中华妇产科杂志
中華婦產科雜誌
중화부산과잡지
CHINESE JOUNAL OF OBSTETRICS AND GYNECOLOGY
2015年
8期
596-602
,共7页
涂画%黄鹤%顾海风%万挺%冯艳玲%刘继红
塗畫%黃鶴%顧海風%萬挺%馮豔玲%劉繼紅
도화%황학%고해풍%만정%풍염령%류계홍
外阴肿瘤%前哨淋巴结活组织检查%淋巴转移%个体化医学%淋巴结切除术
外陰腫瘤%前哨淋巴結活組織檢查%淋巴轉移%箇體化醫學%淋巴結切除術
외음종류%전초림파결활조직검사%림파전이%개체화의학%림파결절제술
Vulvar neoplasms%Sentinel lymph node biopsy%Lymphatic metastasis%Individualized medicine%Lymph node excision
目的：评估基于前哨淋巴结活检术（SLNB）的不同手术方案治疗早期（临床拟诊为Ⅰ～Ⅱ期）外阴癌的可行性及效果，探讨合适的个体化治疗方案。方法收集2004年1月至2013年12月在中山大学附属肿瘤医院接受手术治疗的早期外阴癌患者的临床病理资料，选择其中行前哨淋巴结（SLN）探查的患者共74例，患者平均年龄为55岁（18～87岁）。手术方式包括SLNB、腹股沟淋巴清扫术（IL）和外阴肿物广泛性切除术，术中对SLN进行快速冰冻病理检查，根据SLN有无转移确定手术治疗方案，回顾性分析患者的围手术期情况、病理检查结果，评估SLNB的价值；中位随访时间为41个月（3～122个月），分析患者的复发和生存情况。结果（1）手术治疗方案：74例行SLN探查的患者中，68例（92%，68/74）患者成功识别至少1枚SLN，随后接受了SLNB，并同时行外阴肿物广泛性切除术。这68例患者中，21例患者SLN有转移，其中12例（A组）SLNB后加行双侧IL，9例（B组）于单纯SLNB后行放疗；47例SLN无转移，其中26例（C组）SLNB后加行双侧IL，发现1例非SLN的淋巴结转移，21例（D组）单纯SLNB后予随访观察。（2）围手术期情况：行SLNB+IL患者（A组+C组）的手术时间为（126±38）min，术中出血量为（98±99）ml、平均术后住院时间为32 d（18～62 d），均明显多于单纯SLNB者[B组+D组；分别为（82±22）min、（45±28）ml、15 d（8～24 d）；P<0.05]。38例行SLNB+IL患者（A组+C组）中，21例（55%，21/38）患者（共44例次）出现并发症，包括切口愈合延迟16例、下肢淋巴水肿14例、淋巴瘘8例、下肢静脉血栓3例、感染3例；30例行单纯SLNB患者（B组+D组）均无上述并发症发生。（3）病理检查结果：术前活检、术中冰冻与术后石蜡标本的病理检查结果均符合，符合率均为100%。（4）SLNB的价值：SLNB用于诊断早期外阴癌淋巴结转移的敏感度为95%，特异度为100%。（5）复发及生存情况：随访期内，11例患者复发，总复发率为16%（11/68），中位复发时间为8个月（1～50个月）；9例患者死于本肿瘤，中位生存时间为15个月（3～36个月），3年总生存率为85%。其中，SLN有转移（A组+B组）和SLN无转移（C组+D组）患者的3年生存率分别为58%和97%，两者比较，差异有统计学意义（P=0.003）。A、B组患者的3年生存率分别为66%和52%，两组比较，差异无统计学意义（P=0.709）；C、D组患者的3年生存率分别为100%和92%，两组比较，差异也无统计学意义（P=0.253）。（6）单因素分析显示，患者预后与淋巴结转移、病理分化程度、浸润深度、肿瘤部位类型明显相关（P<0.05）；而与年龄、肿瘤直径、手术方式无关（P>0.05）。多因素分析显示，仅淋巴结转移（RR=21.57，95%CI为2.68～173.10，P=0.002）和肿瘤部位类型（RR=7.85，95%CI为1.79～34.50，P=0.024）是影响患者预后的独立因素。结论淋巴结转移是影响早期外阴癌患者预后的独立因素，SLNB可准确判断早期外阴癌患者的淋巴结转移状态，对SLN无转移的患者免除IL可避免手术并发症的发生，缩短术后恢复时间，且不会显著增加复发的风险。
目的：評估基于前哨淋巴結活檢術（SLNB）的不同手術方案治療早期（臨床擬診為Ⅰ～Ⅱ期）外陰癌的可行性及效果，探討閤適的箇體化治療方案。方法收集2004年1月至2013年12月在中山大學附屬腫瘤醫院接受手術治療的早期外陰癌患者的臨床病理資料，選擇其中行前哨淋巴結（SLN）探查的患者共74例，患者平均年齡為55歲（18～87歲）。手術方式包括SLNB、腹股溝淋巴清掃術（IL）和外陰腫物廣汎性切除術，術中對SLN進行快速冰凍病理檢查，根據SLN有無轉移確定手術治療方案，迴顧性分析患者的圍手術期情況、病理檢查結果，評估SLNB的價值；中位隨訪時間為41箇月（3～122箇月），分析患者的複髮和生存情況。結果（1）手術治療方案：74例行SLN探查的患者中，68例（92%，68/74）患者成功識彆至少1枚SLN，隨後接受瞭SLNB，併同時行外陰腫物廣汎性切除術。這68例患者中，21例患者SLN有轉移，其中12例（A組）SLNB後加行雙側IL，9例（B組）于單純SLNB後行放療；47例SLN無轉移，其中26例（C組）SLNB後加行雙側IL，髮現1例非SLN的淋巴結轉移，21例（D組）單純SLNB後予隨訪觀察。（2）圍手術期情況：行SLNB+IL患者（A組+C組）的手術時間為（126±38）min，術中齣血量為（98±99）ml、平均術後住院時間為32 d（18～62 d），均明顯多于單純SLNB者[B組+D組；分彆為（82±22）min、（45±28）ml、15 d（8～24 d）；P<0.05]。38例行SLNB+IL患者（A組+C組）中，21例（55%，21/38）患者（共44例次）齣現併髮癥，包括切口愈閤延遲16例、下肢淋巴水腫14例、淋巴瘺8例、下肢靜脈血栓3例、感染3例；30例行單純SLNB患者（B組+D組）均無上述併髮癥髮生。（3）病理檢查結果：術前活檢、術中冰凍與術後石蠟標本的病理檢查結果均符閤，符閤率均為100%。（4）SLNB的價值：SLNB用于診斷早期外陰癌淋巴結轉移的敏感度為95%，特異度為100%。（5）複髮及生存情況：隨訪期內，11例患者複髮，總複髮率為16%（11/68），中位複髮時間為8箇月（1～50箇月）；9例患者死于本腫瘤，中位生存時間為15箇月（3～36箇月），3年總生存率為85%。