复发性子宫颈癌的治疗

近年来,官颈癌的治疗取得了较大进展,但是部分宫颈癌治疗后仍发生复发.对于复发性宫颈癌的定义,一般是指宫颈癌经根治性治疗痊愈后再次出现与治疗前病理类型相同的肿瘤,包括局部复发和远处转移.     

《中国实用妇科与产科杂志》2012年第5期中心内容预告

中心内容:妇科恶性肿瘤复发的处理郎景和院士谈妇科恶性肿瘤诊断和治疗中的人文关怀《2012年美国国立综合癌症网宫颈癌临床实践指南》解读复发性子宫颈癌的治疗复发性子宫内膜癌综合治疗复发性卵巢癌的手术治疗复发性卵巢癌腹腔化疗的应用靶向治疗在复发性卵巢癌治疗中的应用复发性卵巢交界性肿瘤诊治复发性外阴癌的处理复发性阴道癌     

复发性宫颈癌的治疗

宫颈癌是世界范围内最常见的女性生殖系统恶性肿瘤,严重威胁女性的生命。在发展中国家占女性癌症死亡率的第二位。宫颈癌治疗失败的主要原因是局部复发和远处转移。复发性宫颈癌患者预后差、5年生存率低。因此,复发性宫颈癌的治疗成为临床关注的重点。     

17例复发性或转移性外阴癌的放疗疗效分析

目的:探讨复发性或转移性外阴癌的放疗疗效情况。方法:17例复发性或转移性外阴癌患者,采用三维适形放疗联合高能电子线及高分割剂量照射放疗,对其结果进行临床分析。结果:随访13~64个月,中位随访31.3个月,2例患者出现远处转移死亡(1例肺转移,1例骨转移),1例死亡原因不明。中位无进展生存时间19个月,中位生存时间31个月,1年生存率64.70%(11/17),5年生存率37.50%(6/16)。局部再次复发5例,复发时间中位数15个月。有淋巴结转移的5例放疗后生存时间均小于3年。放疗副反应主要有泌尿生殖道反应、局部皮肤反应、中性粒细胞减少和发热,副反应可控,无一例因副反应死亡。结论:三维适形放疗技术结合高能电子线及高分割剂量照射放疗治疗复发性或转移性外阴癌,耐受性好,副反应轻,治疗效果明显。     

复发性念珠菌阴道炎病因研究进展

复发性念珠菌阴道炎(RVVC)的病因十分复杂，导致复发的影响因素主要涉及临床因素、宿主局部免疫力以及念珠菌的细胞分子机制等方面。临床因素结合阴道局部免疫力低下导致阴道菌群失调及阴道局部微生态平衡破坏，最终引起念珠菌阴道炎的复发。RVVC在治疗上的难点主要表现为耐药，RVVC耐药的分子机制主要与天冬氨酸蛋白酶(SAP)家族的基因突变、多药耐药基因的异常表达、pH值以及念珠菌毒力因子的基因多态性有关。临床规范用药以及选用非唑类抗真菌将有助于预防和治疗RVVC。     

复发性输卵管癌治疗相关问题

输卵管癌发病率低,恶性度高,易复发,术前诊断及术后监测困难,近年来其发病及治疗后复发有逐年增加的趋势。此外,复发性输卵管癌的治疗仍是一大难题,故有必要加强对该疾病的重视,同时探索新的、有效的治疗方法来改善患者预后是必不可少的。     

会阴模板组织间植入后装治疗复发性宫内膜癌的阴道转移

宫体癌阴道复发多见于有高危因素者,孤立性的阴道复发发生率为18%～33%。拯救性治疗疗效受原先分期、首次治疗至复发时间、组织病理学及分级、复发部位、放疗剂量的影响,局部控制率为16%～100%。 会阴模板组织间植入治疗对靶体积能给予大剂量,且剂量衰退很快使周围组织受量很少。解剖上,腔内治疗不能包括的均得到治疗。1989年9月～     

