Laparoscopic Extraperitoneal Pelvic Lymph Node Debulking in Locally Advanced Cervical Cancer

Study Objective

To show the feasibility of the laparoscopic extraperitoneal approach for pelvic metastatic lymph node debulking in locally advanced cervical cancer.

磁共振成像对子宫内膜癌术前分期及肌层浸润的价值探讨

目的 :回顾性分析了子宫内膜癌的磁共振成像 (MRI)表现和手术病理结果 ,探讨MRI在子宫内膜癌的术前分期和肌层浸润中的诊断价值。方法 :1 9例子宫内膜癌的诊断和分期均经手术和病理检查确诊 ,术前MRI检查采取横断位和矢状位的T1W和T2W成像 ,子宫内膜癌MRI分期按 1 988年FIGO分期原则。结果 :MRI分期的准确率达 78 9% ,其中对Ⅰ期的准确率为 92 .8% ,Ⅱ期的准确率为 1 0 0 % ,Ⅰ期和Ⅱ期的总准确率为 93 .7% ;对肌层浸润定位的准确率为85 .7%。结论 :MRI是子宫内膜癌术前分期和肌层浸润定位的一种优越方法。     

预测子宫内膜癌患者腹主动脉旁淋巴结转移方法的研究进展

子宫内膜癌是妇科常见恶性肿瘤之一,发病率逐年上升。淋巴结转移为子宫内膜癌患者的主要转移途径,其中盆腔淋巴结转移较为常见,腹主动脉旁淋巴结转移较为少见。但存在腹主动脉旁淋巴结转移的患者预后相对较差。腹主动脉旁淋巴结转移情况可以通过术前、术中相关方法进行预测。预测子宫内膜癌患者是否存在腹主动脉旁淋巴结转移方法的研究近年来发展迅速,但目前尚无预测方法的统一标准。综合分析患者的病理、血清学和影像学检查方法对腹主动脉旁淋巴结转移的预测价值,对指导临床决策,避免不必要的腹主动脉旁淋巴结切除术,减少不良反应,降低手术费用以及选择合适的术后辅助治疗显得尤为重要。     

Pelvic Lymph Node Metastases in Early Invasive Carcinoma of the Cervix - Histopathological ''Risk'' Factors

Histopathological features in 89 cases of Stage 1B and early 2A invasive carcinoma of the cervix who underwent Wertheim radical hysterectomy and pelvic lymphadenectomy were studied. Depth of tumour invasion and lymphatic/vascular space permeation by tumour cells were significantly associated with lymph node metastases. The other features such as tumour type, and stromal leucocytic reaction showed no significant relationship to the presence of lymph node metastases.     

前哨淋巴结活检对早期宫颈癌盆腔淋巴结转移诊断的Meta分析

目的:系统评价前哨淋巴结活组织检查术(SLNB)用于宫颈癌早期盆腔淋巴结转移诊断的临床价值。方法:计算机全面检索Pub Med、Embase、Medline数据库及中国知网、万方、维普数据库,检索2001~2013年国内外关于SLNB确定早期宫颈癌盆腔淋巴结的研究,用Meta分析的相关软件Meta Disc1.4进行统计学处理。结果:筛选出文献11篇,患者共581例。最后合并的早期宫颈癌SLNB的敏感度为0.86(95%CI 0.78~0.91),特异度为0.98(95%CI 0.97~0.99)。结论:合并后早期宫颈癌SLNB的敏感度、特异度较高,其对诊断宫颈癌淋巴结转移是可靠的。     

Comparison Study of Laparoscopic Sentinel Lymph Node Mapping in Endometrial Carcinoma Using Carbon Nanoparticles and Lymphatic Pathway Verification

Study ObjectiveTo evaluate the detection rate and accuracy of sentinel lymph node (SLN) mapping using cervical and fundal injections of carbon nanoparticles (CNPs) in laparoscopic surgery of endometrioid endometrial cancer (EC) and to identify uterine lymphatic drainage pathways validated by mapping.DesignA prospective consecutive study (Canadian Task Force classification II-2).SettingAn academic research center.PatientsConsecutive patients with a pathologic diagnosis of early-stage EC scheduled for primary laparoscopic-assisted staging surgery (laparoscopic hysterectomy, bilateral salpingo-oophorectomy, or comprehensive lymphadenectomy).InterventionsEnrolled patients underwent laparoscopic SLN mapping with a 50-mg CNP tracer injection. Fifty patients received fundal subserosal injections at 4 sites (the fundal group), whereas 65 patients received cervical submucosal injections at 2 sites (the cervical group). After SLN mapping, all patients underwent laparoscopic staging surgery.Measurements and Main ResultsNo allergic reactions to CNPs were observed in either group. The overall SLN detection rates were 100% and 92% in the cervical and fundal groups, and the bilateral SLN detection rates were 97% and 68% (p < .001), respectively. A total of 12 metastatic SLNs were accurately detected in 5 patients. The sensitivity of metastatic lymph node detection was 100% in the cervical group, which is higher than that in the fundal group (80%). The false-negative rates were 0% and 20%, respectively, in the cervical and fundal groups. Furthermore, we verified 3 uterine lymphatic pathways using the 2 injection methods. The upper paracervical pathway was the most common drainage pathway in both groups (91.4% in the cervical group vs 80.24% in the fundal group), whereas the infundibulopelvic pathway was observed only in the fundal group (15.11%).ConclusionSLN mapping by CNPs in laparoscopic surgery for EC is a safe and effective alternative, with a higher detection rate and better accuracy with cervical injections than fundal injections. The upper paracervical pathway was the most common lymphatic pathway, whereas the infundibulopelvic pathway was only displayed in fundal injections.     

