早期宫颈癌患者保留生育功能的腹式根治性宫颈切除术相关病理安全性评估

发布时间：2018-05-17 19:30

本文选题：腹式根治性宫颈切除术 + 腹式根治性子宫切除术　；参考：《复旦大学》2014年博士论文

【摘要】：第一部分早期宫颈癌患者行腹式根治性宫颈切除术与全子宫切除术手术范围比对目的：研究对早期宫颈癌患者行腹式根治性宫颈切除术(Abdominal Radical Trachelectomy, ART)与腹式根治性全子宫切除术(Abdominal Radical Hysterectomy, ARH),其手术方式及范围的差异。方法：前瞻性纳入自2012年8月到2013年8月间,我院IA1期伴淋巴脉管浸润及IA2期、IB1期上皮性宫颈癌患者156例,依照其个人手术意愿分为腹式根治性宫颈切除组47例及腹式根治性全子宫切除术组109例患者,术中对新鲜未行福尔马淋固定的标本进行平辅固定,并由同一位医生测量各标本两侧宫旁组织的长度、高度,膀胱宫颈韧带和宫骶韧带长度,以及3、6、9和12点阴道切除长度。应用χ2检验或Fish精确概率方检验方法对标本各韧带手术范围进行比对,分析两种手术方式手术范围的差异性。结果：ART组患者中位年龄为32岁(20-41岁),与ARH组患者相比年纪较轻,51岁(32-80岁),p0.001；在ART与ARH组中,大部分患者病理诊断为鳞癌,37例(72.3%)与79例(72.5%),以FIGO分期IB1期为主,分别为34例(75.6%)与90例(82.6%)。两组双侧宫旁平均长度分别为44.08±17.52mm和44.96±20.77 mm(p=0.432),平均宫旁平均高度分别为25.74±5.24mm和26.09±5.11mm(p=0.361)。两组平均膀胱宫颈韧带长度分别为3.85±1.76mm和4.01±2.06mm(p=0.647),平均宫骶韧带长度分别为13.30±4.86mm和12.88±4.51mm(p=0.605)。除此之外,两组阴道3、6、9及12点处切除长度均不存在统计学差异。结论：早期宫颈癌患者行经腹根治性宫颈切除术与传统的经腹根治性全子宫切除术相比,可切除同样范围的宫旁组织及韧带长度。第二部分早期宫颈癌患者宫旁淋巴结检出及其临床意义目的：采用创新的三段式宫旁淋巴结检出方法,对比经腹根治性宫颈切除术与经腹根治性全子宫切除术宫旁淋巴结检出率的差异,明确宫旁淋巴结检出的意义及其与ART手术的关系。方法：前瞻性采集自2012年8月到2013年8月间,我院IA1期伴淋巴脉管浸润及IA2期、IB1期患上皮性宫颈癌156名患者的术后新鲜标本,依照其最初手术方式将标本为ART组及ARH组,并通过三段取材法分别对两组标本的左右主韧带、子宫膀胱韧带及宫骶韧带进行分段取材,行脱水处理石蜡包埋HE染色后,镜下检查并记录各段组织中淋巴结数目、大小及其与宫旁组织内血管的关系。对于最终病理报告提示伴宫旁淋巴结转移的患者,给予紫杉醇(PTX)+卡铂(CBP)6个周期化疗。采用χ2检验或Fish精确概率方检验方法进行统计学检验。结果：ART组中47例患者共检出86枚宫旁淋巴结,ARH组109例患者共检出341枚宫旁淋巴结。两组的宫旁淋巴结检出率分别为80.85%和96.33%。其中,大部分宫旁淋巴结位于宫旁组织内区,分别为63/86枚(73.26%)和222/341枚(65.10%)。膀胱宫颈韧带与宫骶韧带也存在少量宫旁淋巴结。两组中位宫旁淋巴结检出数分别为2枚和3枚,p=0.04。在盆腔淋巴结阴性患者中,两组宫旁淋巴结转移率分别为6.67%和6.06%,在盆腔淋巴结阳性患者中,宫旁淋巴结转移率为100%和66.67%。患者平均随访时间分别为9.6个月与9.8个月,未出现复发或死亡病例。结论：宫颈周围均存在宫旁淋巴结分布,且阔韧带中可能存在宫旁淋巴结与子宫动脉上行支伴行。三段取材法行宫旁淋巴结检测,检出率较高。且阳性宫旁淋巴结的检出可指导早期宫颈癌患者行术后辅助治疗,降低术后复发风险。第三部分腹式根治性宫颈切除术宫颈切缘安全性的评估目的：采用创新的术中宫颈上切缘全安性取材方法,对经腹根治性宫颈切除术标本宫颈离断面的上切缘进行安全评估,以在术中确保患者保育生育功能的可行性。方法：前瞻性采集自2012年8月到2013年10月,我院IA1期伴淋巴脉管浸润及IA2期、IB1期53名行经腹根治性宫颈切除术患者的新鲜宫颈标本。自宫颈与宫体离断后,送术中快速冰冻病理,采用创新取材方法检测距宫颈手术上切缘10mm处肿瘤累及与否。若发现肿瘤累及,术中采取宫颈补充切除术后,行二次取材。对于二次取材不理想的标本,改行根治性子宫切除术。根据患者术后石蜡最终病理结果,伴中高危复发危险因素者,给予PTX+CBP方案3-6个周期化疗。结果：53例患者,中位年龄32岁(20-41岁),术中剖视标本20例(37.74%)无肉眼肿瘤形态,11例(20.75%)非特异型病灶,22例(41.51%)为明显肿块,三类形态初次切缘累及率分别为5.00%,36.36%以及18.19%。9例患者首次取材肿瘤累及,二次取材后7例(77.78%)患者补充切缘未见肿瘤累及,ART手术的成功率为94.34%。15例(28.30%)患者接受术后辅助治疗,中位随访时间为9.5个月(2个月-17个月),未出现复发或死亡病例结论：术中快速冰冻上切缘取材范围拟定为10mm可行,且该上切缘取材方式易操作、耗时短、且安全可靠,可广泛应用。
[Abstract]:Part 1: comparison of the scope of abdominal radical hysterectomy and hysterectomy in early cervical cancer patients: To study the operation of radical hysterectomy (Abdominal Radical Trachelectomy, ART) and radical hysterectomy (Abdominal Radical Hysterectomy, ARH) for early cervical cancer patients, and the operation of radical hysterectomy (Abdominal, ARH) Methods and range differences. Methods: from August 2012 to August 2013, 156 patients with lymphatic vascular invasion and IA2, IB1 stage IB1 cervical cancer were prospectively divided into 47 cases of abdominal radical hysterectomy group and 