腹主动脉旁淋巴结清扫术在上皮性卵巢癌治疗中的意义

发布时间：2018-08-15 18:53

【摘要】：背景与目的卵巢恶性肿瘤是女性生殖器官常见的三大恶性肿瘤之一,病死率居妇科恶性肿瘤首位。上皮性卵巢癌是卵巢恶性肿瘤中最常见的类型。上皮性卵巢癌的治疗原则为以手术为主、化疗为辅的综合治疗。尽管经过了彻底的手术治疗以及完整规范的化疗,仍有50%-80%的上皮性卵巢癌患者出现复发,晚期患者5年生存率徘徊于30%-40%。国际妇产科联盟手术-病理分期是公认的影响卵巢癌预后的重要因素,而淋巴结是否转移是手术-病理分期的重要因素。早期上皮性卵巢癌盆腔淋巴结转率为5%-14%,腹主动脉旁淋巴结转移率为4%-12%；晚期上皮性卵巢癌盆腔淋巴结转移率达50%以上,腹主动脉旁淋巴结转移率为17%。但是关于上皮性卵巢癌是否需要行腹膜后淋巴结清扫术尤其是腹主动脉旁淋巴结清扫术目前仍然存在着争议。据文献报道,全世界范围内只有10%-30%的卵巢癌患者行全面的分期手术。本文主要的目的是探讨淋巴结转移以及淋巴结清扫范围对上皮性卵巢癌复发及生存率的影响,以及上皮性卵巢癌淋巴结发生转移的危险因素,以期为上皮性卵巢癌的手术治疗提供理论依据。方法1.回顾性分析2012年01月01日-2015年11月30日期间于郑州大学第二附属医院行腹膜后淋巴结清扫术的104例上皮性卵巢癌患者的临床病理资料。根据淋巴结清扫范围分为两组：①盆腔淋巴结清扫组37例；②盆腔+腹主动脉旁淋巴结清扫组67例。总结上皮性卵巢癌盆腔淋巴结和腹主动脉旁淋巴结的转移率以及转移的腹主动脉旁淋巴结的分布情况；对患者进行随访,分析淋巴结转移以及淋巴结清扫范围对上皮性卵巢癌复发及生存率的影响,并行单因素和多因素分析了解影响上皮性卵巢癌盆腔淋巴结转移和腹主动脉旁淋巴结转移的相关因素。2.统计方法应用SPSS21.0软件进行统计学分析,计量资料比较采用t检验,计数资料比较采用x2检验,Kaplan-Meier法计算生存率,生存率的比较采用Log-rank检验,多因素分析采用非条件logistic回归分析,α=0.05为检验水准。结果1.淋巴结转移率及淋巴结转移相关因素：104例病例中共有46例发生腹膜后淋巴结转移,转移率为44.23%(46/104)。41例发生盆腔淋巴结转移,转移率为39.42%(41/104)；24例发生腹主动脉旁淋巴结转移,转移率为35.82%(24/67)。盆腔+腹主动脉旁淋巴结清扫组中7例仅有盆腔淋巴结转移,转移率为10.45%(7/67)；5例仅有腹主动脉旁淋巴结转移,转移率为7.46%(5/67)；19例盆腔及腹主动脉旁淋巴结均有转移,转移率为28.36%(19/67)。单因素分析结果显示临床分期、病理类型、组织学分化是上皮性卵巢癌盆腔淋巴结转移的危险因素,临床分期和盆腔淋巴结转移是上皮性卵巢癌腹主动脉旁淋巴结转移的危险因素。多因素分析结果显示临床分期是上皮性卵巢癌盆腔淋巴结转移的独立危险因素,盆腔淋巴结转移是上皮性卵巢癌腹主动脉旁淋巴结转移的独立危险因素。2.淋巴结切除数量及阳性淋巴结数量与淋巴结清扫范围的关系：盆腔淋巴结清扫组和盆腔+腹主动脉旁淋巴结清扫组淋巴结平均切除个数分别为(19.56±6.14)个和(39.55±15.59)个。随着淋巴结清扫范围的扩大,切除的淋巴结数量增多(P0.05)。盆腔淋巴结清扫组和盆腔+腹主动脉旁淋巴结清扫组平均阳性淋巴结个数分别为(9.09±4.63)个和(32.93±18.10)个。随着淋巴结清扫范围的扩大,阳性淋巴结切除数量增加(P0.05)。3.复主动脉旁淋巴结转移好发区域：左肾静脉水平和腹主动脉旁与下腔静脉间是淋巴结转移率最高的区域,转移率为42.31%(11/26)。4.临床分期与手术-病理分期相符率：8例肉眼病灶局限于卵巢或盆腔者因淋巴结转移而导致期别上升,占17.39%(8/46)。其中5例行盆腔+腹主动脉旁淋巴结清扫术,1例仅有腹主动脉旁淋巴结转移,4例盆腔淋巴结及腹主动脉旁淋巴结均有转移,5例均有左肾静脉水平淋巴结转移。5.复发率及无瘤生存期：104例病例中有41例发生复发,总复发率为39.42%(41/104)。淋巴结转移者和淋巴结无转移者复发率分别为60.87%(28/46)和22.41%(13/58),淋巴结转移者复发率较淋巴结无转移者高(P0.05)。淋巴结转移者和淋巴结无转移者平均无瘤生存期分别为(23±1.963)个月和(32±1.643)个月,淋巴结转移者无瘤生存期较淋巴结无转移者短(P0.05)。盆腔淋巴结清扫组和盆腔+腹主动脉旁淋巴结清扫组复发率分别为54.05%(20/37)和31.34%(21/67),盆腔+腹主动脉旁淋巴结清扫组复发率较盆腔淋巴结清扫组低(P0.05)。盆腔淋巴结清扫组中位无瘤生存期为20个月,盆腔+腹主动脉旁淋巴结清扫组中位无瘤生存期为39个月,盆腔+腹主动脉旁淋巴结清扫组无瘤生存期较盆腔淋巴结清扫组长(P0.05)。结论1.盆腔+腹主动脉旁淋巴结清扫术可以明确上皮性卵巢癌的分期,降低复发率,延长无瘤生存率；2.上皮性卵巢癌需要行盆腔+腹主动脉旁淋巴结清扫术,因左肾静脉下淋巴结转移率高,淋巴结清扫范围应达到左肾静脉水平。3.临床期别晚、浆液性癌、低分化是上皮性卵巢癌淋巴结转移的高危因素,该部分患者尤其需要行盆腔+腹主动脉旁淋巴结清扫术。
[Abstract]:BACKGROUND AND OBJECTIVE Ovarian malignancies are one of the three most common malignancies in female genital organs, with the highest mortality in gynecological malignancies. Epithelial ovarian cancer is the most common type of ovarian malignancies. The principle of treatment for epithelial ovarian cancer is a combination of surgery and chemotherapy. 