原发性卵巢鳞癌23例临床分析

发布时间：2017-12-26 17:11

本文关键词：原发性卵巢鳞癌23例临床分析　出处：《广西医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:原发性卵巢鳞癌是一种发生于卵巢部位的鳞状细胞癌,为罕见的恶性肿瘤,该病预后较其他卵巢上皮癌差。其发病机制、病因仍不明确,临床表现无特异性,该疾病早期诊断困难,术前无有效的辅助诊断方法,需手术病理明确诊断,可误诊为良性肿瘤而延误治疗或未得到有效的手术治疗,目前尚缺乏规范的诊疗方案,本文回顾性分析23例原发性卵巢鳞癌的临床资料,总结其特点,提高各位临床医师对此类肿瘤的认识,得到重视,以帮助本病患者得到更好的治疗。方法:收集1997年1月至2017年1月广西医科大学附属肿瘤医院、玉林市肿瘤医院和玉林市第一人民医院收治的资料较为完整的原发性卵巢鳞癌共23例,并对其肿瘤的一般特点、临床表现、辅助检查、治疗方法及预后进行回顾性分析。结果:1.肿瘤特点:23例患者的发病年龄为35-82岁,主要集中在40-60年龄段内,中位年龄为54.00岁,平均年龄55.30岁。以绝经为主,未绝经人数与绝经人数比例为1:2.8,平均绝经时间为10.94年,PSCC主要发生于绝经15内年。肿瘤的发生主要来源于成熟畸胎瘤鳞癌变(SCC-MCT)占82.61%%,以单侧为主(86.96%),左侧多见(60.00%)。肿瘤直径5.3-21cm,平均直径为11.5cm。肿瘤分化程度以G3为主(65.22%),G(17.39%),G1(17.39%)。无论肿瘤直径的大小,肿瘤分化程度均以G3为主。2.临床表现:23例PSCC患者,临床分期以中早期(Ⅰ、Ⅱ期)为主。无论期别早晚,以下腹部胀痛为主要临床表现,且可为唯一临床表现,可伴有抗生素治疗不理想、不明原因的反复发热,以及伴有排便改变、腰痛、干咳气促。可合并有不同程度的贫血以及肾功能不全。3.辅助检查:23例PSCC患者进行了腺鳞癌肿瘤标志物的检查,其中SCC-Ag、CYFRA21-1、CA125的阳性率相对较高,分别为SCC-Ag阳性10例(43.48%),CYFRA21-1阳性10例(43.48%),CA125阳性12例(52.17%),其他肿瘤标志物均有不同程度及比例的升高。B超主要表现为盆腔的混合性包块,CT、MR主要表现为附件区实性或囊实性占位,囊壁增厚明显,可有不同程度的强化。4.治疗情况不同临床分期患者的治疗情况。(1)ⅠA期4例,其中4例均为手术+化疗。(2)ⅠC期5例,其中2例手术,3例为手术+化疗。(3)ⅡA期1例,其中1例为手术+化疗。(4)ⅡB期8例患者,其中2例手术,5例手术+化疗,1例化疗。(5)ⅢB期2例,2例均为手术+化疗。(6)ⅢC期3例,3例均为手术+化疗。不同临床分期患者的手术情况及术后病理情况:23例PSCC患者中,行全子宫+双附件切除术的有19例。其中ⅠA期4例,ⅠC期4例,ⅡA期1例,ⅡB期5例,ⅢB期2例,ⅢC期3例。1例ⅡB期未切除子宫及附件,1例ⅠC期、2例ⅡB期例只切除了附件。行腹膜后淋巴结切除术的有13例,其中ⅠA期3例,均行盆腔淋巴结清扫+腹主动脉旁淋巴结切除术;ⅠC期4例,2例行盆腔淋巴结切除术,2例行盆腔淋巴结清扫+腹主动脉旁淋巴结切除术;ⅡA期1例行盆腔淋巴结清扫术;ⅡB期4例,1例行盆腔淋巴结清扫术,3例行盆腔淋巴结清扫+腹主动脉旁淋巴结切除术。除了腹膜后淋巴结切除,其中有1例ⅡB期行肠系膜淋巴结切除,1例ⅢC期行肠周淋巴结及肠系膜淋巴结的切除,12例术后病理均未示肿瘤转移,1例ⅢC期腹主动脉旁淋巴结转移,1例肠周淋巴结转移,2例肠系膜淋巴结均未见转移。行大网膜切除术的有13例,其中ⅠA期2例,ⅠC期4例,ⅡB期4例,ⅢC期2例,11例术后病理未示肿瘤转移,2例示有肿瘤侵犯,且均为ⅢC期。行阑尾切除术的有6例,其中ⅠC期3例、ⅢB期1例、ⅢC期2例,6例术后病理均未示肿瘤转移。不同化疗方案的统计情况及不同临床分期患者的化疗情况:23例PSCC患者中18例进行了化疗,其中1例为单药化疗,17例为联合化疗,其中按卵巢上皮癌方案化疗的有13例,按卵巢生殖细胞恶性肿瘤方案化疗的有4例。(1)ⅠA期4例,1例术前予BEP方案行新辅化疗1程,术后BEP方化疗4程,1例于术中顺铂腹腔灌注+环磷酰胺静脉化疗1程,术后予BVP方案、BEP方案化疗各1程;1例于术后予紫杉醇+奈达铂方案化疗7程;1例于术后予紫杉醇+奈达铂方案化疗6程。(2)ⅠC期5例,3例未化疗,1例于术后1月因肿瘤未控予DC方案化疗1程,化疗后予肿瘤细胞减灭术,再予术后DC方案化疗共5程。1例于术后分别予DP,多西他赛+奥沙利铂化疗1程、5程。(3)IIA期1例,于术后予TP方案化疗1程未继续化疗,复发后予TP方案化疗6程。(4)IIB期8例,2例未化疗,1例于活检术后予紫杉醇+洛铂方案化疗1程;2例分别于术后予DP方案化疗2、6程。2例于术后予TP方案化疗2、3程,因化疗毒副反应更换为TC方案继续化疗2程。1例于术后予紫杉醇+奈达铂方案化疗2程,未继续治疗10个月后复发,复发后予紫杉醇+奈达铂方案化疗8程,10个月后二次复发,更改多西他赛+奥沙利铂方案化疗4程。(5)IIIB期2例,1例术后予洛铂化疗,具体不详,1例于术后CTX+DDP方案化疗3程,BEP方案化疗1程。(6)IIIC期3例,1例于术后予DP方案化疗8程,1例于再次肿瘤细胞减灭术后予DP方案化疗3程,因肿瘤未控更改脂质体阿霉素+奈达铂化疗1程,1例于术后TP方案化疗3程、BEP方案化疗3程,复发手术后予DC方案化疗3程,因肿瘤进展更换长春瑞滨+替吉奥化疗3程。5.随访及预后(1)ⅠA期4例,病例序号1-4。病例1:患者发病后1个月进行了手术治疗(子宫+双附件切除术),术中予腹腔灌注化疗,术后3周予化疗1程,之后未继续遵嘱化疗,5个月后肿瘤进展,肿瘤进展后予化疗1程,未继续治疗,最终死亡,生存时间为13个月。