复发性念珠菌阴道炎病因研究进展

复发性念珠菌阴道炎（RVVC）的病因十分复杂，导致复发的影响因素主要涉及临床因素、宿主局部免疫力以及念珠菌的细胞分子机制等方面。临床因素综合阴首局部免疫力低下导致阴道 菌群失调及阴道局部微生态平衡破坏，最终引起念珠菌阴道炎的复发。RVVC在治疗上的难点主要表现为耐药，RVVC耐药的分子机制主要与天冬氨酸蛋白酶（SAP）家族的基因突变、多药耐药基因的异常表达、pH值以及念珠菌毒力因子的基因多态性有关。临床规范用药以及选用非唑类抗真菌将有助于预防和治疗RVVC。     

盆腔脏器摘除术:1974～1992年回顾

1974～1992年英国伊丽莎白医院妇科83例晚期恶性肿瘤患者接受盆腔脏器摘除术。31例晚期病人为首次治疗,其中15例宫颈癌,7例阴道癌及5例外阴癌。外阴癌盆腔脏器切除的指征为肿瘤侵至阴道中上2/3或膀胱,同时行根治性外阴切除术及腹股沟淋巴结剖视。如术前检查提示中心复发要作CT或MRI扫描以确定有无远处或主动脉旁淋巴结转移,有则放弃手术。     

耻骨切除术

原发性局部转移的外阴阴道癌的标准治疗方案是采用传统的外阴广泛切除加腹股沟淋巴结切除术及选择性盆腔淋巴结清扫术。但已有盆骨浸润或固定的局部晚期外阴阴道癌在治疗上是个难题。虽大多数研究认为肿瘤骨固定不能行手术治疗,但亦有采用耻骨切除术的少量报道。本文报道采用这种手术治疗12例病人的结果与评价。 1960年1月至1988年2月,Minnesota大学共对12例晚期及复发或转移外阴阴道癌病人进行了耻     

Recurrent carcinoma of the vagina following Okabayashi's radical hysterectomy for cervical carcinoma

Between 1962 and 1976, 1847 cases of cervical cancer were treated by Okabayashi's radical hysterectomy. Of these, 42 cases developed vaginal invasive carcinoma and 5 developed vaginal intraepithelial carcinoma thereafter, giving a recurrence rate of 2.5%. The vaginal recurrence rate declined annually during the period 1962-1976, and was thought to be due to the efficacy of routinization of postoperative vaginal cuff irradiation. Of the 47 recurrent cases 33 were discovered within 2 years following the operation. Seventy-two percent of the recurrent cases were asymptomatic. The importance of close follow-up of the patients during the first 2 postoperative years was denoted. The incidence of developing a secondary vaginal cancer in the cases of cervical adenocarcinoma was 10.0%, higher than the 2.2% for squamous cell carcinoma. All the recurrent cases were treated with vaginal cuff irradiation, either alone or with external irradiation and/or chemotherapy. The 3-year survival rate of the patients who had vaginal recurrence alone was 40.0%, better than that of the cases accompanied with recurrence at the other sites.     

Malignant melanoma of the vagina: pejorative location

ObjectiveThe aim of this study was to describe the clinical features of vaginal melanoma and treatments available.Patients and methodsThis is a retrospective review of patients with primary vaginal melanoma operated from 2000 to 2010 at Gustave-Roussy Institute.ResultsSix patients had surgery for a vaginal melanoma out of 37 patients operated for vaginal cancer in our institute in the same period (13.6%). Median age was 53.5 years [48–66]. The melanoma presented as a macroscopically visible nodular tumor in all case. Median tumour size was 5.4 cm [1.5–15]. Five of the six patients had a [18F] fluoro-deoxy-glucose positron-emission tomography combined with integrated computed tomography (FDG-PET/CT) before surgery. Initial management included two conservative treatments and four colpectomy with one anterior exenteration. Two sigmoidcolpoplasties were performed. Lymph node metastases were found in only one patient. Median progression free survival was 10.5 months [4–51]. All patients have relapsed, three of them in the 6 months following surgery. Recurrences were local in three patients and distant in three patients. Local recurrences were surgically treated. In one case, electrochemotherapy was performed. One patient with locoregional disease underwent a pelvic isolated perfusion. One patient had a KIT mutation. Two patients died at 12 and 83 months.Discussion and conclusionVaginal melanoma had a poor prognosis. The 5-year overall survival is under 20% from literature data. Local and/or distant recurrences are frequent and new local and adjuvant treatments are currently evaluated.     