其中，SLN有轉移（A組+B組）和SLN無轉移（C組+D組）患者的3年生存率分彆為58%和97%，兩者比較，差異有統計學意義（P=0.003）。A、B組患者的3年生存率分彆為66%和52%，兩組比較，差異無統計學意義（P=0.709）；C、D組患者的3年生存率分彆為100%和92%，兩組比較，差異也無統計學意義（P=0.253）。（6）單因素分析顯示，患者預後與淋巴結轉移、病理分化程度、浸潤深度、腫瘤部位類型明顯相關（P<0.05）；而與年齡、腫瘤直徑、手術方式無關（P>0.05）。多因素分析顯示，僅淋巴結轉移（RR=21.57，95%CI為2.68～173.10，P=0.002）和腫瘤部位類型（RR=7.85，95%CI為1.79～34.50，P=0.024）是影響患者預後的獨立因素。結論淋巴結轉移是影響早期外陰癌患者預後的獨立因素，SLNB可準確判斷早期外陰癌患者的淋巴結轉移狀態，對SLN無轉移的患者免除IL可避免手術併髮癥的髮生，縮短術後恢複時間，且不會顯著增加複髮的風險。
목적：평고기우전초림파결활검술（SLNB）적불동수술방안치료조기（림상의진위Ⅰ～Ⅱ기）외음암적가행성급효과，탐토합괄적개체화치료방안。방법수집2004년1월지2013년12월재중산대학부속종류의원접수수술치료적조기외음암환자적림상병리자료，선택기중행전초림파결（SLN）탐사적환자공74례，환자평균년령위55세（18～87세）。수술방식포괄SLNB、복고구림파청소술（IL）화외음종물엄범성절제술，술중대SLN진행쾌속빙동병리검사，근거SLN유무전이학정수술치료방안，회고성분석환자적위수술기정황、병리검사결과，평고SLNB적개치；중위수방시간위41개월（3～122개월），분석환자적복발화생존정황。결과（1）수술치료방안：74례행SLN탐사적환자중，68례（92%，68/74）환자성공식별지소1매SLN，수후접수료SLNB，병동시행외음종물엄범성절제술。저68례환자중，21례환자SLN유전이，기중12례（A조）SLNB후가행쌍측IL，9례（B조）우단순SLNB후행방료；47례SLN무전이，기중26례（C조）SLNB후가행쌍측IL，발현1례비SLN적림파결전이，21례（D조）단순SLNB후여수방관찰。（2）위수술기정황：행SLNB+IL환자（A조+C조）적수술시간위（126±38）min，술중출혈량위（98±99）ml、평균술후주원시간위32 d（18～62 d），균명현다우단순SLNB자[B조+D조；분별위（82±22）min、（45±28）ml、15 d（8～24 d）；P<0.05]。38례행SLNB+IL환자（A조+C조）중，21례（55%，21/38）환자（공44례차）출현병발증，포괄절구유합연지16례、하지림파수종14례、림파루8례、하지정맥혈전3례、감염3례；30례행단순SLNB환자（B조+D조）균무상술병발증발생。（3）병리검사결과：술전활검、술중빙동여술후석사표본적병리검사결과균부합，부합솔균위100%。（4）SLNB적개치：SLNB용우진단조기외음암림파결전이적민감도위95%，특이도위100%。（5）복발급생존정황：수방기내，11례환자복발，총복발솔위16%（11/68），중위복발시간위8개월（1～50개월）；9례환자사우본종류，중위생존시간위15개월（3～36개월），3년총생존솔위85%。기중，SLN유전이（A조+B조）화SLN무전이（C조+D조）환자적3년생존솔분별위58%화97%，량자비교，차이유통계학의의（P=0.003）。A、B조환자적3년생존솔분별위66%화52%，량조비교，차이무통계학의의（P=0.709）；C、D조환자적3년생존솔분별위100%화92%，량조비교，차이야무통계학의의（P=0.253）。（6）단인소분석현시，환자예후여림파결전이、병리분화정도、침윤심도、종류부위류형명현상관（P<0.05）；이여년령、종류직경、수술방식무관（P>0.05）。다인소분석현시，부림파결전이（RR=21.57，95%CI위2.68～173.10，P=0.002）화종류부위류형（RR=7.85，95%CI위1.79～34.50，P=0.024）시영향환자예후적독립인소。결론림파결전이시영향조기외음암환자예후적독립인소，SLNB가준학판단조기외음암환자적림파결전이상태，대SLN무전이적환자면제IL가피면수술병발증적발생，축단술후회복시간，차불회현저증가복발적풍험。
Objective To evaluate the feasibility and outcomes of different surgical approaches on the basis of sentinel lymph node biopsy (SLNB) in treating early-stage vulvar cancer, and discuss the proper strategy for individualized treatment. Methods The medical charts of patients with early-stage vulvar cancer treated in Sun Yat-sen University between January 2004 and December 2013 were retrospectively collected. A total of 74 patients who received sentinel lymph node(SLN)detection in primary surgery were enrolled (average age 55). The surgical approaches contained SLNB, inguinal lymphadenectomy (IL), and extensive vulvectomy. The SLN were examed on intraoperative frozen sections. The treatment protocols, lymphatic metastasis, postoperative recovery condition, recurrence and survival data were collected and