早期子宫颈癌患者行阴式子宫颈广泛性切除术的治疗效果及生育结局

Oncologic and fertility outcomes of young patients with early stage of cervical cancer treated by vaginal radical trachelectomy

目的总结和分析早期子宫颈癌患者行阴式子宫颈广泛性切除术（ VRT）的治疗效果及生育结局。方法收集2003年12月至2013年11月间中国医学科学院北京协和医院采用VRT联合腹腔镜盆腔淋巴结切除术治疗早期子宫颈癌患者51例，其中48例（另3例患者因盆腔淋巴结受累或子宫颈内口切缘受累改行同步放化疗）成功完成VRT，保留了生育功能。48例患者的中位年龄为29岁；国际妇产科联盟（ FIGO ）临床分期：Ⅰa1期伴淋巴血管间隙受累5例，Ⅰa2期4例，Ⅰb1期39例；肿瘤大小：无肉眼可见肿瘤20例，肿瘤≤2 cm 20例、＞2 cm 8例；病理类型：鳞癌42例，腺癌或腺鳞癌6例。回顾性分析48例成功完成VRT患者的手术相关指标、治疗效果及生育结局。结果（1）手术相关指标：患者的手术时间为（185±35） min；术中出血量为（310±131） ml。手术切除的子宫颈长度为（2.6±0.6）cm；宫旁组织宽度为（1.9±0.5）cm；切除的淋巴结数为（26±10）枚。（2）治疗效果：随访（35±21）个月，随访期内6例复发，复发率为12％（6／48），复发时间平均为20个月。其中，肿瘤＞2 cm患者的复发率为3／8，显著高于肿瘤≤2 cm患者的8％（3／40，P＜0.01）；腺癌或腺鳞癌患者的复发率为3／6，显著高于鳞癌患者的7％（3／42，P＜0.01）。（3）生育结局：随访≥6个月且有生育要求的患者共35例，其中13例患者获妊娠17例次，妊娠率为37％（13／35）；共有9例患者分娩10例新生儿（其中1例患者先后两次足月妊娠，获得2例新生儿），生育率26％（9／35）。结论VRT联合腹腔镜盆腔淋巴结切除术能有效保留早期子宫颈癌患者的生育功能，部分患者术后可成功妊娠和生育。肿瘤＞2 cm患者的复发率显著增高，因而VRT的适应证应严格限于肿瘤≤2 cm的患者。

Objective To evaluate the prognosis and fertility outcomes of patients with early stage of cervical cancer treated by vaginal radical trachelectomy （ VRT ） in combination with laparoscopic pelvic lymphadenectomy.Methods The surgical data , disease recurrences and fertility outcomes were analyzed retrospectively for 51 patients who received VRT in Peking Union Medical College Hospital from Dec.2003 to Nov.2013.Results Forty-eight patients succeeded in preserving fertility.The median age was 29 years.International Federation of Gynecology and Obstetrics （ FIGO ） stage： 5 cases Ⅰa1 with lymph vascular space invasion （LVSI）,4 cases Ⅰa2 and 39 cases in stage Ⅰb1.Tumor size： 20 cases with no visible lesion, 20 cases with tumor size ≤2 cm, 8 cases with tumor size 〈2 cm.Histological type：42 cases with squamous carcinoma , 6 cases with adenocarcinoma or adeno-squamous carcinoma.The mean excised cervical length and parametrial width was （ 2.6 ±0.6 ） cm and （ 1.9 ±0.5 ） cm, respectively.Six recurrences （ 12%） were observed after following up for a mean duration of （ 35 ±21 ） months.The recurrent rate in patients with tumor size〈2 cm was 3/8, which was significantly higher than that of the patients with tumor size ≤2 cm （8%, 3/40;P〈0.01）.Of the 35 patients who desired to conceive after the surgery, 13 women had 17 pregnancies and the pregnant rate was 37% （13/35）.Nine women obtained 10 healthy live birth babies.The fertility rate was 26%（ 9/35 ）.Conclusions VRT in combination with laparoscopic pelvic lymphadenectomy could preserve the fertility of patients with early stage of cervical cancer with acceptable oncologic and fertility outcomes.Tumor size ≤2 cm should be emphasized as the indication of VRT in considering of the higher recurrent rate in patients with tumor size ＆gt;2 cm.