病例2:患者发病1个月进行了手术治疗(患侧附件切除),因术后病理提示恶性,于1个月后补充了分期手术,术后未遵嘱化疗,12个月后出现阴道残端、盆腔复发、腹膜后多发淋巴结转移、全身多处骨转移,复发后予化疗7程,期间肿瘤部分缓解,后因小肠阴道残端瘘未能继续化疗,停化疗2个月后肿瘤继续进展,最终死亡,生存时间为29个月。病例3:患者发病1年进行了手术治疗(患侧附件切除),因术后病理提示恶性,于5周后补充分期手术,术后化疗6次,目前无瘤生存,生存时间为43个月。病例4:患者发病2个月后行手术(患侧附件切除),因术后病理提示恶性,且影像学考虑有肿瘤残留,术后2周行化疗1程,化疗后5周补充分期手术,术后继续化疗4程,目前无瘤生存,生存时间为57个月。(2)ⅠC期5例,病例序号5-9。病例5:患者发病后4个月行手术治疗,术后1个月出现肿瘤进展:未继续治疗,最终死亡,生存时间10个月。病例6:患者发病4年余行手术治疗,要求不扩大手术及不进行化疗,目前无瘤生存,生存时间为74个月。病例7:患者发病3周进行手术治疗,术后出现下肢血栓未能进一步治疗,术后1个月出现肿瘤进展,乙状结肠转移,盆腔转移,术后2个月先予化疗1程,化疗后1个月进行了肿瘤细胞减灭术,肿瘤细胞减灭术后化疗5程,化疗期间肿瘤继续进展,最终死亡,生存时间为18个月。病例8:患者发病1个月行手术治疗,术后8天开始予化疗共6程,目前无瘤生存,生存时间12个月。病例9:患者发病予手术治疗,术后拒绝化疗,已失访。(3)ⅡA期1例,病例序号10:患者发病后进行了手术治疗,术后化疗1程,未遵嘱继续化疗,10个于后发现肝转移,行TP方案化疗6疗程,目前存活,生存时间17个月。(4)ⅡB期7例,病例序号11-14。病例11:患者发病2月行开腹活检确诊,后予化疗1程,因患者合并症严重且身体状况差未继续治疗,最终死亡,生存时间5个月。病例12:患者发病后即予手术治疗,术后化疗5程,因化疗毒副反应未继续化疗,停止化疗后2月肿瘤进展,最终死亡,生存时间12个月。病例13:患者发病2个月后行手术治疗,因不同意化疗未继续治疗,术后5个月出现肿瘤进展,最终死亡,生存时间12个月。病例14:患者发病2周行手术治疗(患侧附件切除),术后病理提示恶性,1个月后行肿瘤细胞减灭术,目前仍存活,继续治疗,生存时间4个月。病例15:患者发病1月予腹腔灌注化疗,化疗后2个月行手术治疗,术后化疗1程,为按时继续化疗,化疗后10个月肿瘤盆腔复发,复发后予8程化疗,疗效评价肿瘤缓解,8个月后肿瘤二次复发,继续化疗4程,肿瘤继续进展,最终死亡,生存时间39个月。病例16:患者发病3周行手术治疗,术后予2程化疗,因体质差未继续化疗,目前无瘤存活,生存时间8个月。病例17:患者发病2个月后行手术治疗(双侧附件切除),1个月后补充分期手术,术后予化疗6程,目前无瘤生存,生存时间22个月。病例18:患者发病后行手术治疗(腹腔镜双侧卵巢切除术),术后病理提示卵巢良性肿瘤(未见病理报告单),1个月后出现肠转移并行乙状结肠切除术+盆腔肿瘤切除术,术后TP方案化疗2个疗程,最终死亡,生存时间8个月。(5)ⅢB期2例,病例序号19-20。病例19:患者发病后即行手术治疗,术后5周开始予化疗共3程,化疗后1个月出现阴道残端、盆腔多发转移,继续予化疗1程,患者体质差,无法耐受继续化疗,肿瘤继续进展,最终死亡,生存时间11个月。病例20:患者发病2周行手术治疗,术后予化疗,疗程不详,因并发症及化疗副反应严重为继续治疗,术后化疗后随诊11个月肿瘤复发,经中医治疗无好转,最终死亡,生存时间为13个月。(6)ⅢC期3例,病例序号21-23。病例21:患者发病1个月进行了手术治疗,术后1个月开始化疗共7程目前存活,仍在继续化疗,疗效评价肿瘤大部分缓解,生存时间为12个月。病例22:于术后1个月出现肿瘤快速进展,再次予手术及术后辅助化疗,化疗过程中肿瘤疗效评价进展,最终死亡,生存时间10个月。病例23:患者发病后进行了手术治疗,术后分别予TP、BEP方案化疗各3程,化疗后1月考虑盆腔转移。予行回盲部肿物根治性右半结肠切除术,后予DP方案化疗3程。疗效评价为进展,更换长春瑞滨+替吉奥化疗3程,最终患者死亡,生存时间22个月。对患者的生存分析结果显示,SCC-Ag阳性的患者的生存率比SCC-Ag阴性的患者低,预后更差。结论:PSCC是一种罕见类型的卵巢癌,其组织来源多见于SCC-MCT。术前诊断PSCC仍具有挑战性,易误诊漏诊,对绝经的中老年女性,肿瘤标志物SCC-Ag阳性、肿瘤直径≥10cm、影像学检查提示囊壁增厚,强化明显的病例需引起重视,对于盆腔包块的患者,SCC-Ag的检查也是必要的,若考虑为卵巢畸胎瘤的患者还应及时处理以免发生恶变。PSCC的术中冰冻切片检测要求病理医师除了仔细检查其实质部分,还应关注囊壁厚度及结节部位,多点取材,并与手术医师充分沟通以减少漏诊。PSCC的治疗采用手术联合辅助化疗,部分患者手术的实施原则参照卵巢上皮癌,对于早期(I期),若肿瘤破裂,进行保留生育功能的手术应慎重,术后是否需要辅助化疗仍存在疑问,而中晚期的患者若需行肠切除术,腹主动脉旁淋巴结切除可能是有必要的。化疗的方案多样,目前无最佳化疗方案,但均为紫杉醇类+铂类化疗方案为主,化疗的患者可延缓复发及进展的时间,化疗患者预后较好,放疗是否有助于PSCC的治疗仍需进一步探讨。PSCC易进展、复发,SCC-Ag阳性、进展、复发及晚期的患者预后差,各临床分期复发率均较高。