Antibody responses to a mucosally delivered HIV-1 gp120-derived C4/V3 peptide

T1-SP10MN(A) is a synthetic peptide containing a T-helper (Th), cytotoxic T cell (CTL) and a B-cell epitope derived from the HIV-1 gp120 envelope protein. This peptide can elicit both systemic and mucosal antibody responses following nasal immunization in various species. In the present study, three different mucosal immunization strategies were performed in rabbits to determine which induced a more vigorous antibody response to T1-SP10MN(A). Nasal immunization followed by nasal boosting was found to be superior at inducing both serum IgG and vaginal secretory IgA (S-IgA) when compared to nasal followed by vaginal boosting. Conversely, vaginal priming followed by vaginal boosting elicited minimal serum IgG and vaginal S-IgA responses to T1-SP10MN(A), but moderate levels of vaginal IgG were detected. This study further demonstrates that vaginal immune responses can be elicited by immunization at distant and local mucosal sites.     

阴道上皮内瘤变20例临床分析

目的 探讨阴道上皮内瘤变(VAIN)的临床特征、治疗方法及预后.方法 收集中国医学科学院肿瘤医院1999年1月-2007年12月收治的20例VAIN患者的临床资料,对其进行回顾性分析.结果 20例患者均无明显临床症状和体征,多数患者(17例,85%)因阴道液基细胞学检查异常或诊断为宫颈癌后而行进一步检查(妇科检查、阴道镜检查及阴道镜下活检组织病理检查)时发现,少数患者(3例,15%)为宫颈癌术后随访时发现.85%(17例)的患者合并宫颈癌(12例)或宫颈上皮内瘤变(CIN,5例).90%的患者为VAIN Ⅲ.主要发生于阴道上段(17例,85%),且多呈多灶性分布(13例,65%).VAIN的治疗主要采用手术治疗(13例)和放疗(7例),治疗后的局部控制率达100%.3例(15%)复发患者均为VAIN Ⅲ,其中1例为放疗后复发,2例为手术后复发,分别经手术或放疗后病变仍可得到有效控制.结论 单纯性VAIN诊断阑难.常合并宫颈癌或CIN,病变多位于阴道上段且呈多灶性分布,手术和放疗均可有效控制VAIN,但治疗后应密切随访,以及早发现、诊断和治疗复发病变.     

Recurrent adenocarcinoma of the endometrium: A clinical and histopathological study of 379 patients

Three hundred and seventy-nine patients with recurrent endometrial cancer were seen in the Norwegian Radium Hospital from 1960 to 1976. Local recurrence was found in 190 patients (50%), distant metastases in 108 patients (28%), and in 81 patients (21%) local recurrence and distant metastases were found simultaneously. Thirty-two percent of all patients had no symptoms at the time of diagnosis of the recurrence. The median time interval between primary treatment and detection of recurrence was 14 months for patients with local recurrence and 19 months for those with distant metastases. Thirty-four percent of all recurrences was detected within 1 year and 76% within three years of primary treatment. In 10% recurrence was diagnosed more than 5 years after primary treatment. Twenty-two of the 190 patients (12%) with local recurrence, 5 of the 108 patients (5%) with distant metastases, and 2 of the 81 patients (2%) with local recurrence together with distant metastases survived and were without evidence of disease at the end of the observation period (3–19 years). Radiotherapy alone or in combination with surgery was given in 24 of the 29 “cured” patients; 16 of them received progestagens in addition. Three of the survivors were treated with progestagens alone. The median survival time for patients with lung metastases only, who were treated with progestagens, was considerably longer when compared to those without treatment (9 vs 2 months). The need for nonhormonal cytotoxic chemotherapy in the treatment of recurrent endometrial carcinoma is stressed.     