宫颈癌和子宫内膜癌诊疗中盆腔淋巴结状态的检测及意义

淋巴结转移作为宫颈癌和子宫内膜癌的主要转移途径,是影响其预后的重要因素。在治疗前和治疗过程中如何检测和评估这2种恶性肿瘤的盆腔淋巴结状态仍处于初步探索阶段。目前检测淋巴结状态的方法有超声检查、计算机断层扫描、磁共振成像（MRI）、正电子发射计算机断层显像（PET-CT）和前哨淋巴结活检定位等。不同检查方法的原理不同,其敏感度、特异度和准确度等方面各有优劣。随着影像学技术及显像生物制剂的发展,淋巴结状态检测已由单纯形态学向功能学转变。彩色多普勒超声、弥散加权成像及PET-CT等均在传统影像学技术上进一步提高了敏感度和特异度,其中PET-CT和功能性MRI在检测的敏感度、特异度和准确度等方面尤其具有优势;显像生物制剂通过不断发展,已逐渐细化为针对淋巴结内肿瘤细胞代谢、血管和淋巴回流等三方面的特异性淋巴造影剂。     

Sentinel Lymph Node Biopsy in Vulvar Cancer: A Health Technology Assessment for the Canadian Health Care Context

ObjectiveInguinofemoral lymphadenectomy for vulvar cancer is associated with a high incidence of groin wound complications and lymphedema. Sentinel lymph node biopsy (SLNB) is a morbidity-reducing alternative to lymphadenectomy. The objective of this health technology assessment was to determine the clinical effectiveness, costeffectiveness, and organizational feasibility of SLNB in the Canadian health care system.MethodsA review of the English-language literature published from January 1992 to October 2011 was performed across five databases and six grey-literature sources. Predetermined eligibility criteria were used to select studies, and results in the clinical, economic, and organizational domains were summarized. Included studies were evaluated for methodologic quality using the Newcastle-Ottawa Scale.ResultsOf 825 reports identified, 88 observational studies met the eligibility criteria. Overall study quality was poor, with a median Newcastle-Ottawa Scale score of 2 out of 9 stars. Across all studies, the detection rate of the sentinel lymph node was 82.2% per groin and the false-negative rate was 6.3%. The groin recurrence rate after negative SLNB was 3.6% compared with 4.3% after negative lymphadenectomy, and complications were reduced after SLNB. No economic evaluations were identified comparing SLNB to lymphadenectomy. Safe implementation of SLNB requires appropriate patient selection, detection technique, and attention to the learning curve.ConclusionAlthough study quality is poor, the available data suggest implementation of SLNB may be safe and feasible in Canadian centres with adequate procedural volumes, assuming that implementation includes careful patient selection, careful technique, and ongoing quality assessment. Cost-effectiveness has yet to be determined.     

An Analysis of Cell Type in Patients with Surgically Staged Stage IB Carcinoma of the Cervix: A Gynecologic Oncology Group Study