[Abstract]:Objective: primary squamous cell carcinoma of the ovary is a kind of squamous cell carcinoma occurring at the site of the ovary. It is a rare malignant tumor, and the prognosis is worse than that of other ovarian epithelial cancer. The pathogenesis, etiology is still not clear, no specific clinical manifestations, early diagnosis of the disease, no preoperative diagnosis methods, surgical pathology diagnosis, may be misdiagnosed as benign tumor and delayed treatment or surgical treatment has not been effective, there is a lack of standardized diagnosis and treatment scheme, this paper analyzed retrospectively the clinical data of 23 cases of primary ovarian carcinoma, summarizes its characteristics, improve your understanding of the tumor to clinicians, get attention, to help patients get better treatment of this disease. Methods: from January 1997 to January 2017 in the Affiliated Tumor Hospital of Guangxi Medical University, Yulin cancer hospital and Yulin First People's Hospital were complete data of primary ovarian carcinoma were 23 cases, and the treatment method of general characteristics of the tumor, clinical manifestation, auxiliary examination, and prognosis were retrospectively analyzed. Results: 1. the characteristics of tumor: the age of the 23 patients was 35-82 years old, mainly in the 40-60 age group, the median age was 54 years and the average age was 55.30 years old. The proportion of the number of menopause and menopause is 1:2.8, the average menopause time is 10.94 years, and PSCC mainly occurs in the 15 year of menopause. The tumor occurred mainly from the mature teratoma squamous cell carcinoma (SCC-MCT) (82.61%%), which was mainly on the unilateral (86.96%) side, and on the left side (60%). The diameter of the tumor was 5.3-21cm, with an average diameter of 11.5cm. The degree of tumor differentiation was G3 (65.22%), G (17.39%), and G1 (17.39%). No matter the size of the tumor, the degree of differentiation of the tumor was G3. 2. clinical manifestations: 23 cases of PSCC patients, the clinical stages were mainly in the middle early stage (stage I and II). No matter the stage sooner or later, following abdominal pain as the main clinical manifestations, and may be the only clinical manifestation, may be associated with antibiotic treatment is not ideal, unexplained recurrent fever, and accompanied by pain, dry cough, shortness of breath and defecation change. It can be combined with varying degrees of anemia and renal insufficiency. 