前哨淋巴结检测结果指导早期子宫颈鳞癌患者行子宫颈广泛性切除术的临床研究

Clinical study of sentinel lymph node detection guided radical abdominal trachelectomy

目的评价前哨淋巴结（SLN）对早期（Ia2～Ib1期）宫颈鳞癌盆腔淋巴结转移状态的预测价值，探讨SLN检测结果指导腹式宫颈广泛性切除术（RAT）的可行性、安全性。方法选择2005年1月一2009年6月间山东省肿瘤医院收治的31例早期宫颈鳞癌患者，术中检测SLN并原位切除，然后行盆腔淋巴清扫术，术中行快速冰冻病理检查排除淋巴结转移后，行RAT，术后将SLN及其他盆腔淋巴结石蜡包埋行常规病理检查和抗角蛋白免疫组化检测。通过观察患者的手术时间、术中出血量、术中和术后并发症、住院时间及术后妊娠、复发情况，评价SLN检测结果指导早期宫颈鳞癌患者行RAT的安全性和可行性。结果31例患者均检测到SLN，共检出SLN109枚，平均每例3．5枚，SLN检出率为100％（31／31）。其中2例患者快速冰冻病理报告SLN转移，放弃RAT改行子宫广泛性切除术。SLN及其他部位盆腔淋巴结抗角蛋白免疫组化检测未检出HE染色病理检查漏诊的微转移灶。SLN检测盆腔淋巴结转移状态的灵敏度和特异度均为100％，阴性预测值为100％。29例SLN阴性的患者均成功实施RAT，其手术时间为205—270min，中位手术时间为240min，术中出血量为220～500ml，中位出血量为310ml；术中2例患者发生膀胱肌层损伤、3例因损伤一侧子宫动脉而只保留了对侧子宫动脉，术后5例患者发生盆腔淋巴囊肿、3例残留宫颈管狭窄、1例残留宫颈肉芽组织增生；术后19例患者有生育要求，5例妊娠，其中1例妊娠达7个月，但均未足月分娩；随访期内（36～90个月），未发现复发或转移患者。结论SLN能准确预测早期宫颈鳞癌患者盆腔淋巴结的转移状态。希望保留生育功能的早期宫颈鳞癌患者在SLN检测结果指导下行RAT安全、可行，值得临床推广应用。

Objective To evaluate the clinical value of sentinel lymph nodes （SLN） in predicting pelvic lymph node status for early cervical squamous cell carcinoma, and approach the clinical significance of SLN detection for guiding radical abdominal tracheleetomy （RAT）. Outcomes of follow up and fertility were also observed. Methods A total of 31 patients with stage I a2 - I b1 squamous cell carcinoma planned to be given RAT and pelvic lymphadenectomy were enrolled. ^（99m）Tc-labeled phytate was injected before surgery. Intraoperatively, SLN were identified, excised, and submitted to fast frozen section. Systematic bilateral pelvic lymphadenectomy was performed, and then RAT was performed in patients with negative SLN. All nodes were sent for routine pathological examination and immunostained with anti-eytokeratin antibody to detect mierometastases. Results SLN were detected in all patients （ 100% ,31/31 ）. A total of 109 SLN were identified with a mean number of 3.5 per patient. Of these, SLN of 2 patients were positive on frozen sections and proved to be metastasis by final pathologic examination and quitted the RAT. No missed micrometastasis was found using immunohistochemieal staining in SLN and other lymph nodes using histologically node-negative cases. No false negative cases was found and the negative value was 100% （31/31）. The sensitivity, accuracy, and false negative rates were 100%, 100%, and 0,respectively. Perioperative complications occured in 5 patients including 2 cases of bladder injury and 3 cases of uterine artery injury. No relapses occurred during follow-up. Five of 19 patients with procreative desire conceived pregnancies （4 spontaneous abortion and 1 premature birth ） after surgery. Conclusions The identification of SLN using ^（99m）Tc-labeled phytate could predict the pelvic lymph node status in early stage cervical cancer. Under the guidance of SLN detection, RAT is a feasible operative modality with well prognosis and low complications for young patients who desire to preserve reproductive function.