【作者】 马莉；

【导师】 孔繁斗；

【作者基本信息】 大连医科大学 ， 妇产科学， 2017， 硕士

【摘要】 研究背景:子宫内膜癌是女性生殖系统最常见恶性肿瘤之一,由于子宫内膜癌的临床表现主要为不规则阴道流血,大多数患者在早期被诊断并获得治疗。根据美国国立综合癌症网络(NCCN)2016指南,对于Ⅰ期子宫内膜癌患者,建议行全子宫双附件切除术+手术分期±术后辅助治疗,若存在高危因素,应同时切除盆腔及腹主动脉旁淋巴结;而对于低危型是否切除淋巴结仍无定论。对于Ⅰ期低危型子宫内膜癌,有研究表明淋巴结转移率很低,行盆腔淋巴结清扫术不能提高患者的生存率,反而增加手术风险。目前不同国家、不同地区及不同医师在Ⅰ期低危型子宫内膜癌患者的手术治疗上存在较大分歧。研究目的:分析我院Ⅰ期低危型子宫内膜癌患者行盆腔淋巴结清扫术是否影响其预后,并进一步分析两种术式在手术时间、术中出血量、住院时长、术后恢复情况及手术并发症方面有无区别。研究方法:检索大连医科大学附属第一医院2007年到2012年间所有诊断为子宫内膜癌并在我院行开腹手术治疗的患者,根据纳入排除标准筛选出符合条件的患者72人,根据有无进行盆腔淋巴结清扫,分为两组,未盆扫组52人,盆扫组20人,采用查找手术病历及电话随访的形式,收集患者年龄、手术时间、术中出血量、术后排气时间、术后留置导尿时间、住院时长、手术并发症及结局等情况。72例患者中有23例失访,最终49例纳入研究,其中未盆扫组32人,盆扫组17人。采用SPSS 21.0软件进行统计学分析,对两组患者手术时间、术中出血量、术后排气时间、术后留置导尿时间、住院时长进行t检验,同时使用卡方检验分析手术并发症发生率及5年生存率,进一步分析各变量之间的差异。研究结果:本研究随访时间48个月至119个月,中位随访时间为85个月;患者年龄介于32岁-82岁,平均年龄54.22± 10.96岁。未盆扫组:32例患者均行筋膜外全子宫双附件切除术。盆扫组:7例行全子宫双附件切除+双侧盆腔淋巴结清扫术;7例行全子宫双附件切除术+选择性盆腔淋巴结清扫术;2例行次广泛性子宫双附件切除+单侧盆腔淋巴结清扫术;1例行次广泛性子宫双附件切除术+双侧盆腔淋巴结清除术。1、未盆扫组与盆扫组的预后分析未盆扫组:存活30例,死亡2例,5年生存率为93.75%。盆扫组:存活15例,死亡2例,5年生存率为88.24%。未盆扫组5年生存率与盆扫组5年生存率比较,差异无统计学意义(P=0.602),盆腔淋巴结清扫术对Ⅰ期低危型子宫内膜癌患者的预后无影响。2、未盆扫组与盆扫组术中情况比较未盆扫组与盆扫组手术平均时间分别为124.69 士 33.48min和170.88 士56.49min,两组手术时间差异有统计学意义(t’=3.095,P=0.005)。盆扫组手术时间较未盆扫组延长。未盆扫组与盆扫组术中平均出血量分别为107.50士82.26ml和175.88士102.66ml,两组术中出血量差异有统计学意义(t’ =2.372,P=0.025)。盆扫组的术中出血量较未盆扫组明显增加。3、未盆扫组与盆扫组术后恢复情况比较未盆扫组与盆扫组术后排气时间分别为2.16±0.57天(1-4天)和2.35士0.49天(2-3天)。两组平均术后排气时间无统计学差异(t=1.196,P=0.238)。盆腔淋巴结清扫术对术后排气时间无影响。未盆扫组与盆扫组术后尿管留置时间分别为2.25士0.57天(2-4天)和3.94士3.41天(2-14天)。两组平均留置导尿时间差异无统计学意义(t’ =2.025,P=0.059)。盆扫组与未盆扫组术后留置导尿时间无明显区别。未盆扫组与盆扫组的住院时间分别为17.56士4.78天(11-34天)和18.59士6.99天(11-39天)。两组平均住院时间无统计学差异(t=0.607,P=0.547)。盆腔淋巴结清扫术未增加住院时间。4、未盆扫组与盆扫组手术并发症比较未盆扫组:术后并发症共10例(31.25%)。盆扫组:术后并发症共8例(47.06%)。两组患者均无术中并发症发生,部分患者合并多种术后并发症。未盆扫组与盆扫组患者术后并发症的发生率比较,差异无统计学意义(X2 =1.194,P= 0.275)。盆腔淋巴结清扫术不增加术后并发症的发生风险。结论:1、Ⅰ期低危型子宫内膜癌患者仅行全子宫双附件切除术对预后没有影响。2、Ⅰ期低危型子宫内膜癌患者行全子宫双附件切除术+盆腔淋巴结清扫术增加了手术时间及术中出血量,对于这些患者不建议行盆腔淋巴结清扫术。更多还原