Interstitial Brachytherapy for Vaginal Recurrences of Endometrial Carcinoma

OBJECTIVE: The aim of this study was to evaluate the efficacy of interstitial brachytherapy in the management of vaginal recurrences of endometrial carcinoma. METHODS: Thirty patients received interstitial irradiation, with or without external beam radiotherapy. They were followed for a minimum of 5 years or until death. RESULTS: The median age was 66 years at initial diagnosis of endometrial cancer. FIGO stages included Stage I (n = 18), Stage II (n = 7), and Stage III (n = 5). All patients were treated originally by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy, and 13 (43%) also received postoperative adjuvant whole pelvis radiotherapy as part of their primary treatment. Vaginal recurrences were diagnosed at a mean interval of 29 months after hysterectomy (range, 3-119 months). No patient had clinical evidence of pelvic sidewall extension or of distant metastatic disease. All patients were treated with interstitial brachytherapy; each implant delivered a mean maximal tumor dose of 25.5 Gy. Eighteen patients (60%) also received external beam radiotherapy (mean dose, 48 Gy) as part of their treatment for vaginal recurrence. Twenty-eight patients (93%) experienced a complete clinical response. Ten patients relapsed in the vagina (n = 5) or at distant sites (n = 5). Eleven patients are dead of disease. From the time of vaginal recurrence, the median overall survival was 60 months and the cause of death adjusted 5-year survival rate was 65%. Major morbidity included radiation proctitis (n = 2), fistula (n = 2), and radiation stricture (n = 1). CONCLUSION: Interstitial irradiation resulted in favorable local control as well as a 5-year survival rate and morbidity comparable to that reported previously for conventional brachytherapy.     

Vulvar and vaginal cancers and dysplasia in France—An analysis of the hospital medical information system (PMSI) database

Objective

Literature on the epidemiology of vulvar and vaginal cancers is scarce. The incidence of these diseases seems to be increasing. It has been reported that about 40% of vulvar and 70% of vaginal cancers may be linked to human papillomavirus (HPV). This study aimed to assess the medical burden associated with hospitalizations and management of vulvar and vaginal cancers and dysplasia (VIN and VaIN) in France.

Study design

A retrospective analysis using the French national hospital database (PMSI) was performed to assess the annual number of patients hospitalized for vulvar and vaginal cancers and VIN/VaIN, based on hospital admissions in 2006. Data for all stays and chemotherapy/radiotherapy sessions were extracted. SAE database (Statistiques annuelles des établissements de santé) was used to take into account patients who had radiotherapy sessions performed in the private sector which are not reported in the PMSI.

Results

In 2006, 1237 and 623 patients were hospitalized for vulvar cancer and VIN, respectively. There were also 728 and 244 patients hospitalized for vaginal cancer and VaIN, respectively. Overall, about 35% of all patients were hospitalized in the private setting. For all lesions except vaginal cancer, surgery was the most common type of management. For vaginal cancer, medical care was the most prevalent (52%), followed by surgery (31%).

Conclusion

The burden of hospitalizations due to vulvar and vaginal cancers is substantial. Further research is needed to assess the outpatient burden due to these diseases especially for precancerous dysplasia which may be mostly managed in an outpatient setting.     

