宫颈癌前哨淋巴结活检指导术式选择的临床研究

Guidance of sentinel lymph nodes detection to selection of operation for early cervical cancer

目的评价前哨淋巴结（sentinellymphnode，SLN）预测早期宫颈癌盆腔淋巴结转移状态的价值，探讨其指导经腹广泛性宫颈切除术（radicalabdominaltrachelectomy，RAT）的临床意义。方法2003—02-01～2014—12—31山东省肿瘤医院收治拟行RAT治疗的96例IA2～IB1期宫颈癌患者，术前将放射性核素”Tc“-硫胶体注射于宫颈示踪SLN，术中检测定位SLN并原位切除，送快速冷冻病理检查。若SLN阴性则行RAT，若SLN阳性则转行广泛性子宫切除（radicalhysterectomy，RH）＋盆腔淋巴清除术。术后将SLN和盆腔其他淋巴结送常规病理检查和抗角蛋白免疫组化检测。通过观察术后复发及妊娠情况等指标，评价SLN检测结果指导早期宫颈癌行RAT的可行性及安全性。结果96例患者均检出SLN，共346枚，平均3．6枚／例，检出率i00．0％（96／96）。术中冷冻病理发现10例SLN阳性而转行广泛性子宫切除＋盆腔淋巴清除术，其余86例成功行RAT。术后石蜡病理检查未发现非SLN转移，抗角蛋白免疫组化检测未检出石蜡病理检查漏诊的微转移灶。术中4例损伤一侧子宫动脉，3例损伤膀胱肌层；术后15例出现盆腔淋巴囊肿，7例残余宫颈管狭窄。41例患者术后有生育要求，8例妊娠，妊娠率为19．5％。随访期间，3倒盆腔复发，1例肺转移，总复发率为4．7％（4／86）。结论SLN可以准确预测早期宫颈癌盆腔淋巴结转移状态，应用于希望保留生育功能的IA2～IB1期宫颈癌患者行RAT是安全可行的。

OBJECTIVE To evaluate the clinical value of sentinel lymph nodes（SLN） in the prediction of the pelvic lymph nodes status for early cervical cancer and to approach the clinical significance of SLN detection for guiding radical abdominal trachelectomy （RAT）. METHODS Ninety-six patients with stage I A2 to I B1 cervical cancer between Febru- ary 1,2003 and December 31, 2014 were enrolled in this study. Isotope 99Tcm-DX was injected into cervix to mark pelvic lymph nodes before operation, SLNs were identified, iusitu resected and submitted to fast frozen section. The RAT was performed if SLNs were negative, if SLNs were positive switched radical Hysterectomy（RH）. After operation, All pelvic lymph nodes were sent for routine pathological examination and anti-cytokeratin immunohistochemistry. Complications and pregnant status were observed to assess the safety and reliability of RAT. RESULTS SLNs were detected in 96 pa- tients（100.0%）. The number of detected SLNs was 346 with an average 3.6 pieces per patient. Of these, SLNs of 10 pa- tients were positive on frozen sections and proved by pathological examination and switched RH. The other 86 patients with negative SLNs underwent RAT successfully. Non SLN metastasis was not found in Paraffin pathological examination among the cases. The missed micro metastasis foci by HE staining pathological examination was not found with the anti- eytokeration immunohistochemistry in all pelvic lymph nodes. Intraoperative and postoperative complications were found in 29 cases. Preoperative complications occurred in 22 patients including 4 cases of uterine artery injury and 3 cases of bladder injury. Pelvic lymphatic cyst was found in 15 cases and residual cervical canal stenosis was seen in 7 cases after operation. Forty-one patients had the desire of conceive and 8 of them pregnanced after surgery. Four relapses occurred and two died of tumor progression during follow-up. The recurrence rate was 4.7%. CONCLUSION SLNs detection has a certain value for judging pelvic lymph nodes metastasis in patients with stage I A2 to I B1 cervical cancer and RAT un- der the of SLN detection is safe and reliable for the young patients who desire to have fertility preservation.