3. auxiliary examination: 23 cases of PSCC patients with adenosquamous carcinoma of the tumor markers examined, the positive rate of SCC-Ag, CYFRA21-1 and CA125 were relatively high, SCC-Ag was positive in 10 cases (43.48%), 10 cases were CYFRA21-1 positive (43.48%), 12 cases were CA125 positive (52.17%), other tumor markers increased in varying degrees and the proportion of. The main manifestations of B-ultrasound are the mixed mass of pelvic cavity. CT and MR are mainly manifested in the solid or cystic mass in the appendage area, and the thickening of the wall of the capsule is obvious, which can be strengthened in varying degrees. 4. treatment of patients with different clinical stages. (1) there were 4 cases in phase I A, of which 4 were operated with chemotherapy. (2) there were 5 cases in stage I C, of which 2 cases were operated and 3 cases were operated plus chemotherapy. (3) 1 cases in phase II A, of which 1 were operated plus chemotherapy. (4) there were 8 patients in phase II B, of which 2 cases were operated, 5 cases were operated with chemotherapy, and 1 cases were treated with chemotherapy. (5) 2 cases in stage III B, 2 cases were all operation plus chemotherapy. (6) 3 cases in stage III C, 3 cases were all operation plus chemotherapy. The operation and postoperative pathology of patients with different clinical stages: 19 of the 23 PSCC patients underwent total uterine plus double annexectomy. There were 4 cases in stage I A, 4 in stage I C, 1 in stage II A, 5 in stage II B, 2 in stage III B, 3 in stage III C. 1 cases of unresected uterus and appendages in phase II B, 1 cases of stage I C and 2 cases of II B were removed. Retroperitoneal lymph node resection in 13 cases, including 3 cases of stage A underwent pelvic lymph node dissection + paraaortic lymph node resection; 4 cases of stage C, 2 cases of pelvic lymph node resection, 2 cases of pelvic lymph node dissection + paraaortic lymph node excision; II A of 1 cases with pelvic lymphadenectomy; 4 patients with stage B, 1 cases of pelvic lymph node dissection, 3 cases of pelvic lymph node dissection + paraaortic lymph node excision. In addition to the retroperitoneal lymph node resection, including 1 cases of stage II B for mesenteric lymph node resection, 1 cases of stage C underwent intestinal lymph node and mesenteric lymph node resection, postoperative pathology in 12 cases were not shown in tumor metastasis, 1 cases of stage C paraaortic lymph node metastasis, 1 cases of intestinal week lymph node metastasis, 2 cases of