50% to 80% of patients with epithelial ovarian cancer recurred after chemotherapy and the 5-year survival rate of patients with advanced ovarian cancer hovered between 30% and 40%. Pelvic lymph node metastasis rate was 5% - 14%, para-aortic lymph node metastasis rate was 4% - 12%; pelvic lymph node metastasis rate of advanced epithelial ovarian cancer was more than 50%, para-aortic lymph node metastasis rate was 17%. But whether retroperitoneal lymph node dissection, especially para-aortic lymph node dissection, was necessary for epithelial ovarian cancer There is still controversy. According to the literature, only 10-30% of the patients with ovarian cancer in the world have undergone comprehensive staging surgery. Methods 1. The clinical and pathological data of 104 patients with epithelial ovarian cancer who underwent retroperitoneal lymphadenectomy in the Second Affiliated Hospital of Zhengzhou University from January 1, 2012 to November 30, 2015 were retrospectively analyzed. Thirty-seven patients were treated with palpation and 67 patients were treated with pelvic and para-abdominal aortic lymph node dissection.The metastasis rates of pelvic and para-abdominal aortic lymph nodes and the distribution of metastatic para-abdominal aortic lymph nodes in epithelial ovarian cancer were summarized. Relapse and survival rate, and single factor and multifactor analysis of the impact of epithelial ovarian cancer pelvic lymph node metastasis and para-abdominal aortic lymph node metastasis related factors. 2. Statistical methods SPSS21.0 software for statistical analysis, statistical data comparison using t test, statistical data comparison using x2 test, Kaplan-Meier method The survival rate was calculated by Log-rank test, and the unconditional logistic regression analysis was used for multivariate analysis. Results 1. Lymph node metastasis rate and related factors of lymph node metastasis: Of 104 cases, 46 cases had retroperitoneal lymph node metastasis, and the metastasis rate was 44.23% (46/104). 41 cases had pelvic lymph node metastasis. Metastasis rate was 39.42% (41 / 104); para-aortic lymph node metastasis was found in 24 cases (35.82% (24 / 67); pelvic lymph node metastasis was found in 7 cases (10.45% (7 / 67); para-aortic lymph node metastasis was found in 5 cases (7.46%); pelvic lymph node metastasis was found in 19 cases (5 / 67). The metastasis rate was 28.36%(19/67). Univariate analysis showed that clinical stage, pathological type and histological differentiation were risk factors for pelvic lymph node metastasis in epithelial ovarian cancer. Clinical stage and pelvic lymph node metastasis were risk factors for pelvic lymph node metastasis in epithelial ovarian cancer. Results showed that clinical stage was an independent risk factor for pelvic lymph node metastasis in epithelial ovarian cancer, and pelvic lymph node metastasis was an independent risk factor for para-abdominal aortic lymph node metastasis in epithelial ovarian cancer. The average number of