The influence of cell type on recurrence-free interval (RFI) and survival after radical hysterectomy for patients with Stage IB carcinoma of the cervix was investigated. Patients with Stage IB carcinoma of the cervix (>3-mm invasion) underwent a radical hysterectomy and pelvic lymphadenectomy. Patients with involved paraaortic nodes or gross extracervical disease were excluded. Of 813 evaluable patients, 645 had squamous, 104 with adenocarcinoma, and 64 had adenosquamous cell type. The time to failure and the following clinical/pathologic characteristics were compared among the three cell types: age, Gynecologic Oncology Group performance status (PS), gross versus occult tumor, histologic grade, depth of invasion, node status, uterine extension, parametrial extension, surgical margins, and capillary–lymphatic space (CLS) involvement. A Cox proportional hazards model was used to compare the patients with adenosquamous and adenocarcinoma to those with squamous while adjusting for prognostic factors. The median age was 40 years (range, 21–87). Pelvic nodes were involved in 119 (15%) of patients. There were no significant differences between cell types in distributions of the following factors: age, PS, positive nodes, depth of invasion, uterine extension, surgical margins, or parametrial extension. There were statistically significant differences between cell types with regards to grade (P< 0.001), gross versus occult primary status (P= 0.016), and CLS involvement (P= 0.005). There was no statistically significant difference detected between cell types in crude comparisons of RFI (P= 0.29); however, there was a difference in survival (P= 0.02) with shorter survival seen in the adenosquamous cell type. After adjusting for CLS involvement, PS, depth of invasion, and clinical tumor size, survival remained worse for patients with adenosquamous primaries when compared to squamous carcinoma (P= 0.02) and adenocarcinoma (P= 0.007). In conclusion, no statistically significant differences were seen in RFI among cell types; however, in patients with Stage I carcinoma of the cervix overall survival after radical hysterectomy may be slightly worse for those with adenosquamous cell type.     

59例Ⅰ期子宫内膜癌的治疗分析

为探讨Ⅰ期子宫内膜癌更为合理的治疗方案,方法将５９例Ⅰ期子宫内膜癌患者随机分为两组：第１组３０例,单纯全子宫,双附件切除加辅助治疗;第２组２９例,行全子宫,双附件切除加盆腔淋续清扫或活检。结果第１组中死亡２例,２年和５年的存活率均为９６．６％平均生存６９．７个月。第２组中死亡３例。     

Epidemiologic and Surgicopathologic Findings of Papillary Serous and Clear Cell Endometrial Cancers When Compared to Endometrioid Carcinoma

PURPOSE: The aim of this study was to identify similarities and differences in epidemiologic and surgicopathologic staging results for papillary serous (PS) and clear cell (CC) endometrial cancers compared with endometrioid (EM) carcinoma of the endometrium. METHODS: Clinical and surgicopathologic data were retrospectively collected on 574 clinical stage I-II endometrial cancer patients, including 53 PS and 18 CC (based on postoperative histology), undergoing hysterectomy at Duke University Medical Center between 1967 and 1990. All staging material was available and reexamined prior to this analysis, and FIGO surgical staging was retrospectively assigned. PS and CC histologic subtypes were compared both as a common category and as discrete categories versus EM, EM grade 1 (EM1), EM grade 2 (EM2), and EM grade 3 (EM3). Fisher's exact test was used to compare proportions with unordered categories (2x2 tables), while the chi(2) test for trend was used to compare proportions in 3x2 tables with ordered categories. Differences in medians were compared with the Wilcoxon rank-sum test. RESULTS: PS tumors accounted for 8%, CC for 2%, and EM for 90% of cases. Overall, 14% of tumors were changed to a different postoperative histology including 64% of PS, 50% of CC, and 8% of EM. Postoperative histology changes were 4% for EM1 and 21% for EM3. PS, CC, and EM3 had more surgical sampling performed than for other EM. Rates for lymph node dissections were similar for EM3 (81%), PS (72%), and CC (67%) tumors, although metastases were more frequent for PS and CC compared with EM3. When PS tumors were confined to the endometrium, paraaortic metastases occurred in 13%. LVSI increased with EM grade and was highest for PS and CC. Upstaging to surgical stage III-IV occurred in 47% of PS, 39% of CC, and 12% of EM. The majority of PS and CC tumors were confined to the inner one-third of the myometrium, compared with EM tumors, where grade correlated with depth of myometrial invasion. Extrauterine metastases occurred in 55% of PS and 45% of CC tumors confined to the inner one-half, compared with 17% of EM3. CONCLUSION: Frequent changes from preoperative to postoperative histology and grade may contribute to misassignment of preoperative and intraoperative risk as determined by depth of myometrial invasion for PS and CC patients. The higher frequency of extrauterine metastases in PS and CC tumors compared with EM3, despite similar surgical sampling rates, supports a more virulent behavior. The poor correlation between depth of myometrial invasion and risk for extrauterine metastases helps to explain poorer survival in PS and CC patients, in addition to more frequent upstaging. These results support routine extended surgical staging for women with preoperative or intraoperative diagnosis of PS and CC tumors. Intraoperative assessment of tumor grade and histology may be indicated and warrants further investigation.     