【Abstract】 Background:endometrial cancer is one of the most common malignant tumor in the female reproductive system.Due to the clinical manifestations of endometrial cancer is mainly irregular vaginal bleeding,most of the patients in the early stage are diagnosed and treatmented.According to the National Comprehensive Cancer Network(NCCN)guidelines,stage I endometrial cancer patients’ surgical procedures indicated include not only hysterectomy and bilateral salpingo-oophorectomy,but also pelvic lymph node dissection.if existing high risk factors,para-aortic lymph node should been cut off.But,for stage I endometrial cancer having low-risk factors,studies have shown that the rate of lymph node metastasis is very low.So the technique of pelvic lymph node dissection can not improve survival,on the contrary,it can increase the risk of surgery.At present,as for the treatment,different countries,clinical centers and physicians have the large differences.Purposes:The aim of this study was analyzed the impact of lymph node dissention on the prognosis of low-risk stage I endometrial carcinoma.At the same time,this study discusses the difference of two kinds of operative methods in operation time,intra-operative blood loss,hospitalization time,postoperative recovery and complications.Methods:We conducted a retrospective study on 72 cases of endometrioid uterine cancer meeting the inclusion standard that involved surgery in the Center of Gynecologic Oncology,The First Affiliated Hospital of Dalian Medical University,from 2007 to 2012.According to the surgery procedure,these patients were divided into two groups,no systemic pelvic lymph node dissection group had 52 cases,systemic pelvic lymph node dissection group had 20 cases,Clinical data,including histology,age at diagnosis,operation time,intra-operative blood loss,postoperative exhaust time,postoperative indwelling catheter time,hospitalization duration,postoperative complications,and outcomes were collected for each patient by look-uping operation records and telephone follow-up.Eventually 49 cases were conducted in the study,including no pelvic lymph node dissection group of 32 cases,pelvic lymph node dissection group of 17 cases.Data analysis was conducted using SPSS statistical software(version 21.0).The relationships between incidence of postoperative complications and 5-year survival rate were compared using the Pearson X2 test or Fisher’ s exact test.Comparisons of two groups of quantitative parameters were performed with the Student’ s t-test and one way ANOVA,respectively.The quantitative parameters include age,operation time,intra-operative blood loss,postoperative exhaust time,postoperative indwelling catheter time,hospitalization time.Survival time was calculated from the date of diagnosis to the date of death or last follow-up.Results:in this study,23 patients were lost to follow-up in the procedure of telephone follow-up.median follow-up time of all cases was 85 months.All patients·age range was 32-82.the average age was 54.22 ± 10.96.Among the 49 uterine cancer patients,32 cases underwent hysterectomy and bilateral salpingo-oophorectomy,7 cases underwent hysterectomy double appendix resection and systemic pelvic lymph node dissection,total 7 underwent hysterectomy and bilateral salpingo-oophorectomy and selective pelvic lymph node dissection,2 cases underwent expanding hysterectomy and bilateral salpingo-oophorectomy and single side pelvic lymph node dissection,1 case underwent expanding hysterectomy and bilateral salpingo-oophorectomy and systemic pelvic lymph node dissection.1.The prognostic analysis of two groupsNo pelvic lymph node dissection group:30 cases of survival,and 2 cases died,the 5-year survival rate was 93.75%.Pelvic lymph node dissection group:15 cases of survival,2 cases died,the 5-year survival rate was 88.24%.The 5-year survival rate of two kinds of operation was no significant difference statistically(P = 0.602).Pelvic lymph node dissection technique have no effect on the prognosis of patients with stage I low-risk type of endometrial carcinoma.2.Intra-operative situation of two groups The average operation time of no pelvic lymph node dissection group and pelvic lymph node dissection group was 124.69±33.48min and 170.88±56.49min,respectively.The operation time difference of two groups was statistically significant(t = 3.095,P =3.095).Pelvic lymph node dissection extended operation time.The average intra-operative blood loss of two groups was respectively 107.50±82.26ml and 175.88±102.66ml,intra-operative blood loss between the two groups has statistical significance(t = 2.372,P = 2.372).Pelvic lymph node dissection increased intraoperatie blood loss.3.Compare the postoperative recovery of two groupsThe postoperative exhaust time of no pelvic lymph node dissection group and pelvic lymph node dissection group was respectively 2.16±0.57 days(1-4 days),and 2.35±0.49 days(2-3 days).The average postoperative exhaust time of two groups has no statistical difference(t = 1.196,P = 1.196).Pelvic lymph nodes were performed had no effect on postoperative exhaust time.The postoperative urine tube indwelling time of no pelvic lymph node dissection group and pelvic lymph node dissection group was 2.25±0.57 days(2-4 days),and 3.94±3.41 days(2-14 days),respectively.Two groups average indwelling catheter time had no statistically significant difference(t = 2.025,P = 2.025).Pelvic lymph nodes were performed has no obviously increased postoperative indwelling catheter time.The hospitalization time between no pelvic lymph node dissection group and pelvic lymph node dissection group was 17.56±4.78 days(11-34 days)and 18.59±6.99 days(11-39 days).Two groups’ average hospital stay had no statistical difference(t = 0.607,P=0.607).Pelvic lymph node cleaning did not increase the length of hospitalization time.4.compare the operative complications of two groupsThe postoperative complications in no pelvic lymph node dissection group have 10 cases(31.25%).The postoperative complications in pelvic lymph node dissection group have 8 cases(47.06%).All patients were not founded intra-operative complications.Some of them have a variety of complications.The accident rate of surgical complication of two groups was not significantly different in statistically(X2 = 1.194,P = 1.194).Pelvic lymph node dissection did not increase the surgical complications.Conclusion:1.stage Ⅰ low-risk patients with endometrial cancer only whole uterus double adnexectomy has no effect on the prognosis.2.stage Ⅰ low-risk patients with endometrial carcinoma whole uterus double adnexectomy + pelvic lymph node cleaning technique increases the operation time and intraoperative blood loss,pelvic lymph node cleaning is not recommended in these patients.更多还原