Salvage treatment with high-dose-rate brachytherapy for isolated vaginal endometrial cancer recurrence

OBJECTIVE: To evaluate the outcome of patients with recurrent vaginal endometrial cancer treated with high-dose-rate brachytherapy (HDRB) and external beam radiation therapy (EBRT). MATERIALS AND METHODS: The records of all patients diagnosed with endometrial cancer who had presented an isolated vaginal recurrence in our institution between January 1, 1997 and December 30, 2003 were reviewed. Twenty-two patients were identified; 18 (82%) received both EBRT and HDRB, and 4 (18%) received HDRB only. The median EBRT dose prescribed was 45 Gy (range: 44-50.4), and median HDRB was 26 Gy (range: 8-48). Recurrence-free intervals as well as disease-specific survival rates were noted. Complications were assessed in terms of early and late Radiation Therapy Oncology Group toxicity (grade 3 or worse) of the gastrointestinal tract, genitourinary tract and vagina. RESULTS: Median age at recurrence for the 22 patients was 72 years (range: 54-86). Median recurrence time was 20 months (range: 4-135). A complete response was achieved in 100% of patients. After a median follow-up of 32 months (range: 11-78), no patient had locoregional recurrence; 1 developed distant metastasis and died from the disease. Five-year local control, disease-free survival and disease-specific survival were 100%, 96% and 96%, respectively. Four patients (18%) presented grades 3-4 gastrointestinal toxicity, and 11 (50%), grade 3 vaginal toxicity. CONCLUSION: Recurrent vaginal endometrial cancer is amenable to salvage therapy with HDRB and EBRT.     

Adjuvant treatment and analysis of failures in patients with high-risk FIGO Stage Ib–II endometrial cancer: An Italian multicenter retrospective study (CTF study)

Objectives

The purpose of this retrospective study was to assess the clinical outcome of patients with high-risk, early-stage endometrioid endometrial cancer (stage Ib or II with myometrial invasion > 50%, grade 2–3).

Methods

We assessed 192 patients who underwent hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy, had histologically negative pelvic nodes, and had negative CT findings for aortic node involvement.

Results

Tumor relapsed in 36 patients after a median time of 21.2 months. The recurrence was vaginal in 7 (19.4%), distant in 16 (44.4%), aortic in 8 (22.2%), and involved multiple sites in 5 (13.9%). There was a trend to a lower vaginal recurrence rate in the 143 patients who received adjuvant radiotherapy (+ chemotherapy) compared with the 46 who did not (2.1% versus 8.7%). Distant or aortic recurrences were lower in the 37 patients who received adjuvant chemotherapy (+ radiotherapy) than in the 152 who did not (2.7% versus 18.4%, p = 0.02). Of the 29 patients who received sequential adjuvant chemotherapy and radiotherapy, none developed local recurrence and only one had distant recurrence. There was a trend for a better 5-year progression-free survival and overall survival for the patients who received chemotherapy (+ radiotherapy) compared with those who did not (86.0% versus 71.3%, and 92.3% versus 75.6%, respectively).

Conclusions

Our data appear to suggest that adjuvant chemotherapy reduces the risk of distant or aortic recurrences and that sequential adjuvant chemotherapy and radiotherapy achieve an excellent local and distant control of disease in these clinical settings.     

老年妇科恶性肿瘤160例临床分析

目的 :探讨老年妇科恶性肿瘤的临床特点及防治经验 ,提出有效保健措施。方法 :回顾分析 16 0例老年妇科恶性肿瘤的病历资料。结果 :6 4例宫体癌居首位 ,其次是卵巢癌 6 2例 ,12例宫颈癌为第 3位。 16 0例中 88例 (5 5 % )以阴道出血为主诉就诊 ,90例(5 6 .2 5 % )有内外科合并症。术前合并内外科疾病的肿瘤患者发生术后并发症例数与无合并症者发生的例数之间差异有高度显著性 (P <0 .0 1)。结论 :子宫内膜癌发病率有上升趋势 ;阴道超声及宫腔细胞学联合检查是较好的筛查内膜癌及癌前病变的方法 ;对老年患者术前应积极治疗合并症 ,加强围手术期的处理 ,减少并发症的发生。只要处理得当、在严密监护下老年人几乎可以耐受各种妇科手术。加强妇女保健、开展普查普治是降低妇科恶性肿瘤发病率 ,提高治愈率的有效措施