analyzed. Results At least one SLN was successfully detected in 68 (92%,68/74) patients. SLN were positive in 21 patients, of whom 12 (group A) underwent bilateral IL, and 9 (group B) received radiotherapy without performed IL. SLN were negative in 47 patients, of whom 26 (group C) underwent bilateral IL and one of them had a non-SLN metastasis, and 21 (group D) were advised to follow-up. The coincidence of pathological results between frozen and paraffin sections was 100%. The sensitivity and specificity of SLNB for diagnosis of lymph node metastasis were 95% and 100%, respectively. A total of 44 complications happened in patients underwent SLNB and IL (group A and C), including 16 poor wound healing, 14 lymphedema, 8 lymphatic fistulas, 3 phlebothrombosis and 3 infections. There were no complications happened in patients underwent SLNB alone (group B and D), among whom the operation time, bleeding amount, and hospital stay were also significantly less than those in patients underwent SLNB and IL. The median follow-up time was 41 months and the 3-year overall survival rate was 85% in the whole series. Recurrences were observed in 11 patients and 9 of them died of the tumor with the median survival time of 15 months. In patients with positive SLN (group A and B), the 3-year overall survival rate was 58% with 8 patients died of the disease, including 4 in group A and 4 in group B. In patients with negative SLN (group C and D), the 3-years overall survival rate was 97% with one patient in group D died of the tumor, and significantly higher than that of patients with positive SLN (P=0.003). The 3-year overall survival rate was significantly difference. In univariate analysis by log-rank test showed that, neither in patients with nor without SLN metastasis the prognosis differed with respect to surgical approaches (group A vs B, P=0.709;group C vs D, P=0.253). Univariate analysis by log-rank test showed that, lymph node metastasis, pathological grade, depth of invasion, and tumor location could significantly affected survival (P<0.05), whereas age, tumor diameter, and surgical approach didn′t (P>0.05). Multivariate analysis showed that lymph node metastasis (RR=21.57, 95%CI:2.68-173.10, P=0.002) and tumor location (RR=7.85, 95%CI:1.79-34.50, P=0.024) were the independent factors for overall survival. Conclusions Lymph node metastasis is an independent prognosis factor for patients with early-stage vulvar cancer. SLNB could accurately diagnose the status of lymph nodes and help to decide subsequent treatment. The omissions of IL in patients with negative SLN avoid surgical morbidity and shorten postoperative recovery period without an increased risk of recurrence.