109 cases of radical hysterectomy in the group of abdominal radical hysterectomy according to their personal operation. The length, height, the height, the length of the uterine cervix, the length of the uterine cervix ligament and the sacral ligament were measured by the same doctor and the length of the uterine cervix and the sacral ligament were measured by the same doctor, and the length of the 3,6,9 and 12 points of the vaginal excision were measured. The operation range of the ligaments of the specimens was compared by the x 2 test or the Fish accurate probability square test. Two Results: the median age of the ART group was 32 years (20-41 years old). Compared with the ARH group, the age was lighter, 51 years (32-80 years), and p0.001. In the ART and ARH group, most of the patients were diagnosed as squamous cell carcinoma, 37 (72.3%) and 79 (72.5%), and 34 (75.6%) and 90 (82.6%) respectively in the IB1 stage of FIGO staging. The average paracesal length of the two groups were 44.08 + 17.52mm and 44.96 + 20.77 mm (p=0.432) respectively. The average paracesal average height was 25.74 + 5.24mm and 26.09 + 5.11mm (p=0.361) respectively. The average length of the cervical ligaments in the two groups were 3.85 + 1.76mm and 4.01 + 2.06mm (p=0.647) respectively. The average length of the flat uterine sacral ligament was 13.30 + 4.86mm and 12.88 + 4.51mm (P), respectively (P). =0.605). Besides this, there is no statistical difference between the two groups of vaginal 3,6,9 and 12 points. Conclusion: early cervical cancer patients with radical hysterectomy and traditional radical hysterectomy can excise the same range of paracerval tissue and ligament length. Second early cervical cancer patients, Gong Panglin Detection and clinical significance Objective: To compare the difference of the detection rate between the paramiceral lymph nodes by radical hysterectomy and radical hysterectomy by a new three segment paramiceral lymph node detection method, and to clarify the significance of the detection of the paramiceral lymph nodes and the relationship with the ART operation. Method: prospective acquisition from August 2012 By August 2013, the fresh specimens of 156 patients with lymphoid vascular invasion and IA2 stage IA1 and IB1 stage of epithelial cervical cancer were collected in group ART and ARH according to their initial operation, and the left and right ligaments of the two groups, the bladder ligaments and the sacral ligaments in the two groups were taken apart by three segments. After the water treated paraffin embedded HE staining, the number, size and relation to the blood vessels in the para Palal tissues were examined and recorded under the microscope. 