Ⅰ期子宫内膜癌腹膜后淋巴结清除术的探讨

目的 探讨Ⅰ期子宫内膜癌的淋巴结转移率及行腹膜后淋巴结清除术的意义。方法 对３８例临床Ⅰ期子宫内膜癌临床、病理及随访资料呃生研究,对照分析经行腹膜后淋巴清除术后,未淋巴转移者２２例,ＦＩＧＯＩ期（Ａ组）,有淋巴结转移者６例,ＦＩＧＯ升级为ⅢＣ期（Ｂ组）及术行腹膜后淋巴清除扔１０例（Ｃ组）结果 经腹膜后淋巴清除术的患者中２１．４％有腹膜后淋巴结转移,因此期别应上升为ⅢＣ期,且腹膜后淋巴结转移与肿瘤细     

Preoperative assessment of myometrial and cervical invasion in endometrial carcinoma by transvaginal ultrasound

Objective

To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in preoperative assessment of the depth of myometrial infiltration and the presence of cervical invasion in endometrial carcinoma.

Methods

298 consecutive patients with a diagnosis of endometrial cancer were evaluated by TVS within 3 days of surgical intervention. The depth of myometrial invasion was classified into two groups: no or < 50% invasion and ≥ 50% invasion. Invasion of cervix was diagnosed when the neoplastic tissue distended the cervix and showed ill-defined borders with the cervical stroma.

Results

The sensitivity, specifity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy of TVS in evaluation of the depth of myometrial infiltration were 68.4%, 82%, 65.1%, 84.1% and 77.5%, respectively. While the sensitivity and PPV were significantly higher among grade 3 tumors, the specifity, NPV and accuracy were significantly higher among grade 1 tumors.The sensitivity, specifity, PPV, NPV, and overall diagnostic accuracy of TVS in assessment of the presence or absence of neoplastic tissue in cervix were 76.5%, 99.3%, 86.7%, 98.2% and 98%, respectively. While the sensitivity and PPV were significantly higher among grade 1 tumors, the NPV and accuracy were significantly lower among grade 3 tumors.

Conclusion

TVS can be considered as a feasible, economical and simple imaging modality with a high diagnostic accuracy for the prediction of cervical involvement. However, it is not a reliable method in estimating the depth of myometrial infiltration.     

影像学检查在宫颈癌盆腹腔淋巴结转移诊断中的价值

2018年国际妇产科联盟（International Federation of Gynecology and Obstetrics,FIGO）更新宫颈癌分期,将治疗前影像学诊断盆腔淋巴结转移定义为ⅢC1r期,腹主动脉旁淋巴结转移定义为ⅢC2r期。术前影像学检查评估盆腹腔淋巴结是否转移与诊疗方案的制定相关,影像学准确地判断盆腹腔淋巴结状态可以明确分期,让患者接受规范的诊疗。目前临床上影像学检查方法众多,常用检查有B超、盆腔磁共振成像（magnetic resonance imaging,MRI）、计算机体层摄影术（computed tomography,CT）、正电子发射体层摄影术（positron emission tomography,PET）/CT及PET/MRI。B超经济方便,但对淋巴结检出率过低;CT在国内使用广泛、检查速度快,扫描范围大,临床应用易于推广,但CT诊断缺乏统一的诊断标准,诊断价值不突出;MRI具有良好的组织分辨率、能同时实现功能成像,但存在检查敏感度不高的情况;PET检查准确性较其他影像学检查较高,但其敏感度较MRI及CT检查并无统计学上的差异。     

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。     

Prognostic Factors for Relapse and Pelvic Lymph Node Metastases in Early Stage I Adenocarcinoma of the Cervix

OBJECTIVES: The aim of this study was to assess the prognostic significance of local tumor factors in predicting lymph node metastases and/or recurrence in early adenocarcinoma of the cervix. METHODS: Patients were selected from the prospective computerized cervical cancer database of the division of gynecologic oncology. All patients had radical surgery and pelvic lymph node dissection. The study population consisted of all patients with stage I adenocarcinoma having tumor thickness <10 mm. Pathology was re-reviewed to assess histological subtype, depth, volume, grade, and presence of capillary lymphatic space involvement. RESULTS: The study group consisted of 68 patients, with a mean age of 40 years. The median follow-up was 40 months (range 8-102 months). The median tumor depth and volume were 2.8 mm (range 0.3-8.0 mm) and 237 mm(3) (range 0.1-7996 mm(3)), respectively. Twenty-two patients had tumor volumes greater than 600 mm(3), and of these, 5 (23%) patients either had positive pelvic lymph nodes (2) or developed recurrent disease (3) (none node positive) at a median time of 49 months. In comparison, 46 patients (68%) had tumor volumes of less than 600 mm(3), none of whom had positive pelvic lymph nodes or developed recurrence (P<0.005). Only 1 of 20 patients with a depth of invasion <2 mm had a tumor volume >600 mm(3) in comparison to 21 of 48 patients with deeper invasion (P<0.002). CONCLUSION: The incidence of positive pelvic lymph nodes and/or recurrence in this patient population is very low. As all patients with metastatic disease or recurrence had tumor volumes >600 mm(3), volume of disease rather than depth of invasion may be the single most important prognostic factor for the above events. However, many more patients will have to be studied to confirm this.