital. Hospital medical records, radiation oncology records, and office charts were reviewed on all patients treated with IORT. IORT was given in the presence of positive surgical margins and where the doses needed for adjuvant postoperative external beam radiotherapy (EBRT) would exceed those tolerated by normal structures. One patient presented with primary disease and 14 with local or regional recurrence. Follow-up time ranged from 3 to 36 months. RESULTS: Treatment in conjunction with IORT included surgery only (7 patients); preoperative EBRT, preoperative brachytherapy, and surgery (1 patient); preoperative chemotherapy and surgery (2 patients); and surgery and postoperative chemotherapy (5 patients). IORT doses ranged from 10 to 22.5 Gy. At the completion of this review, 4 patients (26.6%) have died, 6 (40%) are alive and free of disease, and 5 (33%) are alive with disease persistence or relapse. Of the 10 patients with gross total resection, 5 are alive and free of disease. Of the 5 women with gross residual disease at the time of IORT, only 1 is alive and free of disease. CONCLUSIONS: The volume of residual disease prior to IORT may be an important prognostic indicator for disease relapse. Both local recurrence and distant metastasis were more common among patients with gross residual disease at the time of IORT. Our institutional experience with IORT further supports the importance of optimal surgical resection.