6 cyclical treatments of paclitaxel (PTX) + carboplatin (CBP) were given to the patients with paranathial lymph node metastases. X 2 test or Fish accurate probability square test was used. Results: in group ART, 86 paravesical lymph nodes were detected in 47 patients and 341 paravesal lymph nodes were detected in 109 patients in group ARH. The detection rates of para Palal lymph nodes in the two groups were 80.85% and 96.33%. respectively. Most para Palal lymph nodes were located in the intravesical intravesical region, 63 /86 (73.26%) and 222/341 (65.10%). There were also a small number of paracauterous lymph nodes in the ligaments and the uterine sacral ligaments. The median paracert lymph nodes in the two groups were 2 and 3 respectively. Among the patients with pelvic lymph node negative, two groups of paracauterous lymph node metastases were 6.67% and 6.06%, respectively. In the patients with pelvic lymph node positive, the rate of paracert lymph node metastasis was 100% and 66.67%. in the patients with pelvic lymph node positive. There were no recurrences or deaths in 9.6 months and 9.8 months, respectively. Conclusion: there were paracleal lymph nodes around the cervix, and there might be paracleal lymph nodes and ascending branches of uterine artery in the broad ligament. The detection rate of paracleal lymph nodes in the three segments was higher. The detection of positive paracleal lymph nodes could guide the early uterine. Cervical cancer patients were treated with postoperative adjuvant therapy to reduce the risk of postoperative recurrence. Evaluation of the safety of cervical margin of the third part of the abdominal radical hysterectomy. Methods: from August 2012 to October 2013, we prospectively collected 53 fresh cervical specimens with lymphatic vascular infiltration, IA2 phase, and IB1 period, and 53 patients undergoing radical hysterectomy at stage IB1. 10mm tumor involvement in cervix surgery. If the tumor is involved, two times after the resection of the cervix in the operation. For the two times, the radical hysterectomy is performed. According to the final pathological results of paraffin and the risk factors for high risk of recurrence, 3-6 cycles of the PTX+CBP scheme are given. Results: in 53 patients, the median age was 32 years (20-41 years old), 20 cases (37.74%) had no naked eye tumor, 11 cases (20.75%) non specific, 22 (41.51%) as obvious mass, three primary cutting edge involvement rate 5% respectively, 36.36% and 18.19%.9 patients for the first time. There was no tumor involvement in the patients. The success rate of ART operation was 94.34%.15 (28.30%) patients receiving postoperative adjuvant treatment. The median follow-up time was 9.5 months (2 months -17 months). No recurrence or death case was concluded: the range of rapid frozen upper edge selection in the operation was 10mm feasible, and the cutting edge method was easy to operate. It is short, safe and reliable, and can be widely used.
【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.33

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