lymph nodes resected in para-aortic lymph node dissection group was (19.56+6.14) and (39.55+15.59). With the enlargement of lymph node dissection range, the number of resected lymph nodes increased (P 0.05). The average number of positive lymph nodes in pelvic lymph node dissection group and pelvic+para-aortic lymph node dissection group were (9.09+4.63) and (9.09+4.63) respectively. With the enlargement of lymph node dissection range, the number of positive lymph node resection increased (P 0.05). 3. Prevalent area of multiple paraaortic lymph node metastasis: Level of left renal vein and para-abdominal aorta and inferior vena cava were the areas with the highest lymph node metastasis rate (42.31% (11/26). 4. Clinical stage and surgical-pathological stage The coincidence rate was 17.39% (8/46) in 8 cases with gross foci confined to the ovary or pelvic cavity. 5 cases underwent pelvic + abdominal paraaortic lymphadenectomy, 1 case had abdominal paraaortic lymph node metastasis, 4 cases had pelvic lymph node metastasis and 5 cases had left renal vein level lymph node metastasis. Metastasis. 5. Recurrence rate and tumor-free survival: 41 of 104 cases had recurrence, the total recurrence rate was 39.42%(41/104). The recurrence rates of lymph node metastasis and non-metastasis were 60.87%(28/46) and 22.41%(13/58), respectively. The recurrence rate of lymph node metastasis was higher than that of non-metastasis (P 0.05). The mean tumor-free survival time was (23 + 1.963) months and (32 + 1.643) months, respectively. The tumor-free survival time of patients with lymph node metastasis was shorter than that of patients without lymph node metastasis (P 0.05). The recurrence rates of pelvic lymph node dissection group and pelvic + para-aortic lymph node dissection group were 54.05% (20/37) and 31.34% (21/67), respectively. The median tumor-free survival was 20 months in pelvic lymph node dissection group, 39 months in pelvic + para-aortic lymph node dissection group, and longer in pelvic + para-aortic lymph node dissection group than in pelvic lymph node dissection group (P 0.05). Palpation dissection can determine the stage of epithelial ovarian cancer, reduce the recurrence rate, prolong the tumor-free survival rate; 2. epithelial ovarian cancer needs pelvic + abdominal para-aortic lymph node dissection, because the left renal vein lymph node metastasis rate is high, lymph node dissection should reach the level of the left renal vein. 3. clinical stage late, serous cancer, low differentiation is Epithelial ovarian cancer is a high risk factor for lymph node metastasis. Pelvic + para-aortic lymphadenectomy is especially necessary in this group of patients.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R737.31

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