mesenteric lymph node metastasis were not found. Greater omentum resection in 13 cases, including 2 cases of stage A, 4 cases of stage C, 4 patients with stage B, 2 cases of stage C, 11 cases of postoperative pathology showed 2 cases with tumor metastasis, tumor invasion, and is the stage C. There were 6 cases of appendectomy, of which 3 cases in stage I C, 1 cases in stage III B, 2 cases in stage III C, and no tumor metastasis was found in 6 cases after operation. The statistics of chemotherapy and chemotherapy in different clinical stages of patients: 23 cases of PSCC patients in chemotherapy in 18 cases, including 1 cases of single drug chemotherapy, 17 cases were combined with chemotherapy, the chemotherapy according to ovarian cancer program in 13 cases, malignant germ cell tumors of ovary according to the scheme of chemotherapy in 4 cases. (1) 4 cases of stage A, 1 cases received BEP regimen for new auxiliary chemotherapy in 1, postoperative BEP chemotherapy 4, 1 cases in intraoperative intraperitoneal cisplatin + cyclophosphamide chemotherapy in 1, followed by BVP scheme and BEP chemotherapy in 1; in 1 cases after operation to paclitaxel and nedaplatin chemotherapy in 7; in 1 patients treated with paclitaxel and nedaplatin chemotherapy 6. (2) there were 5 cases of stage I C, 3 cases without chemotherapy, and 1 cases received DC chemotherapy 1 times after surgery in January. After chemotherapy, cytoreductive surgery was performed after chemotherapy, and then DC chemotherapy was given to 5 patients. 1 cases were treated with DP, docetaxel + oxaliplatin chemotherapy and 1 course, 5 course after operation. (3) 1 cases in IIA stage, and after the operation, the chemotherapy of TP regimen was not continued, and the relapse was given to the 6 course of TP regimen. (4) 8 cases in IIB stage, 2 cases without chemotherapy, 1 cases with paclitaxel plus luoplatin regimen 1 course after biopsy; 2 cases were treated with DP chemotherapy 2 and 6 course after operation. 2 cases were treated with TP chemotherapy 2 and 3 course after operation, and the chemotherapy side reaction was replaced by TC regimen to continue the 2 course of chemotherapy. 1 cases were treated with paclitaxel + nedaplatin chemotherapy 2 course after operation, and the recurrence after 10 months was not continued, and the relapse was given to purple.
【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.31

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